Release Notes:
Measure Information Form
Version 2010B
**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**Measure Information Form
Measure Set: Pregnancy and Related Conditions (PR)
Set Measure ID: PR-3
Performance Measure Name: Third or Fourth Degree Laceration
Description: Patients who have vaginal deliveries with third or fourth degree perineal laceration.
Rationale: Third and fourth degree perineal lacerations can produce significant long-term morbidity in women undergoing childbirth. Chronic complications can include anorectal abscess, rectovaginal fistula, fecal incontinence, dyspareunia and can result in the need for operative surgical repair. Therefore, the percentage of deliveries involving third and fourth degree lacerations is a useful quality indicator of obstetrical care and can assist in reducing the morbidity from extensive perineal tears.
Type of Measure: Outcome
Improvement Noted As: Decrease in the rate
Numerator Statement: All patients with third or fourth degree perineal laceration
Included Populations:
Discharges with:
- An ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for third or fourth degree perineal laceration as defined in Appendix A, Table 4.05
Excluded Populations: None
Data Elements:
Denominator Statement: All patients with vaginal deliveries.
Included Populations:
Discharges with:
- An ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for pregnancy with delivery as defined in Appendix A, Table 4.01, 4.02, 4.03, and 4.04
Excluded Populations:
- Patients less than 8 years of age
- Patients greater than or equal to 65 years of age
- Patients who have a Length of Stay >120 days
- Patients enrolled in clinical trials
- Patients with an ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for cesarean section, as defined in Appendix A, Table 4.07
- Patients with an ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for abortion, as defined in Appendix A, Table 4.06
Data Elements:
Continuous Variable Statement:
Included Populations:
Excluded Populations:
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 medical records.
Data Accuracy: * Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency
- This measure is solely derived from ICD-9-CM codes, therefore accurate and thorough coding of all conditions and procedures is essential for reporting of this measure
- 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 is recommended that the performance measurement system should provide the health care organizations the ability to see their measure rates separated by third and fourth degree laceration for quality improvement purposes.
Sampling: Yes. For additional information see the Sampling Section.
Data Reported As: Aggregate rate generated from count data reported as a proportion.
Selected References:
- Ecker J.L., et al: Is there a benefit to episiotomy at operative vaginal delivery? observations over ten years in a stable population. Am J Obstet Gyenecol, 1997: Vol.176:411-414.
- Golden W.E., Sanchez N.: The relationship of episiotomy to third and fourth degree lacerations. J of Arkansas Med Soc, 1996: Vol.92:447-448.
Measure Algorithm:
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