Public Comment: Support of MUC18-52 Cesarean Birth

Submitted to NQF Hospital MAP by Maternal Safety Foundation

January 10, 2018

The Maternal Safety Foundation, an NQF consumer member organization, supports the implementation of MUC18-52 Cesarean Birth (CB) in IQR and the CMS EHR Incentive Program. We are submitting this comment to address MAP’s concerns and fears of negative unintended consequences documented in the Hospital IQR Program final report.

MUC18-52 (also called the NTSV Cesarean Birth Measure or PC-02) measures a specific subset of patients (nulliparous patients with term, singleton, vertex pregnancies without a placenta previa) whose outcomes are shown to be largely influenced by physician factors, rather than patient characteristics or obstetric diagnoses. Over 60% of hospital variation in NTSV patients can be attributed to first birth labor induction rates and first birth early labor admission rates.

As a consumer/patient organization, we consider a robust measure that illuminates practice variation among providers and facilities to be very valuable for comparing hospitals and for holding providers accountable. The addition of Unexpected Newborn Complications (NQF #716) to The Joint Commission’s Perinatal Core Measure Set beginning January 1, 2019, will serve as a balancing measure to the current delivery measures. Whereas there is little further room for improvement in Early Elective Delivery rates, reducing unwarranted practice variation and curbing overuse of medically unnecessary cesarean births--both primary and repeat—as well as ensuring that patients have access to risk-appropriate care remain top public health priorities.

MAP’s question about whether or not measuring CB rates directly relates to improved maternal health outcomes seems to originate from a discussion that “some states” have seen “unintended consequences that may arise such as increased maternal mortality with decreased CB rates.”

Research shows that the NTSV cesarean rate can be quickly lowered with no adverse maternal or infant outcomes. In fact, they fared better in a 2015 California Maternal Quality Care Collaborative three-hospital pilot program. While implementing a quality improvement program to lower NTSV cesarean rates, data were collected for NTSV cesarean births and balancing measures, including the NQF Unexpected Newborn Complications measure (now TJC’s PC-06) and 3rd/4th degree maternal lacerations occurring in vaginal births. The hospitals in the pilot program averaged a 18.6% reduction in their NTSV. Newborn complications fell (significantly) by 24.5% and 3rd/4th degree lacerations dropped by 4.7%.

With regards to MAP’s suggestion that the NQF Scientific Methods Panel and Perinatal Standing Committee pay special attention to risk adjustment, exclusions, and unintended consequences (full-disclosure: I am a new member of the Perinatal and Women’s Health Standing Committee), the cesarean birth measure in question was just re-endorsed as one of NQF’s Perinatal and Women’s Health measures in 2016 with 96% of the committee supporting the measure, and The Joint Commission is now the steward of the measure. This measure and its exclusions have already undergone recent rigorous review by the appropriate NQF committees.

We apologize for late involvement with this, as we learned that CB was up for discussion by MAP just prior to the final meeting on December 11, 2018. In mid-2018, the same measure was being discussed by the MAP Rural Health Workgroup measure, with the committee recommending that it not be included due to concerns about low-volume in critical access and rural hospitals. We ran some numbers and found that the majority of rural hospitals with maternity services meet TJC’s reporting threshold of 300 births and asked that the committee please ensure that their decision was data-driven. PC-02 was changed to a “yes” for recommendation as a rural-relevant measure with a caveat that low volume should be taken into consideration.

The cesarean section is the most commonly performed surgery in the United States, and pregnancy accounts for almost 25 percent of all hospitalizations. Overuse of cesarean births is a significant contributor to both short-term and long-term maternal morbidity as well as maternal mortality and we as consumer/patient advocates strongly recommend the implementation of MUC18-52 Cesarean Birth (CB) in IQR and the CMS EHR Incentive Program.

Sincerely,

Jill Arnold

Executive Director, Maternal Safety Foundation

MAP Final Report published December 21, 2018