Joint Commission to Publicly Report Health Systems with High Cesarean Delivery Rates

In a recent blog post, Executive Vice President David Baker, MD of Health Care Quality Evaluation at the Joint Commission, announced that public reporting of high cesarean rates is slated to begin by July 1, 2020. 

Why now? Previous attempts by the Joint Commission to get hospitals to reduce cesarean delivery rates have not been successful.  Even with PC-02 rate reporting, which began in 2010, cesarean delivery rates among reporting hospitals have remained around 26 percent without evidence of reduction [1].

Additionally, the media has become aware of both consumer and payer concerns over potentially unnecessary cesarean deliveries.  The current national focus on maternal morbidity and mortality has shed light on the connection between cesarean delivery and increased post-partum complications, driving both consumers and payers to re-evaluate their safety and necessity.  A recent Consumer Reports (2018) article discusses the “danger of unnecessary C-sections” and encourages readers to investigate their local hospitals cesarean delivery rates and make an informed decision about where they choose to deliver. Cesarean delivery can serve a critical need, but the varying rates of cesarean delivery suggest that some may not be medically necessary. Cesarean delivery rates are an important quality issue for patients and maternity clinicians alike.

What measurement will they be using? The Joint Commission will use the following three criteria to determine a hospital’s PC-02 rating:

1. ≥30 cases reported in both years

2. PC-02 rate >30% for the current year

3. Overall two-year average PC-02 rate >30%

Hospitals will be identified on Quality Check, Joint Commission’s online reporting platform, with either a plus (+) or minus (-) symbol for the PC-02 measure.

·       The plus (+) symbol will signify that the hospital has an acceptable rate.

·       A minus (-) symbol will signify that the hospital’s rate is consistently high and has a large enough sample size to make this determination.

Note: 2018 and 2019 data will be used for the Joint Commission’s initial release.

Michigan hospitals’ PC-02 rates The state of Michigan currently has 80 hospitals that offer maternity care services. On average 17 of those hospitals are below the Healthy People 2020 recommended rate of 23.9% [2]. Between 2017 and 2018, approximately 23 of the 80 Michigan maternity hospitals had NTSV Cesarean Delivery rate equal to or greater than 30% .  Based on the Joint Commission’s July 2020 reporting, these hospitals’ PC-02 rates would be reported. An additional 17 hospitals had a 2017-2018 average NTSV Cesarean Delivery rate between 27% - 29.9%, putting them at high risk for fluctuations that may put them within the reporting range [3].

How can hospitals work to improve their rates? The Joint Commission encourages hospitals to engage in state-wide quality improvement collaborative such as the California Maternal Quality Care Collaborative (CMQCC), Reducing Primary Cesareans, and the Obstetrics Initiative (OBI), as well as modeling best practices after existing tools made available by organizations such as Alliance for Innovation on Maternal Heath (AIM).   

As of August 2019, 74 of Michigan’s 80 maternity hospitals are participating in the Obstetrics Initiative (OBI). OBI is a statewide data-driven quality improvement project working to support vaginal delivery and safely reduce the use of cesarean delivery among low risk births in Michigan. There are a number of ways to safely reduce the primary cesarean delivery rate. OBI’s strategy supports the implementation of one of two evidence-based options to optimize care and support in the first stage of labor by focusing on the management of latent labor and arrest disorders for women at low risk for cesarean delivery. Over the past three decades, evidence indicates that women admitted to the hospital during traditionally defined labor (<4cm) have a significantly higher risk of delivering by way of cesarean delivery than women who are admitted during active labor. Delaying admission until active labor can lead to 672,000 fewer epidurals, 67,232 fewer cesarean deliveries, 9.6 fewer maternal deaths, and an annual cost savings of $694 million [4].

What about unintended consequences? While the Joint Commission recognizes that lower is not always better when it comes to cesarean delivery rates, recent literature has shown that large scale quality improvement efforts to reduce rates, when conducted using national guidelines, do not increase poor infant or maternal outcomes [5].  To provide more concrete safety data, the Joint Commission also began collecting the PC-06, Unexpected Complications in Term Newborns, measure in January, 2019.  PC-06 will serve as a balancing measure to inform quality improvement progress at the hospital level [2].

The OBI Data Registry is being developed to create obstetric reports with reliable, actionable data to identify opportunities for quality improvement in maternal and neonatal outcomes and focus on effectiveness of care. OBI is working toward cesarean delivery rates with improved or stable rates of maternal and neonatal morbidity.