Pregnancy and Related Conditions (PR)

Set Measures

Set Measure ID	Measure Short Name
PR-1	VBAC
PR-2	Inpatient Neonatal Mortality
PR-3	Third or Fourth Degree Laceration

General Data Elements

Element Name	Collected For
Birthdate	All Records,
Discharge Date	All Records, (used in algorithm for AMI-1, AMI-6, PN-1, PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, PN-7, PR-2, SCIP-Inf-4, SCIP-VTE-1, SCIP-VTE-2)
Discharge Status	All Records, (used in algorithm for AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, AMI-6, AMI-9, AMI-T1a and AMI-T2 [CMS Optional Test Measures], CAC-3 [Joint Commission Test Measure], All HF Measures, All PN Measures, PR-2)
First Name	All Records, CMS Only,
Hispanic Ethnicity	All Records, CMS Only,
Hospital Patient Identifier	All Records, CMS Only, NOTE: Refer to the Hospital Clinical Data XML File Layout in the Transmission section of this manual.
Last Name	All Records, CMS Only,
Patient HIC#	All Records, CMS Only, Collected by CMS for patients with a Payment Source - Medicare who have a standard HIC number.
Physician 1	All Records, Optional for All Records, (CMS Optional Element)
Point of Origin for Admission or Visit	All Records, (used in algorithm for AMI-1, AMI-6, AMI-7, AMI-7a, AMI-8, AMI-8a, AMI-9, PN-1, PN-3a, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b
Postal Code	All Records, CMS Only,
Race	All Records, CMS Only,

Algorithm Output Data Elements

Element Name	Collected For
Measure Category Assignment	Joint Commission Only, Calculation, Transmission, Hospital Clinical Data File

Measure Set Specific Data Elements

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Pregnancy and Related Conditions (PR) Initial Patient Population

The PR measure set is unique in that there are two distinct Initial Patient Populations within the measure set, mothers and neonates.

Mothers
The population of the PR-Mother measures (PR-1 and PR-3) are identified using 4 data elements:

• ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes
• Admission Date
• Birthdate
• Discharge Date

Patients with an ICD-9-CM Principal or Other Diagnosis Code as defined in Appendix A, Tables 4.01, 4.02, 4.03, or 4.04, a Patient Age (Admission Date – Birthdate) >= 8 years and < 65 years, and a Length of Stay (Discharge Date - Admission Date) <= 120 days are included in the PR-Mother Initial Patient Population and are eligible to be sampled*.

Neonates
The population of the PR-Neonate measure (PR-2) is identified using 3 data elements:

• Admission Date
• Birthdate
• Discharge Date

Patients with a Neonate Patient Age at admission (Admission Date – Birthdate) < 28 days and a Length of Stay (Discharge Date - Admission Date) <= 120 days are included in the PR-Neonate Initial Patient Population and are eligible to be sampled.

• View the PR Initial Population Algorithm

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Sample Size Requirements

Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may choose to use a larger sample size than is required. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter/month for the sub-population cannot sample that sub-population.

Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Because the sample for a measure set will rarely be equal to the effective sample due to exclusions and contraindications, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size.

The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual.

Quarterly Sampling

A modified sampling procedure is required for hospitals performing quarterly sampling for PR. Hospitals selecting sample cases must ensure that each individual sub-population Initial Patient Population and effective sample size meet the following conditions:

• Select within the two individual measure sub-populations (mothers and babies). The effective sample size within a sub-population at least 35 cases per quarter; and
• The required sample size is at least 20% of the sub-population’s Initial Patient Population for the quarter.

Quarterly Sample Size
Based on Initial Patient Population for the PR Measure Set

Hospital's Measures
Average Quarterly Initial Patient Population “N”	Minimum Required Sample Size “n”
>= 1246	250
311 – 1245	20% of the Initial Patient Population
62 – 310	62
< 62	No sampling; 100% of the Initial Patient Population is required

Monthly Sampling

A modified sampling procedure is required for hospitals performing monthly sampling for PR. Hospitals selecting sample cases must ensure that each individual sub-population Initial Patient Population and effective sample size meet the following conditions:

• Select within the two individual measure sub-populations (mothers and babies). The effective sample size within a sub-population at least 12 cases per month; and
• The required sample size is at least 20% of the sub-population’s Initial Patient Population for the month.

Monthly Sample Size
Based on Initial Patient Population for the PR Measure Set

Hospital's Measures
Average Monthly Initial Patient Population “N”	Minimum Required Sample Size “n”
>= 416	84
106 – 415	20% of the Initial Patient Population
21 – 105	21
< 21	No sampling; 100% of the Initial Patient Population is required

Sample Size Examples

Note: In order to take advantage of data collection efficiencies, one available sampling option for the PR core measure set is to collect data on the entire population for PR-1 and PR-3 (mother records), and select a sample for PR-2 (baby records). This option will allow hospitals to reduce their data collection burden for PR-2, which may require some medical record abstraction, while encouraging 100% data collection for measures that may be derived entirely from administrative data sources (PR-1 and PR-3).

• Quarterly sampling:
  • A hospital’s Initial Patient Population size for the PR-Mothers is 400 and 451 for PR-Babies for the second quarter. The hospital chooses to sample 100% of their mothers, or all 400 cases. However, the hospital desires to sample fewer baby cases. The 451 quarterly Initial Patient Population Size for the babies requires a 20% sample size, or 91 baby cases (twenty percent of 451 equals 90.2 rounded to the next highest whole number = 91). In total, the hospital will sample 400 mother cases (100%) and 91 baby cases (20%), for a total of 491 cases.
  • A hospital’s Initial Patient Population size for the PR-Mothers is 1255 and 1260 for PR-Babies for the third quarter. The hospital chooses to sample both sub-populations. The required sample of each sub-population is 250 cases. That is 250 mothers and 250 babies for a total of 500 cases.
• Monthly sampling
  • The PR-2 Initial Patient Population size for a hospital has been 50 newborns per month during the past year. The required monthly sample size would be 21 newborns per month.
  • A hospital’s Initial Patient Population size for the PR-Mothers is 106 and 106 for PR-Babies for July. The hospital chooses to sample 100% of their mothers, or all 106 cases. However, the hospital desires to sample fewer baby cases. The 106 monthly Initial Patient Population Size for the babies requires a 20% sample size, or 22 baby cases (twenty percent of 106 equals 21.2 rounded to the next highest whole number = 22). In total, the hospital will sample 106 mother cases (100%) and 22 baby cases (20%), for a total of 128 cases.