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  • Measure Summary
  • NQMC:005543

Maternity care: vaginal birth after Cesarean (VBAC) delivery rate, uncomplicated.

AHRQ quality indicators. Guide to inpatient quality indicators: quality of care in hospitals - volume, mortality, and utilization [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 91 p.
AHRQ quality indicators. Inpatient quality indicators: technical specifications [version 4.2]. IQI #22 vaginal birth after Cesarean delivery rate, uncomplicated. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2010 Sep. 2 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates previous versions:

  • AHRQ quality indicators. Guide to inpatient quality indicators: quality of care in hospitals -- volume, mortality, and utilization [version 3.0]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006 Feb 20. 99 p.
  • AHRQ quality indicators. Inpatient quality indicators: technical specifications [version 4.1]. IQI #22 vaginal birth after Cesarean delivery rate, uncomplicated. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2009 Dec 1. 2 p.

Primary Measure Domain

Use of Services

The validity of measures depends on how they are built. By examining the key building blocks of a measure, you can assess its validity for your purpose. For more information, visit the Measure Validity page.

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the number of provider-level vaginal births per 100 discharges with a diagnosis of previous Cesarean delivery.

Selection bias due to patient preferences and other factors may impact performance on this indicator. Supplemental adjustment with linked birth records or other clinical data may be desirable to address bias from clinical differences not identifiable in administrative data.

Rationale

About 30% of personal health care expenditures in the United States go towards hospital care, and the rate of growth in spending for hospital services has only recently leveled out after several years of increases following a half a decade of declining growth. Simultaneously, concerns about the quality of health care services have reached a crescendo with the Institute of Medicine's series of reports describing the problem of medical errors and the need for a complete restructuring of the health care system to improve the quality of care. Policymakers, employers, and consumers have made the quality of care in U.S. hospitals a top priority and have voiced the need to assess, monitor, track, and improve the quality of inpatient care.

The policy of recommending vaginal birth after Cesarean (VBAC) delivery represents to some degree a matter of opinion on the relative risks and benefits of a trial of labor in patients with previous Cesarean delivery. VBAC has been identified as a potentially underused procedure.

The best rate for VBAC has not been established. This indicator should be used in conjunction with area rates, national rates, and complication rates (maternal uterine rupture and length of stay, neonatal length of stay) to assess whether a rate is truly too high or too low.

Note:

The following caveats were identified from the literature review for the "Vaginal Birth After Cesarean Mortality Rate, Uncomplicated" indicator:

  • Selection biasb: This results when a substantial percentage of care for a condition is provided in the outpatient setting, so the subset of inpatient cases may be unrepresentative. Examination of outpatient care or emergency care data may help to reduce this in these cases.
  • Confounding biasa: Patient characteristics may substantially affect the performance of the indicator; risk adjustment is recommended.
  • Unclear constructa: There is uncertainty or poor correlation with widely accepted process measures.
  • Unclear benchmarka: The "correct rate" has not been established for the indicator; national, regional, or peer group averages may be the best benchmark available.

Refer to the original measure documentation for further details.

a - The concern is theoretical or suggested, but no specific evidence was found in the literature.

b - Indicates that the concern has been demonstrated in the literature.

Primary Clinical Component

Maternity care; vaginal birth after Cesarean (VBAC) delivery

Denominator Description

All deliveries with a previous Cesarean delivery diagnosis in any diagnosis field

Exclude cases:

  • Any diagnosis of abnormal presentation, preterm, fetal death, multiple gestation diagnosis codes
  • Breech procedure codes

Note: Refer to the Technical Specifications document for specific International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, Diagnosis-Related Groups (DRGs) and Medicare Severity DRGs (MS-RGs).

Numerator Description

Number of vaginal births in women among cases meeting the inclusion and exclusion rules for the denominator

Note: Refer to the Technical Specifications document for specific Diagnosis-Related Groups (DRGs) and Medicare Severity DRGs (MS-DRGs).

Evidence Supporting the Value of Monitoring Use of Service

One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Need for the Measure

Monitoring and planning

Variation in use of service

Evidence Supporting Need for the Measure

AHRQ quality indicators. Guide to inpatient quality indicators: quality of care in hospitals - volume, mortality, and utilization [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 91 p.

State of Use

Current routine use

Current Use

External oversight/State government program

Monitoring and planning

Care Setting

Hospitals

Professionals Responsible for Health Care

Physicians

Lowest Level of Health Care Delivery Addressed

Single Health Care Delivery Organizations

Target Population Age

Unspecified

Target Population Gender

Female (only)

Stratification by Vulnerable Populations

Unspecified

Source(s)

AHRQ quality indicators. Guide to inpatient quality indicators: quality of care in hospitals - volume, mortality, and utilization [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 91 p.

AHRQ quality indicators. Inpatient quality indicators: technical specifications [version 4.2]. IQI #22 vaginal birth after Cesarean delivery rate, uncomplicated. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2010 Sep. 2 p.

Incidence/Prevalence

Unspecified

Association with Vulnerable Populations

Unspecified

Burden of Illness

Unspecified

Utilization

Unspecified

Costs

Unspecified

IOM Care Need

Not within an IOM Care Need

IOM Domain

Not within an IOM Domain

Case Finding

Users of care only

Description of Case Finding

All deliveries with a previous Cesarean delivery (see the "Denominator Inclusions/Exclusions" field)

Denominator Sampling Frame

Patients associated with provider

Denominator Inclusions/Exclusions

Inclusions
All deliveries with a previous Cesarean delivery diagnosis in any diagnosis field

Exclusions
Exclude cases:

  • Any diagnosis of abnormal presentation, preterm, fetal death, multiple gestation diagnosis codes
  • Breech procedure codes

Note: Refer to the Technical Specifications document for specific International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, Diagnosis-Related Groups (DRGs) and Medicare Severity DRGs (MS-RGs).

Relationship of Denominator to Numerator

All cases in the denominator are not equally eligible to appear in the numerator

Denominator (Index) Event

Clinical Condition

Institutionalization

Therapeutic Intervention

Denominator Time Window

Time window brackets index event

Numerator Inclusions/Exclusions

Inclusions
Number of vaginal births in women among cases meeting the inclusion and exclusion rules for the denominator

Note: Refer to the Technical Specifications document for specific Diagnosis-Related Groups (DRGs) and Medicare Severity DRGs (MS-DRGs).

Exclusions
Unspecified

Measure Results Under Control of Health Care Professionals, Organizations and/or Policymakers

The measure results are somewhat or substantially under the control of the health care professionals, organizations and/or policymakers to whom the measure applies.

Numerator Time Window

Institutionalization

Data Source

Administrative data

Level of Determination of Quality

Does not apply to this measure

Pre-existing Instrument Used

Unspecified

Scoring

Rate

Interpretation of Score

Undetermined

Allowance for Patient Factors

Analysis by subgroup (stratification on patient factors, geographic factors, etc.)

Description of Allowance for Patient Factors

Observed (raw) rates may be stratified by hospitals, age groups, race/ethnicity categories, and payer categories.

Risk adjustment by age is recommended.

Application of multivariate signal extraction (MSX) to smooth risk adjusted rates is also recommended.

Standard of Comparison

External comparison at a point in time

External comparison of time trends

Internal time comparison

Extent of Measure Testing

Each potential quality indicator was evaluated against the following six criteria, which were considered essential for determining the reliability and validity of a quality indicator: face validity, precision, minimum bias, construct validity, fosters real quality improvement, and application. The project team searched Medline for articles relating to each of these six areas of evaluation. Additionally, extensive empirical testing of all potential indicators was conducted using the 1995-97 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) and Nationwide Inpatient Sample (NIS) to determine precision, bias, and construct validity. Table 2 in the original measure documentation summarizes the results of the literature review and empirical evaluations on the Inpatient Quality Indicators. Refer to the original measure documentation for details.

Evidence for Reliability/Validity Testing

AHRQ quality indicators. Guide to inpatient quality indicators: quality of care in hospitals - volume, mortality, and utilization [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 91 p.

Original Title

IQI #22 vaginal birth after Cesarean rate, uncomplicated.

Measure Collection Name

Agency for Healthcare Research and Quality (AHRQ) Quality Indicators

Measure Set Name

Inpatient Quality Indicators

Submitter

Agency for Healthcare Research and Quality

Developer

Agency for Healthcare Research and Quality

Funding Source(s)

Agency for Healthcare Research and Quality (AHRQ)

Composition of the Group that Developed the Measure

The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators are in the public domain and the specifications come from multiple sources, including the published and unpublished literature, users, researchers, and other organizations. AHRQ as an agency is responsible for the content of the indicators.

Financial Disclosures/Other Potential Conflicts of Interest

None

Adaptation

Vaginal birth after Cesarean was included in the original Healthcare Cost and Utilization Project Quality Indicator (HCUP QI) set.

Parent Measure

Successful vaginal birth after Cesarean delivery (Agency for Healthcare Research and Quality)

Release Date

2004 Jul

Revision Date

2010 Sep

Measure Status

This is the current release of the measure.

This measure updates previous versions:

  • AHRQ quality indicators. Guide to inpatient quality indicators: quality of care in hospitals -- volume, mortality, and utilization [version 3.0]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006 Feb 20. 99 p.
  • AHRQ quality indicators. Inpatient quality indicators: technical specifications [version 4.1]. IQI #22 vaginal birth after Cesarean delivery rate, uncomplicated. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2009 Dec 1. 2 p.

Measure Availability

The individual measure, "IQI #22 Vaginal Birth After Cesarean Rate, Uncomplicated," is published in "AHRQ Quality Indicators. Guide to Inpatient Quality Indicators: Quality of Care in Hospitals -- Volume, Mortality, and Utilization" and "AHRQ Quality Indicators. Inpatient Quality Indicators: Technical Specifications." These documents are available in Portable Document Format (PDF) from the Inpatient Quality Indicators Resources External Web Site Policy page at the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Web site.

For more information, please contact the QI Support Team at support@qualityindicators.ahrq.gov.

Companion Documents

The following are available:

  • AHRQ quality indicators. Inpatient quality indicators: software documentation, SAS [version 4.2]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2010 Sep. 41 p. This document is available in Portable Document Format (PDF) from the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Web site External Web Site Policy.
  • AHRQ quality indicators. Software documentation: Windows [version 4.1a]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2010 Jul 2. 97 p. This document is available in PDF from the AHRQ Quality Indicators Web site External Web Site Policy.
  • AHRQ quality indicators. Inpatient quality indicators composite measure workgroup. Final report. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Mar. various p. This document is available in PDF from the AHRQ Quality Indicators Web site External Web Site Policy.
  • UCSF-Stanford Evidence-based Practice Center. Davies GM, Geppert J, McClellan M, et al. Refinement of the HCUP quality indicators. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2001 May. 24 p. (Technical review; no. 4). This document is available in PDF from the AHRQ Quality Indicators Web site External Web Site Policy.
  • AHRQ quality indicator. Comparative data for the IQI based on the 2008 Nationwide Inpatient Sample (NIS) [version 4.1b]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2010 Sep. 20 p. This document is available in PDF from the AHRQ Quality Indicators Web site External Web Site Policy.
  • AHRQ quality indicator. Risk adjustment coefficients for the IQI [version 4.2]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2010 Sep. 20 p. This document is available in PDF from the AHRQ Quality Indicators Web site External Web Site Policy.
  • AHRQ quality indicators. Composite measures user guide for the inpatient quality indicators (IQI) [version 4.2]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2010 Sep. 6 p. This document is available in PDF from the AHRQ Quality Indicators Web site External Web Site Policy.
  • HCUPnet: a tool for identifying, tracking, and analyzing national hospital statistics. [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [accessed 2011 May 24]. HCUPnet is available from the AHRQ Web site External Web Site Policy. See the related QualityTools External Web Site Policy summary.

NQMC Status

This NQMC summary was completed by ECRI on February 3, 2006. The information was verified by the measure developer on March 6, 2006. This NQMC summary was updated by ECRI Institute on May 29, 2007, on October 20, 2008 and again on August 27, 2010. This NQMC summary was reviewed and edited by ECRI on July 13, 2011.

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