Clinical Rationale
For almost three decades, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have had in place a standard requiring 39 completed weeks gestation prior to elective delivery, either vaginal or operative (ACOG, 1996). A 2007 ACOG and March of Dimes survey of almost 20,000 births conducted in Hospital Corporation of America hospitals found that almost one-third of all term babies 37 weeks gestational age or greater were electively delivered with 5 percent delivered in a manner violating ACOG/AAP guidelines. Most of these are for convenience, and result in significant short term neonatal morbidity (neonatal intensive care unit admission rates of 13- 21%) (Clark et al., 2009).
According to Glantz (2005), compared to spontaneous labor, elective inductions result in more cesarean deliveries and longer maternal length of stay. The American Academy of Family Physicians (2000) also notes that elective induction doubles the cesarean delivery rate. Repeat elective cesarean sections before 39 weeks gestation also result in higher rates of adverse respiratory outcomes, mechanical ventilation, sepsis and hypoglycemia for the newborns (Tita et al., 2009).
The focus on elective deliveries prior to 39 weeks was the first step in an effort to reduce the rate of C-sections in Washington State. In 2010, the rate of elective delivery prior to 39 weeks in Washington was 15.5%. Washington is now at about 1%. Since 2010, other strategies have been implemented such as best practices for induction of labor between 39 and 41 weeks, and first and second stage labor management.
Selected References:
- American Academy of Family Physicians. (2000). Tips from Other Journals: Elective induction doubles cesarean delivery rate, 61, 4.Retrieved May 29, 2013:http://www.aafp.org/afp/2000/0215/p1173.html.
- American College of Obstetricians and Gynecologists. (November 1996). ACOG Educational Bulletin.
- Clark, S., Miller, D., Belfort, M., Dildy, G., Frye, D., & Meyers, J. (2009). Neonatal and maternal outcomes associated with elective delivery. [Electronic Version]. Am J Obstet Gynecol. 200:156.e1-156.e4.
- Glantz, J. (Apr.2005). Elective induction vs. spontaneous labor associations and outcomes. [Electronic Version]. J Reprod Med. 50(4):235-40.
- Tita, A., Landon, M., Spong, C., Lai, Y., Leveno, K., Varner, M, et al. (2009). Timing of elective repeat cesarean delivery at term and neonatal outcomes. [Electronic Version]. NEJM. 360:2, 111-120.
Definition – The Joint Commission Definition using Total Population (not sampling)
This measure is defined by The Joint Commission under PC-01. The complete definition can be found at https://manual.jointcommission.org/releases/TJC2014A1/MIF0166.html
The most up to date definition from The Joint Commission for the data collection period will be used. Data will include information from applicable patients regardless of payor.
Sampling will not be used. The current minimum data sampling by The Joint Commission and also followed by CMS is problematic for quality improvement as it results in extremely small denominator sizes. This process results in unstable rates with wide variations in high and low rates. In order to make the data more precise and meaningful for the Medicaid Quality Incentive hospitals will utilize the patient population who deliver at 37-http://www.waperinatal.org/content.cfm?categoriesID=29
Definition:
Numerator: Patients with elective deliveries >=37 and < 39 weeks gestation
Included Populations: ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for one or more of the following:
- Medical induction of labor as defined in Appendix A, Table 11.05
- Cesarean section as defined in Appendix A, Table 11.06 and all of the following:
- Not in Labor
- Not experiencing Spontaneous Rupture of Membranes
- No history of a Prior Uterine Surgery per Joint Commission acceptable list:
- Prior classical cesarean section which is defined as a vertical incision into the upper uterine segment
- Prior myomectomy
- Prior uterine surgery resulting in a perforation of the uterus due to an accidental injury
- History of a uterine window or thinning of the uterine wall noted during prior uterine surgery or during ultrasound
- History of uterine rupture requiring surgical repair
Denominator: Patients delivering newborns between >=37 and < 39 weeks of gestation.
Included Populations:
- ICD-9-CM Principal Diagnosis Code for pregnancy as defined in Appendix A, Tables 11.01, 11.02, 11.03 or 11.04
- ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for planned cesarean section in labor as defined in Appendix A, Table 11.06.1
Excluded Populations:
- ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix A, Table 11.07
- Less than 8 years of age
- Greater than or equal to 65 years of age
- Length of stay > 120 days
- Enrolled in clinical trials
- Gestational Age < 37 or >= 39 weeks
Sampling: Sampling is not accepted because The Joint Commission method results in an extremely small denominator size.
Data Source
Data are to be submitted to Quality Benchmarking System. Data will be collected quarterly.
Fields to be reported:
- Patients with elective deliveries >= 37 and < 39 weeks of gestation
- Patients delivering newborns with >= 37 and < 39 weeks of gestation after exclusions removed (see denominator definition above)
Data collection period: July 1, 2014 – December 31, 2014
Reporting deadline: 45 days following the end of a quarter
Data collection system: Data submitted to the Washington State Hospital Association Quality Benchmarking System.
QBS file name: Elective_Delivery_(Hospital_Name).xls
Audits and validation: Data are subject to audit by the state. WSHA will not audit but will complete a few basic validity checks.
Review Process for Safety
It is understood that The Joint Commission definition does not exclude from the denominator all patients needing an elective delivery. As an example, if an expectant mother finds out that she has cancer and needs chemotherapy as soon as possible, the patient and medical staff may elect to deliver early. With the current definition, this patient would be counted against the hospital.
To ensure that the Medicaid Quality Incentive does not encourage poor care, in cases where the hospital and medical staff determine through a multidisciplinary review that the elective delivery was medically necessary they may submit the case for review by the Chief Medical Officer of the Health Care Authority who will work in collaboration with a small group of obstetricians as HIPPA allows. HCA will have the final authority. This was a consideration in the design of the point awards and payment thresholds.
Any cases that the hospital wishes to be reviewed must be submitted to the Health Care Authority Chief Medical Officer in writing by February 1, 2015.
Elective Delivery Between 37 and 39 Weeks Award Table:
| Threshold | >2% | 2 – 1.1% | 1 – 0.1% | <0.1% |
| Point Award | 0 | 3 | 5 | 10 |
This measure is used in the quality incentive for acute care hospitals with maternity units.
For questions, please contact:
Reporting process or definitions:
Jonathan Bennett at jonathanb@wsha.org or 
(206) 577-1851
Specific financial questions:
Andrew Busz at andrewb@wsha.org or (206) 216-2533
