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Postpartum Visits
CMS Post-Partum Measure: https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_336_MIPSCQM.pdf
DENOMINATOR: All patients, regardless of age, who gave birth during a 12-month period seen for postpartum care visit before or at 8 weeks of giving birth
Denominator Criteria (Eligible Cases): All patients, regardless of age AND Patient procedure during performance period (CPT): 59400, 59410, 59430, 59510, 59515, 59610, 59614, 59618, 59622 AND Postpartum care visit before or at 8 weeks post-delivery
NUMERATOR: Patients receiving the following at a postpartum visit:
• Breast-feeding evaluation and education, including patient-reported breast-feeding
• Postpartum depression screening
• Postpartum glucose screening for gestational diabetes patients
• Family and contraceptive planning counseling
• Tobacco use screening and cessation education
• Healthy lifestyle behavioral advice
• Immunization review and update
For PP Visit definitions: Refer to existing Data Dictionary
Consider methods to look for all visits not just PP coding
Contraceptive counseling and provision
Refer to existing Data Dictionary
Previous Resources
Diabetes screening for women with GDM-affected pregnancies
Refer to existing Data Dictionary
Previous Resources
Postpartum depression and anxiety screening, referral, and treatment
ACOG guideline: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression
HEDIS measure: https://www.ncqa.org/hedis/measures/postpartum-depression-screening-and-follow-up/
The percentage of deliveries in which members were screened for clinical depression during the postpartum period, and if screened positive, received follow-up care. Two rates are reported.
Depression Screening: The percentage of deliveries in which members were screened for clinical depression using a standardized instrument during the postpartum period. [within 12 weeks of delivery?]
Follow-Up on Positive Screen: The percentage of deliveries in which members received follow-up care within 30 days of a positive depression screen finding.
retest to show improvement (easier with PHQ-2)
Follow up diagnoses of post-partum depression?
Number of screens?
“Appropriate screening at the comprehensive post-partum visit”
Screen at every visit? - varies by health center
Link to UDS measure Preventive Care and Screening: Screening for Depression and Follow-Up Plan (Line 21), CMS2v9 and Depression Remission at Twelve Months (Line 21a), CMS159v8
Validated tools for screening?
Edinburgh? (EDPS)-- short vs long
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PHQ-2, PHQ-9 - most health centers probably have this already
Other validated tools?
PHQ-9 validated longitudinally, may be becoming preferred
Not possible to map/provide equivalence scores?
Patients with prior screening in pregnancy?
High risk patients/SMI [exclude from measure]
SMI diagnosis codes?
Mood disorder diagnosis codes?
Prior history of PPMD
Addressing PP anxiety/psychosis?-- EDPS does this
Emergent treatment: active SI, psychosis – gather data? offer resources at the health centers? (link to relevant EDPS elements)
Flag positive high risk questions
Implementation approach:
Screening:
Screen in clinic- EDPS, PHQ2/9
What constitutes a positive screen? need dummy element “screen+”
Can send via patient portal
View PP screening data:
Part of postpartum note-- prepopulate screening dates and scores
Measure on OB dashboard
Follow up:
Generate a structured referral – ideally to close the loop
OR a visit with a diagnosis of PPMD
OR a behavioral health encounter with PMDD
OR a new SSRI?
Dashboard?
PPMD Denominator 1: Women with a pregnancy ending in delivery
Numerator 1: Screening for PMDD was completed
PPMD Denominator 2: Screening for PMDD was positive
Numerator 2: Follow up visit occurred (medical or behavioral health) OR referral was provided
Cardiovascular care
Hypertension:
NICE Guidelines 2019: https://www.nice.org.uk/guidance/ng133/resources/hypertension-in-pregnancy-diagnosis-and-management-pdf-66141717671365
Diagnosis and management of hypertension in pregnancy: summary of updated NICE guidance https://www.bmj.com/content/366/bmj.l5119
CMQCC: Hypertensive disorders of pregnancy toolkit https://www.cmqcc.org/resources-tool-kits/toolkits/HDP
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Bulletin 203 https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/01/chronic-hypertension-in-pregnancy
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Hypertensive disorders of pregnancy
Chronic hypertension—Hypertension that is present at the booking visit or before 20 weeks’ gestation, or if the woman is already taking antihypertensive medication when starting maternity care. It can be primary or secondary in etiology
Gestational hypertension—New hypertension presenting after 20 weeks of pregnancy without significant proteinuria
Pre-eclampsia—New onset hypertension (>140 mm Hg systolic or >90 mm Hg diastolic) after 20 weeks of pregnancy and the coexistence of one or both of the following new-onset conditions:
Proteinuria (urine protein:creatinine ratio ≥30 mg/mmol, or albumin:creatinine ratio ≥8 mg/mmol, or ≥1 g/L [2+] on dipstick testing)
Other maternal organ dysfunction, including features such as renal or liver involvement, neurological or haematological complications, or uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth)
Combination of these is possible:
Highest risk patients are combined chronic HTN and Pre-eclampsia or early Pre-eclampsia
Postpartum HTN Management: Highest impact of maternal mortality
Post-partum HTN screening and management is critical
Consider capturing in dataset all BP measurements in critical periods
Need to get data from hospital setting – look for dx and BP if possible (get data from Alliance Quality Collaborative)
Consider use of direct secure messaging (could be used for all follow up actions)
F/u on FHIR/ADT requirements from hospital discharge
HTN screening:
HTN Denominator 1: Women with pregnancy >20 weeks
HTN Numerator 2: Women with BP and urine protein screening
HTN Denominator 2: Women with chronic HTN and gestational HTN
HTN Numerator 2: High risk follow up and low dose aspirin
HTN Denominator 3: Women in high risk follow up
HTN numerator 3a: Women with BP >160/110/diagnosis of Preeclampsia, Eclampsia or HELLP
HTN numerator 3b: Women with 7 day follow up after delivery (BP check and symptom check)
(NICE 1.9): (replace with ACOG)
1.9.3 As antihypertensive agents have the potential to transfer into breast milk: • consider monitoring the blood pressure of babies, especially those born preterm, who have symptoms of low blood pressure for the first few weeks • when discharged home, advise women to monitor their babies for drowsiness, lethargy, pallor, cold peripheries or poor feeding. [2019]
1.9.4 Offer enalapril[5] to treat hypertension in women during the postnatal period, with appropriate monitoring of maternal renal function and maternal serum potassium. [2019]
1.9.5 For women of black African or Caribbean family origin with hypertension during the postnatal period, consider antihypertensive treatment with: • nifedipine[3] or • amlodipine if the woman has previously used this to successfully control her blood pressure. [2019]
1.9.6 For women with hypertension in the postnatal period, if blood pressure is not controlled with a single medicine, consider a combination of nifedipine[3] (or amlodipine) and enalapril[5] . If this combination is not tolerated or is ineffective, consider either: • adding atenolol or labetalol to the combination treatment or • swapping 1 of the medicines already being used for atenolol or labetalol. [2019]
1.9.7 When treating women with antihypertensive medication during the postnatal period, use medicines that are taken once daily when possible. [2019]
1.9.8 Where possible, avoid using diuretics or angiotensin receptor blockers[5] to treat hypertension in women in the postnatal period who are breastfeeding or expressing milk. [2010, amended 2019]
1.9.9 Treat women with hypertension in the postnatal period who are not breastfeeding and who are not planning to breastfeed in line with the NICE guideline on hypertension in adults. [2019]
Cardiovascular Disease in Pregnancy/Postpartum:
Preeclampsia:
USPSTF: Preeclampsia Guidelines
Aspirin use BPA
Hypertension on medications during L&D:
7 day follow up required-- telemed or in person with BP check and symptom screening
Postpartum Cardiomyopathy: (f/u with CMQCC)
CMQCC Cardiovascular Disease
Substance use disorder screening, referral, and treatment:
WHO Guidelines: https://www.who.int/publications/i/item/9789241548731
Screening and brief interventions
urine drug screening
current diagnosis
MEND/other screening tools
Interventions for substance use:
Psychosocial interventions for harmful use and dependence on alcohol and other substances in pregnancy
Detoxification or quitting programmes for alcohol and other substance dependence in pregnancy
Pharmacological treatment (maintenance and relapse prevention) for alcohol and other substance dependence in pregnancy
Breastfeeding?
Management of infants exposed to alcohol and other psychoactive substances?
SAMHSA Opiate Treatment in Pregnancy: https://store.samhsa.gov/sites/default/files/d7/priv/sma18-5054.pdf
CMQCC: Substance abuse toolkit
High risk category: substance abuse and dependence
pathway for care and coordination with BH, L&D
SUD Denominator 1: All pregnancies
SUD Numerator 1: Presence of SUD screening
SUD Denominator 2: Presence of SUD (high risk: SUD status)
SUD Numerator 2: Presence of follow up for SUD: referral, behavioral health, SUD counseling or treatment program
Other supporting evidence-based recommendations for postpartum care services:
Breastfeeding Support:
CDC Guide to Strategies Supporting Breastfeeding: https://www.cdc.gov/breastfeeding/pdf/bf-guide-508.pdf
CMS Exclusive Breastfeeding:
https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=2579
Denominator 1 BF: All pregnancies ending in delivery of one or more live neonate
Numerator 1 BF: Patient is exclusively BF, partially BF or not BF
Comments:
Michele Whitt (Unlicensed) Many local and state and national programs expect support for breastfeeding (WIC, etc)
Epic has a navigator section that might be usable for directing users to breastfeeding support
Elements for breastfeeding can come from the eCQM
Consider offering or tracking lactation services/consults in express lane/pp pathway
Lisa Masinter (Unlicensed) May be difficult in EHR platforms because of 1) data capture and variability 2) referrals for lactation not already part of the scope of EHR
Priority may be low to moderate
Consider a low lift approach
Need to get feedback from sites
Breastfeeding Measurement in the Outpatient Electronic Health Record (ucsdcommunityhealth.org)
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Tobacco use screening and cessation education:
Include tobacco screening-- can look at existing data approaches
UDS Table 6B, Line 14a Tobacco Use: Screening and Cessation Intervention* CMS138v9
Can pull existing data-- may be in UDS: http://bphcdata.net/docs/table_6b.pdf
Should be present in EHR
Align data elements to UDS/CMS measures
Follow up recommendations/therapy?
Utilize eCQM recommendation
Low lift approach-- can capture the data to get background, could reuse existing CDS/recommendation from non-pregnant patients
Healthy lifestyle behavioral advice
Need to define?-- diet/exercise generally
Does this add value?
Could put a check box in or could refer to a site for education/support
Immunization review and update
HEDIS Prenatal immunization quality measure: https://www.ncqa.org/hedis/measures/prenatal-immunization-status/
The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) recommends influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccines for pregnant women to protect them and their infants from serious illness and death.
Presume review done during pregnancy for prenatal immunizations
Ideally would trigger missing vaccinations that are NOT recommended in prenatal timeframe
Low priority but could gather immunization data/history review
Consider COVID/flu vaccination status review
High Risk Categories
separate maternal and fetal risk?
Outcomes: referrals, high risk management,
Pre-existing Medical Conditions:
Heme
Onc
CV
Pulm HTN
Pulm
Diabetes
Substance Abuse
ID
Risk of Developing Complications:
Antepartum anemia
HIV
Unvaccinated
SDOH and ACES
High risk category:
SDOH screening positive?
SDOH screening for all patients in pregnancy?
Referral pathway
F/u on PRAPARE, SDOH data elements (see data dictionary)
Recognition and treatment of postpartum anemia
High risk category: anemia in the antepartum period
Fever/infection: less focus on outpatient setting
Outcomes:
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Postpartum Visit
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Updated Measures will be located here when completed. Draft version is available here.
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