Measure Information Form

Measure Set: Perinatal Care (PC)

Set Measure ID: PC-05

Performance Measure Name: Exclusive Breast Milk Feeding

Description: Exclusive breast milk feeding during the newborn's entire hospitalization

The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization.

Rationale: Exclusive breast milk feeding for the first 6 months of neonatal life has long been the expressed goal of World Health Organization (WHO), Department of Health and Human Services (DHHS), American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG). ACOG has recently reiterated its position (ACOG, 2018). A Cochrane review substantiates the benefits (Kramer et al., 2012). Much evidence has now focused on the prenatal and intrapartum period as critical for the success of exclusive (or any) breastfeeding (Centers for Disease Control and Prevention [CDC], 2020; CDC, 2013; Petrova et al., 2007; Taveras et al., 2004). Exclusive breast milk feeding rate during birth hospital stay has been calculated by the California Department of Public Health for the last several years using newborn genetic disease testing data. Healthy People 2020 and the CDC have also been active in promoting this goal.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Newborns that were fed breast milk only since birth

Included Populations: Not applicable
Excluded Populations: None
Data Elements:

Exclusive Breast Milk Feeding

Denominator Statement: Single term newborns discharged alive from the hospital

Included Populations: Liveborn newborns with ICD-10-CM Principal Diagnosis Code for single liveborn newborn as defined in Appendix A, Table 11.20.1 Single Liveborn Newborn
Excluded Populations:

Admitted to the Neonatal Intensive Care Unit (NICU) at this hospital during the hospitalization

ICD-10-CM Other Diagnosis Codes for galactosemia as defined in Appendix A, Table 11.21 Galactosemia

ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for parenteral nutrition as defined in Appendix A, Table 11.22 Parenteral Nutrition

Experienced death

Length of Stay >120 days

Patients transferred to another hospital

Patients who are not term or with < 37 weeks gestation completed

Data Elements:

Admission Date

Admission to NICU

Birthdate

Discharge Date

Discharge Disposition

ICD-10-CM Other Diagnosis Codes

ICD-10-CM Principal Diagnosis Code

ICD-10-PCS Other Procedure Codes

ICD-10-PCS Principal Procedure Code

Term Newborn

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records.

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 breast milk feeding 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 Academy of Pediatrics. Section on Breastfeeding. Policy Statement. Breastfeeding and the Use of Human Milk. Pediatrics 2012 Mar; 129 (3): e827-841.
ACOG Committee Opinion No. 756: Optimizing Support for Breastfeeding as Part of Obstetric Practice. (2018). Obstetrics and gynecology, 132(4), e187–e196. https://doi.org/10.1097/AOG.0000000000002890
California Department of Public Health. (2017). Division of Maternal, Child and Adolescent Health, Breastfeeding Initiative, In-Hospital Breastfeeding Initiation Data, Hospital of Occurrence: Available at: https://www.cdph.ca.gov/Programs/CFH/DMCAH/Breastfeeding/Pages/In-Hospital-Breastfeeding-Initiation-Data.aspx
Centers for Disease Control and Prevention. (2020). Division of Nutrition, Physical Activity and Obesity. Breastfeeding Report Card. Available at: https://www.cdc.gov/breastfeeding/data/reportcard.htm
Centers for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Atlanta: U.S. Department of Health and Human Services; 2013. Available at: https://www.cdc.gov/breastfeeding/pdf/bf-guide-508.pdf
Feltner, C., Weber, R. P., Stuebe, A., Grodensky, C. A., Orr, C., & Viswanathan, M. (2018). Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries. Agency for Healthcare Research and Quality (US).
Kramer, M. S., & Kakuma, R. (2012). Optimal duration of exclusive breastfeeding. The Cochrane database of systematic reviews, 2012(8), CD003517. https://doi.org/10.1002/14651858.CD003517.pub2
Perrine CG, Chiang KV, Anstey EH, et al. Implementation of Hospital Practices Supportive of Breastfeeding in the Context of COVID-19 — United States, July 15–August 20, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1767–1770. DOI: http://dx.doi.org/10.15585/mmwr.mm6947a3
Petrova, A., Hegyi, T., & Mehta, R. (2007). Maternal race/ethnicity and one-month exclusive breastfeeding in association with the in-hospital feeding modality. Breastfeeding Medicine. 2(2):92-8.
Taveras, E.M., Li, R., Grummer-Strawn, L., Richardson, M., Marshall, R., Rego, V.H., Miroshnik, I., & Lieu, T.A. (2004). Opinions and practices of clinicians associated with continuation of exclusive breastfeeding. Pediatrics. 113(4):e283-90.
US Department of Health and Human Services. (2020). Healthy People 2020 Final Review. Washington, DC: US Department of Health and Human Services. Available at: https://www.cdc.gov/nchs/healthy_people/hp2020-final-review.htm
World Health Organization. (2007). Indicators for assessing infant and young child feeding practices. Washington, DC, USA: World Health Organization. Available at: http://apps.who.int/iris/bitstream/10665/43895/1/9789241596664_eng.pdf

Original Performance Measure Source / Developer:
California Maternal Quality Care Collaborative

Measure Algorithm:

PC-05: Exclusive Breast Milk Feeding Algorithm Narrative

Numerator: Newborns that were fed breast milk only since birth
Denominator: Single term newborns discharged alive from the hospital

Variable Key: Length of Stay

1. Start processing. Run cases, which are included in the PC Newborn Initial Patient Newborns with Breast Feeding and pass the edits defined in the Clinical Data Processing Flow , through this measure.

2. Calculate Length of Stay. Length of Stay, in days, is equal to the Discharge Date minus the Admission Date. continue processing and proceed to check Length of Stay.

3. Check Length of Stay

If Length of Stay greater than 120 days, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
If Length of Stay equals to or less than 120 days, continue processing and proceed to check ICD-10-CM Other Diagnosis Codes.

4. Check ICD-10-CM Other Diagnosis Codes

If at least one of the ICD-10-CM Other Diagnosis Codes is on Table 11.21, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
If all ICD-10-CM Other Diagnosis Codes are missing or none of them on Table 11.21, continue processing and proceed to check ICD-10-PCS Principal or Other Procedure Codes.

5. Check ICD-10-PCS Principal or Other Procedure Codes

If at least one of the ICD-10-PCS Principal or Other Procedure Codes is on Table 11.22, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
If all ICD-10-PCS Principal or Other Procedure Codes are missing or none of them on Table 11.22, continue processing and proceed to check Discharge Disposition.

6. Check Discharge Disposition

If Discharge Disposition is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
If Discharge Disposition equals 4, 5 or 6, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
If Discharge Disposition equals 1, 2, 3, 7 or 8, continue processing and proceed to check Term Newborn.

7. Check Term Newborn

If Term Newborn is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
If Term Newborn equals 2 or 3, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
If Term Newborn equals 1, continue processing and proceed to check Admission to NICU.

8. Check Admission to NICU

If Admission to NICU is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
If Admission to NICU equals Y, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
ca. If Admission to NICU equals N, continue processing and proceed to check Exclusive Breast Milk Feeding.

9. Check Exclusive Breast Milk Feeding

If Exclusive Breast Milk Feeding is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
If Exclusive Breast Milk Feeding equals Y, the case will proceed to a Measure Category Assignment of E and will be in the numerator population. Stop processing.
If Exclusive Breast Milk Feeding equals N, the case will proceed to a Measure Category Assignment of D and will be in the population. Stop processing.

Specifications Manual for Joint Commission National Quality Measures (v2023B)
Discharges 07-01-23 (3Q23) through 12-31-23 (4Q23)

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