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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

  1. /wiki/spaces/UCSF/pages/2090436077

  2. 2021-04-28 PP+Measure+Specification+Document_+Post-Partum+Followup+for+Contraception-EDIT.docx (sharepoint.com)

Diabetes screening for women with GDM-affected pregnancies

Refer to existing Data Dictionary

Previous Resources

  1. 2021-04-28 GDM+Measure+Specification+Document_+Post-partum+followup+for+gestational+diabetes_EDIT.docx (sharepoint.com)

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.

  1. 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.

    1. retest to show improvement (easier with PHQ-2)

  2. Follow up diagnoses of post-partum depression?

  3. Number of screens?

  • PHQ-2, PHQ-9 - most health centers probably have this already

  • Other validated tools?

  • PHQ-9 vs EDPS: Patient health questionnaire-9 versus Edinburgh postnatal depression scale in screening for major depressive episodes: a cross-sectional population-based study

    • 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)

  • 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

ACOG: https://journals.lww.com/greenjournal/fulltext/2013/11000/hypertension_in_pregnancy___executive_summary.36.aspx Nicole Ford (Unlicensed) outdated. Replace with Bulletin 203 and 222:

  1. Bulletin 203 https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/01/chronic-hypertension-in-pregnancy

  1. Bulletin 222 https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/06/gestational-hypertension-and-preeclampsia

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

ACOG: https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/06/gestational-hypertension-and-preeclampsia

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:

ACOG 2019: https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/05/pregnancy-and-heart-disease

ESC 2018: https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Cardiovascular-Diseases-during-Pregnancy-Management-of

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)

Tobacco use screening and cessation education:

  • Include tobacco screening-- can look at existing data approaches

  • 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:

  1. Postpartum Visit

  2. Transfer of Care to Primary Care Team

  • No labels

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