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Release Notes:
Measure Information Form
Version 2010A1


Measure Information Form

Measure Set: Pregnancy and Related Conditions (PR)

Set Measure ID: PR-2

Performance Measure Name: Inpatient Neonatal Mortality

Description: Live-born neonates who expire before the neonate becomes age 28 days

Rationale: Neonatal (0 to less than 28 days of age) mortality continues to account for the largest proportion of infant (0 through 11 months of age) deaths. Low birth weight is a very important risk factor of neonatal mortality.

Type of Measure: Outcome

Improvement Noted As: Decrease in the rate

Numerator Statement: All neonates who expire at the facility before the neonate becomes age 28 days
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: All live-born neonates

Included Populations: Discharges with:
  • An age at admission of less than 28 days including those that are transferred in from another acute care hospital

Excluded Populations:

  • Patients with an age at admission of 28 days or greater
  • Patients transferred out to another acute care hospital with an age at time of transfer of less than 28 days
  • Patients who have a Length of Stay >120 days
  • Patients enrolled in clinical trials

Data Elements:

Risk Adjustment: Yes. This section has been moved to the ORYX Risk Adjustment Guide. This guide is available to the public on the Joint Commission’s website and, in addition, it is available to performance measurement systems via the Joint Commission’s extranet site for measurement systems (PET).

Data Elements:

Data Collection Approach: Retrospective data sources for required data elements include administrative data and, if applicable, medical record documents.

Data Accuracy: * Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency

  • Since Birth Weight is a risk factor for inpatient neonatal mortality, ICD-9-CM codes have been provided in Appendix A, Tables 4.09-4.13 to assist in identifying neonates with prematurity and fetal growth retardation with a fifth digit subclassification to denote birth weight (less than 500 grams up to birth weight 2000-2499 grams). Therefore, neonates with birth weights greater than or equal to 2500 grams will need to be captured using the data element Birth Weight.
  • It is important to ensure that all weight conversions from pounds and ounces to grams are accurate and concise. Birth Weight should not be rounded off i.e., when converting from pounds and ounces to grams, do not round to the nearest pound before converting the weight to grams.
  • Discrepancies can occur between Birth Weights obtained from labor and delivery vs. nursery departments. Organizations should determine which is the most reliable source for this data element value and consistently obtain it from that source.
  • Clinical Trial data element:
    • For Pregnancy and Related Conditions measures ONLY it is appropriate for the Performance Measurement System to default the data element to "No" unless the ICD-9-CM diagnosis code of V70.7, “Examination of participant in a clinical trial” is present. If this code is present, or the organization knows via some other electronic method that the patient is participating in a clinical trial, default the data element to "Yes".
    • Hospital abstractors may change defaulted value of “No” based on hospital participation in clinical trial

Measure Analysis Suggestions: It may be helpful to provide healthcare organizations neonatal mortality rates stratified by birth weights to assist in the interpretation of the overall rate. Recommended birth weight strata are based on ICD-9-CM coding.

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

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

Selected References:

  • Bird ST, Bauman KE: State-level infant, neonatal, and postneonatal mortality: The contribution of selected structural socioeconomic variables. International Journal of Health Services,1998.28:1:13-27.
  • Healthy people 2010. Centers for Disease Control and Prevention, Health Resources and Services Administration. Vol. 2:16.
  • Rowley DL, et al: Neonatal and postneonatal mortality. From data to action: CDC’s Public Health Surveillance for Women Infants and Children,1994:251-262.
  • State definitions and reporting requirements for live births, fetal deaths, and induced terminations of pregnancy. U.S. Department of Health and Human Services. 1997.
  • Guidelines for perinatal care, American Academy of Pediatrics, The American College of Obstetricians and Gynecologists. 5th edition, 2002.
  • Gestation and Birthweight – 2004, http://www.cdc.gov/nchs/datawh/vitalstats/VitalStatsbirths.htm Information contained in Birth Tables

Measure Algorithm:

Attach file

Related Topics

Measure Information Form PR-2
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)