v2.3 July 2013

Specifications for Unexpected Newborn Complications (UNC) v2.3

• Introduction/ Overview• Figures 1-4: Flow Charts for Denominator and Numerator

calculations• Table 1: Total, Severe and Moderate UNC rates;

Statewide, California 2011• Figure 5: Frequency Distribution of UNC (Total),

for all California Hospitals 2011• Table 2: UNC Sub-measures to help interpretation and drive

quality improvement activities• Appendices 1-6 (ICD-9 Code tables, see Excel file)

v2.3 July 2013

Unexpected Newborn Complications (UNC): Overview (1) aka NQF 716: Healthy Term Newborn

• Key maternity outcome measure– The most important childbirth outcome for families is a healthy baby. UNC is the

first well-balanced and validated measure to address this gap.–Also serves as a balancing metric for maternal measures such as NTSV CS, 3rd/4th

degree lacerations, episiotomy and early elective delivery rates• Denominator: Term infants without “pre-existing conditions”:

– Exclusions: preterm, <2500gm BWt, multiple gestations, all congenital anomalies (“big or small”), other fetal conditions, and exposures to maternal drug use

• Numerator: a set of either short or long term complications that would significantly concern for the mother/family. – Identified by focus groups of neonatologists and families– Grouped into severe and moderate levels– An additional principle is the identification of cases of family separation

/disruption: term babies that require neonatal transport to another facility or baby complications that require a stay longer than their mother

v2.3 July 2013

Unexpected Newborn Complications: Overview (2)

• Utilizes administrative data sets with unique safeguard strategies for both under- and over-coding

– Combines diagnosis codes and procedure codes and Length of Stay• Under-coding:

– If a baby is missing a diagnosis code (e.g. HIE/asphxia), the case is still likely to be identified using procedure codes (head cooling, intubation, resuscitation) or a neonatal LOS > mother LOS

– A baby would also be included if it has a very long LOS without any diagnosis codes to explain it after excluding drug withdrawal, jaundice, social reasons (adoption, placement, homeless)

• Over-coding:– Certain codes may not truly represent serious morbidity such as Sepsis with an

under 4 day LOS (most likely represents “r/o sepsis” rather than true sepsis), or “other birth injuries” that do not keep the baby longer than the mother

v2.3 July 2013

Unexpected Newborn Complications: Overview (3)

Advantages (over other approaches to neonatal morbidity)• No administrative data source for term baby NICU admissions

– In any case, term NICU admissions can include observation cases and those with minor issues and local protocols vary for many conditions

• Composite Measures that use ICD-9 codes alone are subject to over or under stating the true morbidity– For the AHRQ Birth Injury measure (PS-17), more than 2/3 of the cases identified belong to the

non-specific birth injury codes (767.8, 767.9)–Many California hospitals have no reporting of codes 768.5 or 768.6, birth asphyxia, presumably

for medical-legal reasons• Can be calculated with administrative data alone

Disadvantage• Requires a linked set (that provides the proper checks and balances)

– Baby Discharge Diagnosis file (ICD-9 codes, LOS and Disposition)– Birth Certificate (Birth Weight, Gestational Age, Method of delivery)– Linkage algorithms well established by CMQCC

v2.3 July 2013

Revised Specifications v2.3NQF #716: Unexpected Newborn Complications

(aka Healthy Term Newborn) Figure 1: Denominator Inclusions

BWt ≥2.5kg?

Hospital Discharge Diagnosis File

Use Birth Certificate or Medical Record: Birthweight

Not in Measure Population

Yes

GA ≥37wks?

GA ≥37wks?

BWt ≥3kg?

GA Unknown

Yes

Yes

Yes

GA Unknown

No

No

No

Starting Denominator

Use Birth Certificate or Medical Record: Best Obstetric Estimate of Gestational Age

Use Birth Certificate or Medical Record: LMP-based Gestational Age

Use Birth Certificate or Medical Record: Birthweight

Singleton Livebirth?

No orUnknown

Screen for ICD-9 Diagnosis Codes V3000 or V3001

Yes

No orUnknown

These represent back-up criteria. Birth

Certificate Obstetric Estimate of GA

usually is present for >99% of cases, and

then these two steps may be omitted

Note: ICD9 and DRG codes alone are very poor at identifying term infants. Therefore, the GA from BC is used.

v2.3 July 2013

Revised Specifications v2.3NQF #716: Unexpected Newborn Complications

(aka Healthy Term Newborn) Figure 2: Denominator Exclusions

Congenital malformations?

Starting Denominator

Use Patient Discharge Diagnosis Data, examining both Primary and Other Diagnosis fields for specific ICD-9

Codes defining a wide array of Fetal Malformations and Genetic Disorders (see Appendix 2, Group A)

Exclusions

No

Other Fetal Conditions?

Maternal Drug Use?

No

No

Yes

Yes

Final Denominator

Use Patient Discharge Diagnosis Data, examining both Primary and Other Diagnosis fields for specific ICD-9 Codes defining an array of other Maternal and Fetal

Conditions (see Appendix 2, Group B)

Use Patient Discharge Diagnosis Data, examining both Primary and Other Diagnosis fields for specific ICD-9

Codes defining an array of Maternal Drug Use Diagnoses (see Appendix 2, Group C)

Yes

In summary, the Final Denominator excludes most serious fetal conditions that are “preexisting” (present before labor), including: prematurity, multiple gestations, poor fetal growth, congenital malformations and genetic disorders, other specified fetal and maternal conditions and maternal drug use.

v2.3 July 2013

Revised Specifications v2.3NQF #716: Unexpected Newborn Complications

(aka Healthy Term Newborn) Figure 3: Numerator Inclusions: Severe Complications

NeonatalTransfer?

Use Patient Discharge Diagnosis Data: Disposition Code for Transfer to Higher Level of Care

Numerator: Severe Complications

No

5’ or 10’ Apgar ≤3?

Severe ICD-9Code?

Sepsis and LOS >4 days?

No

No

Yes

Yes

Yes

Starting Population for Moderate Complications Analysis

Use Birth Certificate or Medical Record: Apgar Score at 5 minutes or 10 minutes ≤3

Use Patient Discharge Diagnosis Data, examining both Primary and Other Diagnosis and Procedure fields for specific ICD-9

Codes defining a array of specific Severe Complications, included selected codes from the categories of: Birth Injuries,

Hypoxia/Asphyxia, Shock/Complications, Respiratory Complications/Procedures, Infections, Neurologic

Complications. (see Appendix 3, Groups 3A thru 3I)

Use Patient Discharge Diagnosis Data, examining both Primary and Other Diagnosis fields for the specific ICD-9 Code defining

sepsis but also requiring a neonatal Length of Stay >4 days. (see Appendix 3, Group 3J)

Neonatal Death?

Use Patient Discharge Diagnosis Data: Disposition Code for Death

No

Final Denominator

Yes

Yes

No

v2.3 July 2013

Revised Specifications v2.3NQF #716: Unexpected Newborn Complications

(aka Healthy Term Newborn) Figure 4: Numerator Inclusions: Moderate Complications

LOS >4d CS orLOS >2d Vag?

Use Patient Discharge Diagnosis Data for LOS and for ICD-9 Diagnosis Codes V3000 (vaginal birth) or V3001 (Cesarean

birth)

Numerator: Moderate Complications

Yes

Moderate Comps(with LOS)?

LOS>5d?

Jaundice or Social codes?

No

Yes

Yes

No

Starting Population for Moderate Complications Analysis

Use Patient Discharge Diagnosis Data to determine LOS

Use Patient Discharge Diagnosis Data, examining both Primary and Other Diagnosis and Procedure fields for the specific ICD-9

Code defining Neonatal Jaundice or Social Indications for prolonged hospitalization. (see Appendix 5, Groups A thru C)

Moderate Comps(No LOS)?

Use Patient Discharge Diagnosis Data, examining both Primary and Other Diagnosis and Procedure fields for specific ICD-9

Code defining a specific Moderate Complication, that do not require a prolonged LOS (see Appendix 4, Groups A thru C)

No

Yes

Use Patient Discharge Diagnosis Data, examining both Primary and Other Diagnosis and Procedure fields for specific ICD-9 Codes defining a array of specific Moderate Complications,

included selected codes from the categories of: Birth Injuries, Hypoxia/Asphyxia, Shock/Resuscitation, Respiratory Complications/Procedures, Infections, Neurologic Complications. (see Appendix 4, Groups D thru H)

Not in Numerator

No

Yes

No

v2.3 July 2013

Unexpected Newborn Complications (Total): (rate per 1,000 livebirths)(Severe Complications Numerator + Moderate Complications Numerator) x 1,000

Final DenominatorCalifornia state-wide rate in 2011: 39.3 per 1,000 births

Unexpected Newborn Complications (Severe): (rate per 1,000 livebirths)(Severe Complications Numerator) x 1,000

Final DenominatorCalifornia state-wide rate in 2011: 23.1 per 1,000 births

Unexpected Newborn Complications (Moderate): (rate per 1,000 livebirths)

(Moderate Complications Numerator) x 1,000 Final Denominator

California state-wide rate in 2011: 16.2 per 1,000 births

NQF #716: Unexpected Newborn Complications(aka Healthy Term Newborn, Revised Specifications) Table 1: Final Measure Calculations

v2.3 July 2013

Fig. 5: Frequency Distribution of UNC MeasureIn California Hospitals (2011-2012)

0-10 11-20

21-30

31-40

41-50

51-60

61-70

71-80

81-90

91-100

101-110

0

10

20

30

40

50

60

70Total Unexpected Newborn Complications

Rate (per thousand)

Num

ber o

f Hos

pita

ls

California Mean = 36.0/1,000 (3.6%)

Significant variation noted in both large and small hospitals

v2.3 July 2013

Revised SpecificationsNQF #716: Unexpected Newborn Complications

(aka Healthy Term Newborn)Table 2: Sub-Measure Calculations

An additional feature is the ability to calculate several sub-measures to direct Quality Improvement efforts. These “buckets” include like-diagnoses from both severe and moderate categories. Hospital level comparisons show significant variation in these categories. This Sub-measure analysis allows hospitals to focus on specific care practices to drive QI. See Appendix 6 for details on the Sub-Category groupings.

Neonatal Complication Sub-Categories

Proportion of Total Complications(California 2011-12)

Rate of each Complication Category

(per 1,000 births)

Respiratory 41.9% 14.9

Infection 21.1% 7.5Transfer to Higher Level

of Care 16.6% 5.9

Neurologic/Birth Injury 12.9% 4.6

Shock/Resuscitation 3.1% 1.1Long LOS (without clear

diagnosis) 3.9% 1.4

v2.3 July 2013

Unexpected Newborn Complications:Validation Studies

• Face Validity: – In a comparison trial for neonatal morbidity by gestational age

tracked very closely to NPIC (major East Coast perinatal data set) analysis using NICU admissions and major complications (in press)

• Formal Reliability Testing – NQF requirement using RAND statistical tools– Tests ability to discriminate among hospitals– Good is 0.8, excellent is 0.9– Mean Reliability among 220 California hospitals =0.92

• Stability within a hospital over time– Tested for 3 6-month periods with minimal variation noted in

>90% of California hospitals