Specifications Manual for Joint Commission National Quality Measures (v2019A)

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Release Notes:
Measure Information Form
Version 2019A

**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Perinatal Care (PC)

Set Measure ID: PC-03

Performance Measure Name: Antenatal Steroids

Description: Patients at risk of preterm delivery at >=24 and <34 weeks gestation receiving antenatal steroids prior to delivering preterm newborns

Rationale: The National Institutes of Health 1994 recommendation is to give a full course of corticosteroids to all pregnant women between 24 weeks and 34 weeks of gestation who are at risk of preterm delivery. Repeated corticosteroid courses should not be used routinely, because clinical trials show decreased brain size, decreased birth weight, and adrenal insufficiency in newborns exposed to repeated doses. Treatment should consist of two doses of 12 mg of betamethasone given intramuscularly 24 hours apart or four doses of 6 mg dexamethasone given intramuscularly every 12 hours.

A single course of corticosteroids should be given at 24 0/7 to 33 6/7 weeks gestation (NIH, 2000). A Cochrane meta-analysis reinforces the beneficial effect of this therapy regardless of membrane status and further concludes for all preterm deliveries the single course of corticosteroids should be routinely administered (Roberts & Dalziel, 2006).

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients with antenatal steroids initiated prior to delivering preterm newborns
Included Populations: Antenatal steroids initiated (refer to Appendix C, Table 11.0, antenatal steroid medications)

Excluded Populations: None

Data Elements:

Denominator Statement: Patients delivering live preterm newborns with >=24 and <34 weeks gestation completed
Included Populations:
  • ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for delivery as defined in Appendix A, Table 11.01.1

Excluded Populations:
  • Less than 8 years of age
  • Greater than or equal to 65 years of age
  • Length of Stay >120 days
  • Documented Reason for Not Initiating Antenatal Steroids
  • ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for fetal demise as defined in Appendix A, Table 11.09.1
  • Gestational Age < 24 or >= 34 weeks or UTD

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Data are collected as weeks and days of gestation, but the vendor converts to total days of gestation for data transmission and measure calculation.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: In order to identify areas for improvement in antenatal steroid administration rates, hospitals may wish to review documentation for reasons. Education efforts can be targeted based on the specific reasons identified.

Sampling: Yes. For additional information see the Sampling Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:
  • American College of Obstetricians and Gynecologists. (ACOG). (2013). Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists for Premature rupture of membranes.
  • Lockwood, C.J., ed. & Lemons, J.A., ed. (2007). Guidelines for Perinatal Care, Sixth Edition, American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, ISBN 978-1-58110-270-3; ISBN 978-1-932328-36-3, pp. 178-181.
  • NIH Consensus Development Conference Statement: The Effect of Corticosteroids for Fetal Maturation on Perinatal Outcomes. February 28-March 2, 1994.
  • NIH Consensus Statement: Antenatal corticosteroids revisited: repeat courses.2000. 17(2)1-18.
  • Roberts, D. & Dalziel, S.R. (2010) Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth (Review). The Cochrane Collaboration. Issue 9.

Original Performance Measure Source / Developer:
Providence St Vincent's Hospital/Council of Women and Infant's Specialty Hospitals

Measure Algorithm:

Measure Information Form PC-03
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Specifications Manual for Joint Commission National Quality Measures (v2019A)
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19)

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