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NORTH CAROLINA NEONATAL

PERINATAL QUALITY
COLLABORATIVE
Obstetric and Neonatal Metrics from the
Administrative Data Set
January 24, 2019
Janet H. Muri, MBA, President
Providence, RI

EMPOWERED by Data. CONNECTED by Purpose
Webinar Objectives

• Brief overview of NPIC
• Overview of Hospital Discharge Abstract Data
• Value of using this “Green Data” to complement state-wide
Perinatal QI initiatives

• Specifics of NC Data Set

• Samples analyses
• Unexpected Complications of the Term Newborn (PC 06)
• Severe Maternal Morbidity (AIM metrics)
National Perinatal Information Center

• A non-profit organization established in 1985 in Providence, RI
• Dedicated to the improvement of perinatal health through
comparative data analysis, program evaluation, health services
research and professional continuing education

• Developers of quality improvement reports for member, contracted
hospitals and research partners
• Data partners with developers of the Adverse Outcome Index,
Defense Health Agency, Research Triangle International and Ariadne
Labs

• The administrative data set drives 80-90 % of our analyses
Data Source(s) for QI Initiatives

Primary Data Collection
• Medical Record- abstracted data
• Electronic Health Record
• Customized perinatal data sets
• Project specific abstraction/collection tool (Redcap)

Secondary Data Collection
• Administrative Data (“Hospital Discharge/ UB04/ Billing Data”)
• Birth Certificate Data
Why Pay Attention to the
Administrative Data Set?

• Industry-wide data set: every patient discharged from the hospital has
a hospital discharge record

• The data elements are fairly standard (CMS) and because it is used for
billing of hospital based services, the clinical and financial details
require accuracy

• Its universality, completeness and (hoped for) accuracy make it
relatively easy and inexpensive to analyze
Administrative/UB04: “Green” Data

“Building a hospital/statewide culture of excellence – minimize
data collection burden by using “green data” – data that is
collected for another purpose but can support QI activities”

Jeffrey Gould, MD
Director, Perinatal Epidemiology and Outcomes Unit
Department of Pediatrics
Stanford University School of Medicine
PI, CMQCC, CPQCC
~ Speaking at the MA Neonatology Quality Forum, June, 2015 ~
State Administrative Data

• Most states collect administrative/UB 04 data from all hospitals on all
patients (47 collect; 38 mandate submission)

• “Owner” of data sets: Hospital Association, DPH/MCH

• Perinatal data can be easily isolated by codes, Major Diagnostic Category
(MDC) or Diagnosis Related Group (DRG)

• Reporting selected metrics back to all birth hospitals “pulls” them into the
conversation: value of the data, need to improve the data, opportunities for
statewide or region-wide QI projects

• Primary data collection can supplement more in-depth research or QI projects
Privacy and Confidentiality

• Very critical issue but not a barrier to creating valuable analyses
• All files are patient specific and contain identifiers that are protected from
disclosure

• Each state will have a different level of agreement with their hospitals
regarding reporting hospital identifiers and patient PHI (protected health
information)
• Hospital identifiers can be masked with numbers/letters to preserve
anonymity but also show multi-site comparisons

• Access to patient identifiers that can assist hospitals in auditing their
numerator cases for accurate documentation and coding
Value of Comparative Data

• Changes in your hospital over time
• Your hospital compared to a peer group or the statewide average

• Identify outlier status allowing you to drill down and validate provider
documentation and coding of the data

• If problems, initiate education with clinicians and coders

• Focus internal or statewide QI activities
• Uses limited QI resources effectively
North Carolina Data Set (NC 1300)

• Quarterly files submitted by each facility to Truven/IBM Watson

• Processed and aggregated to CY
• Sent to Shepps Center at UNC; have state contract to manage the
data
• 2017 data; will not receive 2018 until August, 2019 (Q1, 2018 1.5
years old)

• Standard utilization, volume, inpatient/outpatient activity
• Special requests can be made
NC Components of Administrative Data Set
(Demographic & Clinical Information)

Hospital Identifier Type of Admission: Newborn
Medical Record Number (Pt. Identifier) Discharge status
Date of Birth Age in months and years Principal & Secondary Diagnoses
(max-25) (ICD 10)
Sex
Principal & Secondary Procedures
Race
(max-25) (ICD-10)
Marital Status
Present on Admission
Primary Payer/Secondary
Discharge Status
Zip Code Distance from hospital in miles
Patient Billing Number (Unique Pt. Episode Identifier) Physician Identifier

Source of Admission: ER/Transfer from hospital/born DRG/APR DRG Code
outside hospital/
Date/Time of Admission and Discharge LOS Total Charges

Provider ID
Additional Variables Sometimes Available

Charges by accommodation and Ancillary category Perinatal Variables
Routine Adult/Pediatric Charges Birth weight

Adult Intensive Care Charges GA

Newborn Routine Charges; Includes Special care APGAR 1 & 5
nursery charges Mother/Baby Link
Newborn Intermediate Care Charges Service Line:
Newborn Intensive Care Charges Newborn/Obstetrics

Pediatric Intensive Care Charges Length of time from
admission to first
Total Ancillary Charges :detail by category procedure
Total Charges
Why don’t PQCs pay more attention
to the administrative data set?

Problem: Many clinicians are unfamiliar with the administrative
data set or dismiss the data as “coded” data
Challenge: Time delay, regulatory restrictions

Dilemma: This data set is being used to calculate all types of
quality/performance metrics and clinicians need to know what
their hospital’s data is saying about the quality of care at their
hospital
Goal: Gain more timely access to hospital specific
administrative data to supplement/expand and monitor QI
investments and successes
Metrics Using the Administrative Data Set

• Severe Maternal Morbidity for Hemorrhage Cases (AIM)
• Unexpected Newborn Complications (Joint Commission PC 06)
ALLIANCE FOR INNOVATION IN
MATERNAL HEALTH (AIM) SEVERE
MATERNAL MORBIDITY (SMM)
Severe Maternal Morbidity
Joint Commission Definition vs. AIM Definition

Joint Commission Severe Maternal Morbidity: A patient safety event that occurs intrapartum
through the immediate postpartum period (24 hrs), that requires the transfusion of 4 or more
units of blood products (fresh frozen plasma, packed red blood cells, whole blood, platelets)
and/or admission to the intensive care unit (ICU). Admission to the ICU is defined as admission
to a unit that provides 24-hour medical supervision and is able to provide mechanical
ventilation or continuous vasoactive drug support. These events are to be reviewed by the
hospital to determine if they rise to the level of a sentinel event. Reporting to the JC is optional
but they must have the disposition of their findings available during their JC Survey.

***AIM Severe Maternal Morbidity (SMM): Delivered women who experience at least one of
the 21 CDC defined morbidities during their delivery hospitalization. (Blood transfusion is the
largest driver of SMM so SMM is calculated two ways: with and without cases with ONLY a
blood transfusion event.)
AIM Severe Maternal Morbidity
(SMM)

• 2012 Callaghan article1 profiling 25 morbidities making up Severe Maternal Morbidity

• 12 years of administrative data 1998-2009; found 12 of 25 morbidities increased over this
period

• Rate of cases with at least one morbidity increased 75% between 1998/1999 and
2008/2009; Greatest increases in shock (+100.7%); blood transfusions (+183.2%); and acute
renal failure (+97.3%)

• SMM with and without transfusions are the two universal outcome metrics being used by
Alliance for Innovation in Maternal Health (AIM)

• SMM with and without transfusions for cases coded with a PP Hemorrhage are the two
outcome metrics specific to the implementation of the AIM Hemorrhage Bundle

1
Callaghan, W.M., Creanga, A.A., Kuklina, E.V. Severe Maternal Morbidity Among Delivery and Postpartum Hospitalization in
the United States. American Journal of Obstetrics and Gynecology 2012; 120:5. 1029-1036.
Severe Maternal Morbidity Defined
CDC metric profiled in 2012 article by William Callahan et. al.*

Denominator: Deliveries
Numerator: Any case with a severe morbidity code as defined by latest CDC ICD 9/ICD 10 code list
(www.safehealthcareforeverywomen.org)

Categories of morbidity: (list)
Acute Myocardial Infarction Heart failure/arrest during surgery or procedure
Blood transfusion Acute Renal Failure
Puerperal cerebrovascular disorders Conversion of cardiac rhythm
Adult RDS Pulmonary edema/acute heart failure
Hysterectomy Amniotic fluid embolism
Severe anesthesia complications Temporary tracheostomy
Aneurysm Sepsis
Ventilation Cardiac arrest/ventricular fibrillation
Shock Disseminated intravascular coagulation
Sickle cell disease with crisis Eclampsia
Air and thrombotic embolism

* Callaghan, W.M., Creanga, A.A., Kuklina, E.V. Severe Maternal Morbidity Among Delivery and Postpartum Hospitalization in the United States.
Obstetrics and Gynecology 2012; 120:5. 1029-1036.
SAMPLE SMM (HEM) TABLE

O3: SMM among Hemorrhage Cases TIME PERIODS 1-6
Hospital Numerator 58 46 42 54 7 17
Hospital Denominator 144 114 136 145 29 51
Hospital Rate 40.3% 40.4% 30.9% 37.2% 24.1% 33.3% -17.3%
Regional Average 28.1% 27.4% 29.0% 37.6% 27.9% 28.2% 0.3%
Statewide Average 26.1% 27.5% 28.3% 27.1% 28.8% 27.9% 6.8%

O4: SMM (excluding transfusions)
among Hemorrhage Cases
Hospital Numerator 10 5 4 3 1 0
Hospital Denominator 144 114 136 145 29 51
Hospital Rate 6.9% 4.4% 2.9% 2.1% 3.5% 0.0% --
Regional Average 5.0% 4.1% 4.5% 6.6% 5.6% 3.2% -35.9%
Statewide Average 5.1% 5.4% 4.9% 4.4% 4.5% 2.9% -44.2%
SMM (HEM)

6.9%

6.4%

PCT Change=
-7.24%
UNEXPECTED COMPLICATIONS OF THE TERM
NEWBORN
Joint Commission PC 06.0, 06.1 and 06.2
Required reporting starting1/1/2019
Unexpected Complications
of the Term Newborn
(NQF # 716 and PC 06)

• Measure developed by the California Maternal Quality Care
Collaborative (CMQCC)
• Composite measure designed to identify the most important outcome
for families: a healthy, term infant
• Endorsed by NQF in January, 2011 (#716); re-endorsed: in 2016;
displayed tables show ICD 10 algorithm

• Adopted by the Joint Commission as the newest Perinatal Care Core
Measure: required submission by most hospitals with > 300 deliveries
starting with 1/1/2019 discharges, calculated on 100% of newborns
PC 06: Unexpected Complications
of the Term Newborn

Denominator: Singleton, term infants (≥ 37 weeks; ≥ 2500 grams)
without congenital anomalies or fetal malformations, not exposed to
maternal drug use or selected maternal/fetal conditions

Numerator: Total Unexpected Newborn Complications (PC 06.0)
• Severe complications (PC 06.1): neonatal death, transfer to a higher
level of care, other severe complications, septicemia with LOS > 4
days
• Moderate complications (PC06.2): Less severe birth trauma,
respiratory or neurological complications , complications requiring
longer LOS, longer LOS not related to jaundice or social issues
Sample Table:
Unexpected Newborn Complications (UNC)
Hospital compared to peer subgroup and
statewide average
Comparative Graph: UNC
Sample Multi-hospital Display
Other Applications of Administrative Data

• Regionalization Analysis
• Match level of care with acuity of population delivered at
that facility
• Analysis of maternal and neonatal transfer patterns
• Analysis by payer to determine efficient use of resources

• Linking/Cross Validating Birth Certificate Data
• Count of cases
• Location of births/transfers
• Prenatal complications
• Merging of additional variables – Parity, gravida, APGAR
• Dilemma – access and timing of BC data
Summary

• Administrative data, while not perfect, should not be overlooked
as an tool to support PQC Initiatives
• All perinatal events are captured in the data set

• Many of the core variables can be added to a primary data
collection tool eliminating the need to “re-abstract” basic
information

• Can provide historic baseline rates and ongoing updates to
monitor pre and post QI metrics
Thank you!

Jmuri@npic.org
www.npic.org