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CVD Risk Assessment Measure - Proportion of pregnant/postpartum patients who receive CVD Risk Assessment with a standardized tool.

CBE ID
4360
1.4 Project
Initial Recognition and Management
Endorsement Status
Not Endorsed
E&M Committee Rationale/Justification

Not Endorsed due to No Consensus

1.1 New or Maintenance
New
Previous Endorsement Cycle
Spring 2024
Is Under Review
No
1.3 Measure Description

The University of California, Irvine (UCI) implemented and tested a CVD risk assessment tool that immediately identifies patients who are at increased risk for CVD or developing CVD. This tool can be integrated into the electronic health record (EHR) system. 

 

The population includes all patients who have a prenatal or postpartum visit at a healthcare facility or hospital network office; this includes pregnant and postpartum minors. The denominator in the CVD Risk Assessment Measure is all patients seen for pregnancy or postpartum care at a healthcare facility or hospital network. A hospital network includes Labor and Delivery (L&D), outpatient care in hospitals or at affiliated clinics, and private providers contracted with hospitals for delivery. The measure excludes patients who have another reason for visiting a clinic [not prenatal or postpartum care] and have a positive pregnancy test but plan to terminate the pregnancy or seek prenatal services elsewhere. 

 

This measure determines the percentage of pregnant or postpartum patients at a given clinic who were assessed for CVD risk with a standardized tool, such as the CVD risk assessment algorithm developed by the California Maternal Quality Care Collaborative (CMQCC). The aim is to perform CVD risk assessment using a standardized tool on all (100 %) eligible pregnant/postpartum patients.  All patients should be assessed for CVD risk at least once during their pregnancy and, if needed, additional times when new symptoms present during the pregnancy and/or postpartum period. A threshold has still to be determined (“at least xxx % of patients who received risk assessment”). The measure can be calculated on a quarterly or annual basis.

    • 1.5 Measure Type
      Process
      1.6 Composite Measure
      No
      1.7 Electronic Clinical Quality Measure (eCQM)
      No
      1.8 Level Of Analysis
      Clinician: Group/Practice
      Clinician: Individual
      1.9 Care Setting
      Birthing Center
      Clinician Office/Clinic
      Emergency Department
      Hospital: Inpatient
      Hospital: Outpatient
      Urgent Care - Ambulatory
      1.10 Measure Rationale

      Cardiovascular disease (CVD) is a leading cause of maternal mortality in the United States, responsible for over one-third of pregnancy-related deaths. Misdiagnosis of CVD is expected due to similar symptoms caused by pregnancy. Hence, it is crucial to identify pregnant and postpartum people at risk for CVD disease and/or with previously unknown CVD with a standardized risk assessment. Monitoring of these patients and timely interventions contribute to the prevention and mitigation of CVD-related complications and mortality. The proposed measure will allow clinicians to gauge the extent to which they use a standardized tool in their clinic practice and inform interventions to encourage its use.

      1.11 Measure Webpage
      https://sites.uci.edu/cvdriskassessmentmeasures/
      1.20 Testing Data Sources
      Electronic Health Records
      Paper Patient Medical Records
      1.25 Data Sources

      The California Maternal Quality Care Collaborative (CMQCC) developed a CVD risk assessment tool that guides stratification and initial evaluation of symptomatic or high-risk pregnant or postpartum patients. This is currently (May 2024) the only standardized tool to identify pregnant and postpartum patients who are at risk for CVD.  The acceptability of the tool is further strengthened by the support it has received from ACOG, and its inclusion in the CVD bundle by the Alliance for Innovation for Maternal Health.

      The tool is integrated into EPIC and Cerner electronic health records, and all data can be retrieved from the EHR. For facilities that do not have electronic health record systems or patient volumes to warrant the inclusion of the tool in the EHR system, the tool can be administered on a hardcopy and the score calculated manually.  Facilities who administer the tool manually, can monitor follow up of patients with positive risk assessment in an excel file. 

    • 1.14 Numerator

      The percentage of all pregnant and postpartum patients who received a CVD risk assessment with a standardized tool

      1.14a Numerator Details

      Pregnant and postpartum patients who receive risk assessment for CVD risk via a standardized risk assessment tool. Currently the only available tool is that developed by the California Maternal Quality Care Collaborative (CMQCC). A completed CVD risk assessment using the tool will have a calculated risk score and clinician signature (group E “Cardiovascular Screening Completed” in the CPT-ICD 10 Code Book).  Patients receive CVD risk assessed at their first or the subsequent contact with the provider for pregnancy-related care (prenatal visit, L&D, postpartum visit). The measure can be calculated quarterly or annually. For the complete list of CVD confirmation CPT codes, refer to the Excel attachment “CPT – ICD 10 Code Book.” 

    • 1.15 Denominator

      All patients receiving prenatal care and postpartum care at a given clinic, hospital, healthcare network, or private practice (group B “Pregnant and Postpartum Office Visit” in the CPT-ICD 10 Code Book). Any person who is receiving antepartum or postpartum care in a healthcare system should undergo risk assessment. 

      1.15a Denominator Details

      Any patient who is pregnant or postpartum who attends a pregnant or postpartum clinic visit at any participating site should undergo a risk assessment.

       

      Patients (a) who have an office visit for prenatal or postpartum care at the intervention site (regardless of gestational age or prior prenatal care at other sites), (b) Any age (including pregnant and postpartum minors), (c) Outpatient OB visit at the hospital or in affiliated clinics; Labor and Delivery including private providers contracting with the hospital for delivery. The measure can be calculated annually or quarterly, depending on the patient volume.

    • 1.15b Denominator Exclusions

      Patients who have a reason other than ongoing pregnancy care for visiting the clinic (Group C).

      1.15c Denominator Exclusions Details

      Patients who have another reason for visiting the clinic [not prenatal or postpartum care] and have a positive pregnancy test but have not established the clinic as OB provider (plan to terminate the pregnancy or seek prenatal services elsewhere).

    • OLD 1.12 MAT output not attached
      Attached
      1.13 Attach Data Dictionary
      CPT-ICD 10 CodeBook_0.xlsx
      1.13a Data dictionary not attached
      No
      1.16 Type of Score
      Rate/proportion
      1.17 Measure Score Interpretation
      Better quality = Higher score
      1.18 Calculation of Measure Score

      Denominator: All patients who have an outpatient or inpatient visit for pregnancy, labor and delivery, or postpartum care receive a risk assessment for CVD at the first or subsequent encounter with the health care system or clinic. The measure can be calculated for clinician group/practices and individual clinicians regardless of their patient volume (Group A Pregnancy episode,  Group B prenatal or postpartum office visit in codebook, and Group C Exclusion Criteria for Risk Assessment)

       

      Numerator: The numerator for this measure is patients who receive a score to be at risk for CVD using a validated tool. If a patient is found to be at risk, the algorithm provides the clinician with a set of potential referrals for tests and cardiovascular consults (a sidebar with a Smartset in the electronic health record or a handout). (Group E: Cardiovascular Risk Assessment Completed)

       

      Measure Reporting: The data on individual patients can be aggregated by the EHR reporting system and be requested by the medical director on a regular basis for the site and quality improvement activities. 

      Time and Period of Data: Depending on the patient volume, the measure can be calculated on an annual or a quarterly basis for public reporting purposes.

       

      Data extraction for public reporting purposes: The IT department extracts the number of eligible patients (Medical Record Number, visit date, denominator) and the number of patients who received a risk assessment (Date risk assessment was completed, numerator). 

      1.19 Measure Stratification Details

      While not part of the measure, facilities may decide to extract data by subgroups, such as clinic site, clinician, race/ethnicity of mother, insurance, gestational age, date of birth of infant (to identify whether the assessment was completed during pregnancy or postpartum).

      1.26 Minimum Sample Size

      N/A

    • Steward
      University of California, Irvine
      Measure Developer Secondary Point Of Contact

      Heike Thiel de Bocanegra
      University of California, Irvine
      3800 West Chapman Avenue, Suite 3400
      Orange, CA 92868
      United States

    • 2.1 Attach Logic Model
      Conceptual Framework_0.pdf
      2.2 Evidence of Measure Importance

      Cardiovascular disease (CVD) is the leading cause of maternal mortality in the United States, accounting for over one-third of all pregnancy-related deaths.1 Peripartum cardiomyopathy (PPCM) constitutes the largest group among CVD-related deaths. Twenty-four percent of ALL CVD pregnancy-related deaths (and 31% of cardiomyopathy deaths) were determined to be potentially preventable. 2CVD also accounts for many-fold higher maternal morbidity, a longer length of hospital stays, intensive care unit (ICU) admissions, and future pregnancy risks.3 Racial/ethnic disparities in pregnancy-related mortality have also been well established.4, 5, African American patients exhibit 3-12 times higher mortality 1, 6, 7 as they are more likely to have pre-existing CVD,3 hypertensive disorders of pregnancy 3, 5 and peripartum cardiomyopathy (PPCM) 5,8 when compared to patients from other racial /ethnic groups. The diagnostic challenge lies in the similarity between pregnancy-induced hemodynamic symptoms and those of CVD, leading to frequent misdiagnoses. A structured, standardized CVD risk assessment tool is imperative. Such an assessment, particularly during the maiden encounter with an obstetrics provider, promises to diminish CVD-related morbidity and mortality rates.

      CVD risk factors like high blood pressure or comorbidities lead to the development of CVD later in life, including but not limited to preeclampsia, hypertensive disorders, and metabolic disorders.9 There is a need to establish standardized CVD risk assessment tools to triage pregnant and postpartum patients and provide options for appropriate follow-up. This population-wide risk assessment is likely to reduce CVD-related morbidity and mortality, particularly among African American patients. Use of this measure improves the accurate diagnosis of heart failure rather than attributing symptoms of persistent cough and shortness of breath, and bilateral infiltrates on chest X-ray to pneumonia or pregnancy. 

       

      Pregnant and postpartum patients who die from CVD represent the most extreme consequence of missed or delayed recognition of CVD. Accordingly, any triage algorithm should be able to detect the most serious cases and not return a ‘false negative’ assessment in a patient with underlying CVD. To assess how well the triage algorithm would have identified pregnant and postpartum patients with the most need of further work-up, the authors compared the 64 cardiovascular disease deaths identified by CA-PAMR for 2002-2006, using the seven critical risks and abnormalities, including heart rate, systolic blood pressure, respiration rate, oxygen saturation, tachypnea, cough, and wheezing. The analysis found that the use of the algorithm would have identified 56 out of 64 (88%) cases of CVD.1 The proportion of patients identified increased to 93% when the authors restricted comparison to the 60 cases of patients who were symptomatic or had sufficient documentation with which to compare to the algorithm.1

       

      To address these issues, CMQCC, together with the California Department of Public Health: Maternal, Child and Adolescent Health Division, published the Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum Toolkit in 2017.2 The California Maternal Quality Care Collaborative (CMQCC) developed a CVD risk assessment algorithm, that guides stratification and initial clinical evaluation of symptomatic or high-risk pregnant or postpartum patients. The toolkit includes a risk assessment algorithm, which guides the stratification and initial evaluation of symptomatic or high-risk pregnant or postpartum patients. The algorithm risk stratifies patients using 18 parameters, including the patient’s history, abnormal symptoms, vital signs, and physical examination findings to identify patients who warrant further cardiac workup. The CMQCC tool is based on the clinical presentation and quality improvement opportunities identified in CVD related maternal deaths and was implemented and evaluated at major hospital systems.2,10

       

      Reports using the CMQCC cardiovascular risk assessment algorithm and other methodologies using physical examination and electrocardiograms as screening tests for CVD detection in pregnant patients have been published to identify pregnant patients at increased risk of CVD. 11-14 Most of the existing literature focuses on postpartum CVD risk assessment in patients with adverse pregnancy outcomes as a surrogate for future CVD.15

       

      The CMQCC Cardiovascular Disease in Pregnancy toolkit also includes resources for providers, infographics for patients on signs and symptoms of CVD, future CVD risk and long-term health issues, contraception options, and planning a pregnancy with known CVD. The toolkit also includes a discussion on racial and ethnic disparities in CVD prevention and diagnosis.

       

      National professional organizations call for the need to standardize CVD risk assessment during pregnancy and the postpartum period. The consensus statement of the American Heart indicates that screening pregnant people for cardiac conditions in all care settings is a key step to lowering CVD-related maternal mortality. 16 Earlier recognition of a previously unknown CVD or a timely diagnosis of pregnancy-associated cardiomyopathy is bound to improve maternal and fetal outcomes.16

       

      The Alliance for Innovation on Maternal Health Cardiac Conditions in Obstetrical Care includes the CMQCC CVD Assessment Algorithm for Pregnant and Postpartum Patients in the Cardiac Conditions in Obstetrical Care Bundle (COCC).6 In the bundle, cardiac conditions refer to disorders of the cardiovascular system that may impact maternal health. Such disorders may include congenital heart disease or acquired heart disease, including but not limited to cardiac valve disorders, cardiomyopathies, arrhythmias, coronary artery disease, pulmonary hypertension, and aortic dissection despite limitations, recognized as an emerging best practice and an important tool for assessing symptoms and risk in a standardized way.

       

      The American College of Obstetricians and Gynecologists (ACOG) recently endorsed the California (CA) cardiovascular disease (CVD) risk assessment algorithm for pregnant and postpartum patients. We believe our empirical validity analysis (described in the validity section) also adds important evidence supporting this measure's endorsement by PMQ.

       

      1. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-Related Mortality in the United States, 2011–2013. Obstet Gynecol. 2017;130(2):366-373. doi:10.1097/AOG.0000000000002114.
      2. Hameed AB, Foster E, Main EK, Khandelwal A, Lawton ES. Cardiovascular Disease Assessment in Pregnant and Postpartum Women | California Maternal Quality Care Collaborative. Cardiovascular Disease in Pregnancy Toolkit. Published November 2017. Accessed June 14, 2019.https://www.cmqcc.org/resource/cardiovascular-disease-assessment-pregnant-and-postpartum-women.
      3. Fraser A, Nelson SM, Macdonald-Wallis C, et al. Associations of pregnancy complications with calculated cardiovascular disease risk and cardiovascular risk factors in middle age: the Avon Longitudinal Study of Parents and Children. Circulation. 2012;125(11):1367-1380. doi:10.1161/CIRCULATIONAHA.111.044784
      4. Say L, Pattinson RC, Gülmezoglu AM. WHO systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity (near miss). Reprod Health. 2004;1(1). doi:10.1186/1742-4755-1-3.
      5. Petersen EE, Davis NL, Goodman D, et al. Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016. MMWR Morb Mortal Wkly Rep. 2019; 68:762–765. doi:10.15585/mmwr.mm6835a3.
      6. Hameed AB, Lawton ES, McCain CL, et al. Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy. Am J Obstet Gynecol. 2015;213(3):379.e1-379.e10. doi:10.1016/j.ajog.2015.05.008.
      7. Gentry MB, Dias JK, Luis A, Patel R, Thornton J, Reed GL. African-American Women Have a Higher Risk for Developing Peripartum Cardiomyopathy. J Am Coll Cardiol. 2010;55(7):654-659. doi:10.1016/j.jacc.2009.09.043.
      8. Hunter S, Robson SC. Adaptation of the maternal heart in pregnancy. Br Heart J. 1992;68(6):540-543. doi:10.1136/hrt.68.12.540.
      9. Cusimano MC, Pudwell J, Roddy M, Cho CKJ, Smith GN. The maternal health clinic: an initiative for cardiovascular risk identification in women with pregnancy-related complications. American Journal of Obstetrics and Gynecology. 2014;210(5):438.e1-9. doi:https://doi.org/10.1016/j.ajog.2013.12.001
      10. Hameed AB, Tarsa M, Graves CR, et al. Cardiovascular Risk Assessment as a Quality Measure in the Pregnancy and Postpartum Period. JACC Adv. 2023;2(1):100176-100176. doi:https://doi.org/10.1016/j.jacadv.2022.100176
      11. Black A, Gute J, Kindschuh A. Implementing a Cardiovascular Screening Tool for High-Risk Pregnant Women in a Hospital Setting. Nurs Womens Health. 2022;26(1). doi:10.1016/j.nwh.2021.11.001
      12. Blumenthal EA, Crosland BA, Senderoff D, et al. California Cardiovascular Screening Tool: Findings from Initial Implementation. AJP Rep. 2020;10(4). doi:10.1055/s-0040-1718382
      13. Dinarti LK, Nurdiati DS, Hartopo AB, et al. The screening of heart disease by cardiac auscultation and electrocardiography examination in pregnant women in Puskesmas Tegalrejo, Yogyakarta, Indonesia. Journal of Community Empowerment for Health. 2021;4(3). doi:10.22146/jcoemph.64970
      14. Adedinsewo DA, Johnson PW, Douglass EJ, et al. Detecting cardiomyopathies in pregnancy and the postpartum period with an electrocardiogram-based deep learning model. European Heart Journal - Digital Health. 2021;2(4). doi:10.1093/ehjdh/ztab078
      15. Gladstone R, Pudwell J, Pal R, Smith G. Referral to Cardiology Following Postpartum Cardiovascular Risk Screening. Journal of Obstetrics and Gynaecology Canada. 2019;41(5). doi:10.1016/j.jogc.2019.02.182
      16. Hameed AB, Haddock A, Wolfe DS, et al. Alliance for Innovation on Maternal Health: Consensus Bundle on Cardiac Conditions in Obstetric Care. Obstetrics and Gynecology. 2023;141(2). doi:10.1097/AOG.0000000000005048
    • 2.3 Anticipated Impact

      If implemented, the measure has the potential to impact the early identification of risk factors associated with CVD during pregnancy and postpartum stages for birthing people. In doing so, this will decrease maternal mortality as more than half of the serious cardiac complications are preventable in women with cardiac disease. Screening for CVD risk factors, including age, hypertension, diabetes, and obesity is a key component in the efforts to minimize adverse pregnancy events and can lower the healthcare costs associated with these events, reducing the economic burden. Furthermore, CDC data reveals that annually, Americans experience 1.5 million heart attacks and strokes, costing over $320 billion in healthcare and lost productivity, with projections indicating a surge to $818 billion by 2030, and lost productivity costs reaching $275 billion. 

      2.5 Health Care Quality Landscape

      People with undiagnosed unknown CVD and those with CVD index diagnosis during their pregnancy usually present in a similar manner with symptoms and abnormal vital signs, however, may not be diagnosed in time to receive guideline recommended medical care. Healthcare providers may not suspect CVD when evaluating pregnant or postpartum patients with symptoms that may signify an underlying diagnosis of CVD. There is a need to establish a standardized CVD risk assessment tool to triage pregnant and postpartum patients and provide standardized options of appropriate follow-up. Our measure is used for standardized identification of individuals with suspected disease, or suspected high risk for disease. A CVD risk assessment distinguishes patients with a high probability of disease by analyzing several variables indicated by the algorithm.

       

      For cardiovascular risk assessment and follow-up in pregnant and postpartum women, a reliable clinical screening approach that monitors the hospital and clinician performance is lacking. Timely identification of women at risk of CVD and follow-up may improve maternal health outcomes, i.e., maternal morbidity and mortality and lifetime onset of CVD.

      2.6 Meaningfulness to Target Population

      The measure performance of three hospital networks were reviewed with the co-investigators during virtual co-investigator meetings. Each site co-investigators individually contacted medical directors and/or clinicians with low CVD risk assessment rates to identify any implementation barriers. In addition, UCI conducted semi-structured interviews with five clinicians at each site (n=15) in May 2021 to elicit the value of the measure and barriers to follow up of the measure. The aggregate data presented in the measure facilitated the identification of system problems, such as need to obtain insurance approval for procedures, scheduling timely appointments, and patient logistics to keep health appointments (childcare, transportation, taking time off from work).  Overall, clinicians appreciated the ability to monitor their performance and get a benchmark of their peer’s performance. 

       

      We formed a 14-member Technical Expert Panel (TEP) representing diverse stakeholders (Measure Developers, Clinical Content – Cardiology, Clinical Content – OB/GYN/MFM, Clinical IT, Patient Representatives). TEP members met virtually every 2-3 months and provided input on the individual elements of the algorithm, the integration of the algorithm in the EHR, and discussed additional clinical criteria such as the appropriate BNP cutoff. The TEP members agreed that: 

      1. There should not be any upper or lower age limit (so adolescent pregnancies and women with IVF are included). 
      2. Private providers who contract with the hospital for L&D services can be included in the denominator. 
      3. How to calculate the measure if the algorithm was administered more than once during a pregnancy episode.

       

      Furthermore, we conducted 10 in-depth interviews to gauge patients’ firsthand experiences with the CVD screening tool.  We recruited a purposive sample of 10 patients from Montefiore Medical Center, New York, and University of California, Irvine who had received a positive risk assessment score. Patients were seen at different clinics (high risk, general obstetric, family medicine) and presented a range of demographic variables, and comorbidities. Three of the ten participants identified as Black, seven identified as Hispanic and three participants preferred the interview in Spanish. The interviews highlighted several themes: 

      • Respondents were oblivious of the relationship between pregnancy and cardiovascular health risk. Heart disease was typically associated with older age. 
      • The main reactions to the news of being at risk for CVD were fear and surprise; especially patients who already kept a balanced diet and were physically active had not thought that they might be at risk. 
      • Participants wanted to know more how the CVD risk could impact their baby. 
      • Empathic provider communications and the feeling that providers know what to do were important than the facts themselves at the time of the clinical encounter. However, patients would have liked to have more written or digital information so that they can process the news at home.
      • All patients were eager to address modifiable behaviors. Some were expecting to get guidance by the clinicians while others had already changed their diet, increased physical activity and stress-reducing activities to improve their mental health and manage their blood pressure at the time of the interview. 

      The thematic analysis of the interviews suggested that the risk assessment was accepted by patients and effective in initiating provider patient communication about lifestyle risk and resulting changes to reduce CVD risk factors. These data were used to develop a semi-structured interview that will recruit 80 patients on similar themes to provide data on a larger sample. Results are not yet published. 

       

      As a result of the qualitative patient interviews, we recruited three additional patients with lived CVD experience to our TEP. These TEP patient representatives stressed the importance of patient support groups in helping pregnant and postpartum people at CVD risk to improve cardiovascular health. The TEP members provided crucial input in expanding the patient education resources on UCI’s CVD website and provided input in the dissemination of the quality measure.  

       

    • 2.4 Performance Gap

      N/A

    • 3.1 Feasibility Assessment

      The feasibility of implementing the measure is high given the required data can be extracted from the electronic health record system (for automatized risk score calculation) or documented on paper form (for manual risk score calculation). The primary changes needed to implement the measure revolve around integration of the risk assessment in the clinic flow. For example, in clinics where medical assistants did the pre-screen, clinicians may not have been informed that the patient has a positive score, was not always have been discussed with the providers. 

      3.3 Feasibility Informed Final Measure

      There were no changes in specifications. All the data needed to calculate the measure is available in the electronic health record (EHR). 

    • 3.4a Fees, Licensing, or Other Requirements

      COPYRIGHT: The Copyright in the CVD Risk Assessment Measure is held by the © The Regents of The University of California 2023
       

      Copyright in works referenced in CVD Risk Assessment Measure-Proportion of Pregnant/Postpartum Patients that receive CVD Risk Assessment with a Standardized instrument includes: 

       

      CMQCC CVD Risk Assessment Tool: © California Department of Public Health, 2017; supported by Title V funds. Developed in partnership with California Maternal Quality Care Collaborative Cardiovascular Disease in Pregnancy and Postpartum Taskforce. Visit: WWW.CMQCC.org for details.

       

      CPT® contained in the Measure specifications is copyright 2004-2023 American Medical Association. LOINC® copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms® (SNOMED CT®) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved.

       

      Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for the use or accuracy of any third-party codes contained in the specifications.

       

      THE CVD RISK ASSESSMENT MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

      3.4 Proprietary Information
      Proprietary measure or components (e.g., risk model, codes), without fees
    • 4.1.3 Characteristics of Measured Entities

      Our measure was tested at geographically and ethnically diverse hospital networks: 

      Initial Users:

      • University of California, Irvine/UC Irvine Health (UCI Health), lead agency, 1,500 births annually
      • University of California, San Diego/UC San Diego Health (UCSD Health) 3,000 births annually 
      • University of Tennessee/ St. Thomas Health, Tennessee (UTenn), 11,000 births annually

       

      In 2022 two additional networks implemented the tool and transferred data to UCI for measure calculation. Data on these networks are not yet included in the present submission

      • Albert Einstein College/Montefiore Medical Center, New York(MMC), 5,000 annually
      • University of Missouri, Kansas City/St. Luke’s Health System, Kansas City, 5,000 annually 

      The hospital networks UCI and UCSD are located in Southern California and UTenn in Tennessee. They include regional Level 3 birthing centers with the full scope of inpatient and outpatient hospital services and affiliated community and private medical clinics. All hospitals have Obstetrics/Gynecology (OB/GYN) residency training programs, a high volume of Medicaid patients, and a diverse racial/ethnic demographic mixture. The information on the measure is used for staff training at other additional sites that have adopted the measure, such as Albert Einstein College and the University of Missouri. 

      4.1.1 Data Used for Testing

      Electronic health records of all pregnant and postpartum patients from the University of California, Irvine (1,500 deliveries per year), University of California, San Diego (3,000 births per year), and University of Tennessee Medical Center (11,000 deliveries per year) includes data from September 2020 to February.   The tool is integrated into EPIC and Cerner electronic health records. UTenn implemented a feasible system to administer the tool manually was implemented for clinics that were not connected to its Cerner EHR system.   

      4.1.4 Characteristics of Units of the Eligible Population

      Data was collected on the number and descriptive characteristics of patients who received a CVD risk assessment compared to the total number of patients from September 2020 to February 2022. This data was collected from three hospital networks, including the University of California, Irvine Health System, the University of California, San Diego Health System, and the University of Tennessee Health System.  Each hospital network includes affiliated clinics, outpatient facilities, and private practices that administer cardiovascular disease (CVD)risk assessments. The three hospital network assessments were on 31,309 assessments during the time. Below is a comprehensive analysis that reveals the demographic characteristics and variations in patient profiles across these diverse healthcare networks. 

       

      A total of 2,611 patients in the UCI Health System received a CVD risk assessment, representing 54.4% of all patients. Patient ages ranged from under 20 years old (2.0%), 20 to 29 years old (40.1%), 30-39 years old (50.9%), and 40 or older (7.4%). Regarding race, 4.1% were Black, 68.3% were White, 14.4% were AAPI, and 13.5% were categorized as Others. Regarding ethnicity, 57.0% were Hispanic, and 43.0% were non-Hispanic. The insurance breakdown included 52.7% with public insurance, 34.1% with private insurance, and 13.5% with unknown insurance status. The timing of assessments revealed that 37.3% occurred during prenatal care, and 63.0% took place postpartum.

       

      During the specified period in the UCSD Health System, out of 5,985 patients, 4,285 patients underwent a CVD risk assessment, accounting for 71.6% of the patient population. The age distribution was as follows: 0.9% of patients were below the age of 20, 32.9% were between the ages of 20-29, 59.2% were between the ages of 30-39, and 6.8% were 40 years old or above. The racial distribution was 5.9% Black, 51.5% White, 12.2% AAPI, and 30.3% Other. In terms of ethnicity, 29.8% of patients were identified as Hispanic, and 70.1% were non-Hispanic. With regards to insurance coverage, 32.6% had public insurance, 51.6% had private insurance, and 15.6% had unknown insurance status. In terms of the timing of assessments, 32.5% were conducted prenatally while 67.4% were done postpartum.

       

      Finally, in the UTenn Health System, all 22,713 patients received CVD risk assessments during the specified period. Age-wise, 5.1% were under 20, 48.5% were aged 20-29, 43.3% were 30-39, and 3.1% were 40 or older. Regarding race, 14.8% were Black, 60.6% were White, 1.7% were AAPI, and 22.8% were categorized as Others. Regarding ethnicity, 17.4% were Hispanic, and 80.1% were non-Hispanic. The insurance breakdown included 26.4% with public insurance, 72.0% with private insurance, 1.4% with self-pay, and 0.2% with unknown insurance status. The timing of assessments showed 41.9% during prenatal care and 58.1% during postpartum.

      4.1.2 Differences in Data

      None

    • 4.2.1 Level(s) of Reliability Testing Conducted
      Person– or encounter–level (i.e., data element) (e.g., inter–abstractor reliability)
      Accountable Entity-Level (e.g., signal-to-noise analysis)
      4.2.2 Method(s) of Reliability Testing

      We used signal-to-noise analysis. The signal in this case is the proportion of the variability in measured performance that can be explained by real differences in performance. A reliability of zero implies that all the variability in a measure is attributable to measurement errors.  Reliability of one implies that all the variability is attributable to real differences in performance. 

      We eliminated clinics with a relatively large sample size (Denominator, or n) that could have a disproportionate influence. Then excluded if n>75th percentile+1.5*(interquartile range).

      • Calculate the 25th at 75th percentile of n across the 23 clinics.
        • 25th percentile: 95
        • 75th percentile: 846
        • interquartile range: 748
        • 75th percentile+1.5*(interquartile range) =1968
      • VLI WOMENS HEALTH SVCS (n=2724), ST Midtown (n=13627), and ST Rutherford (n=7746) are removed for the purpose of the parameter estimation. 

      Next, we used empirical Bayes shrinkage with n2 weighting to estimate the signal and noise variances as outlined in Section 5. of Morris1:

              A^=σ2(provider-to-provider)

             Si2=σ2error

      Then we calculated using Reliability=(σ2(provider-to-provider))  / (σ2(provider-to-provider)+σ2error) for each clinic. 

       

      As most of the patients received, EKG or echo as follow-up procedure, we assessed this as the primary outcome. We reviewed 1,399 patients that underwent CVD risk stratification using the CMQCC algorithm over an 18-month period at a the UCI network. We reviewed the rate of abnormal EKG or echo, defined as abnormal cardiac structure and/or function, among patients who were determined to be at increased risk for CVD.  Of 29 patients identified to be at increased risk, 20 received follow-up testing with EKG or echo within 60 days of the risk assessment. Over half (65%) of the patients were found to have underlying EKG or echo abnormality. Abnormal cardiovascular testing results included findings such as sinus tachycardia (HR > 100 bpm), conduction delays, Wolff Parkinson-White syndrome, left ventricular hypertrophy/diastolic dysfunction, and chamber dilation. Using these results as a surrogate for CVD, the CMQCC risk assessment tool identified 13 cases of previously undiagnosed cardiovascular dysfunction in the study population. 

      4.2.3 Reliability Testing Results

      Signal to Noise (SNR)

      k: 20

      A (Signal Variance): 0.0655

      SD: 0.2558

      b-hat (Mean): 0.714

      V-bar: 0.000230

      Median Reliability: 0.992

      Min SNR: 0.839

      Max SNR: 1.000

      Patient Encounter Level

      Kappa: 1.0

      Table 2. Accountable Entity–Level Reliability Testing Results by Denominator-Target Population Size
      Accountable Entity-Level Reliability Testing Results
        Overall Minimum Decile_1 Decile_2 Decile_3 Decile_4 Decile_5 Decile_6 Decile_7 Decile_8 Decile_9 Decile_10 Maximum
      Reliability 0.992 0.839 0.914 0.961 0.972 0.983 0.991 0.993 0.995 0.996 0.999 1.000 1.000
      Mean Performance Score 58.9% 37.5% 64.2% 73.9% 43.2% 29.8% 88.7% 48.2% 68.3% 50.7% 72.4% 50.0% 100%
      N of Entities 20 1 2 2 2 2 2 2 2 2 2 2 2
      N of Persons / Encounters / Episodes 7212 16 27 102 197 199 263 744 1089 1558 1276 1657 1657
      4.2.4 Interpretation of Reliability Results

      The Signal-to-Noise (SNR) reliability ratio was calculated for 20 entities. The range of SNR reliability is 0.839 to 1, and the median is 0.992. A reliability close of 1 implies that all the variability is attributable to real differences in performance. Our results demonstrate consistent and dependable results across different levels of testing, supporting the proposed quality measure's reliability.

    • 4.3.1 Level(s) of Validity Testing Conducted
      Accountable entity–level (e.g., criterion validity)
      4.3.2 Type of accountable entity-level validity testing conducted
      Empirical validity testing at the accountable entity-level (e.g., criterion validity, construct validity, known groups analysis)
      4.3.3 Method(s) of Validity Testing

      Face validity: We reviewed the measure specifications with the Technical Expert Panel, which unanimously agreed that the measure assesses the quality of CVD risk assessment. Case report evaluations were used to assess whether the cardiovascular risk variable is consistent with a CVD diagnosis.

       

      Empirical Validity Testing:  Sensitivity, specificity, positive predictive, and negative predictive values were calculated to assess the measure’s performance. The CVD risk assessment measure and the percent of confirmed CVD cases were calculated for 23 entities. We hypothesized them to be positively correlated. Pearson Correlation Coefficient (r) was calculated to test the correlation between the measure and the % of confirmed CVD cases. The Pearson chi-square test p<0.0001 indicates that measure 1 rates in different clinics are significantly different. 

       

      To estimate the evidence, UCI Health built a cohort of all obstetric patients seen at UCI Medical Center for the period from September 2020 to March 2024. Patients with known CVD at first prenatal or obstetric visit were excluded from the analysis. Of the remaining cohort of 10,860 pregnant and postpartum patients, a total of 5,902 patients (54.3%) had a risk assessment (“screened,” follow-up and monitoring based on risk assessment results and clinician discretion) compared to 4,958 patients who did not receive a risk assessment (“unscreened”, follow up and monitoring based on clinician discretion). 

       

      We found that the yield for patients who were screened with the algorithm was significantly higher. Screened patients had a significantly higher percentage of follow-up tests with abnormal test results (52%) than unscreened patients (42%) (Chi-square test p-value<0.0001). These differences remained to be significantly different when controlling for race/ethnicity, insurance status, and age. 

       

      Among patients who were referred for follow-up tests, screened patients were twice as likely to have a comorbidity (diabetes, hypertension, obesity) than patients in the unscreened group (28.8% vs. 14.1%) .

       

      Among the group of patients with a risk assessment, we compared patients who had a positive risk assessment (RA+) with those with a negative risk assessment (RA-).  RA+ patients were significantly more likely to have an abnormal follow-up test result than RA- patients (Chi-square test p-value<0.0001). 

      Previously unknown CVD diagnosis: RA+ patients were significantly more likely to be identified with previously unknown CVD diagnosis than RA- patients (Fisher's exact test p-value<0.0001).

       

      4.3.4 Validity Testing Results

      Empiric Validity: The r=0.424 (p-value=0.0437)

      Face Validity: 100% 

       

      4.3.4a Attach Additional Validity Testing Results
      Empirical Valildity.pdf
      4.3.5 Interpretation of Validity Results

       Empiric Validity: The r=0.424 (p-value=0.0437) shows that the CVD risk assessment measure and percent of confirmed CVD cases have a moderate positive correlation with a statistically significant p-value. This supports an inference of validity for the measure because measure performance correlates with actual confirmed CVD cases.

       

      Additional testing on the yield of the tool demonstrates that the risk assessment effectively identifies  a higher proportion of patients with abnormal follow-up test results (EKG, echocardiogram, etc.) than the proportion of patients who were not screened; thereby leading to higher efficiency of identifying  patients in need of CVD monitoring during their pregnancy and avoidance of unnecessary tests. 

    • 4.4.1 Methods used to address risk factors
      No risk adjustment or stratification
      Risk adjustment approach
      Off
      Risk adjustment approach
      Off
      Conceptual model for risk adjustment
      Off
      Conceptual model for risk adjustment
      Off
    • 5.1 Contributions Towards Advancing Health Equity

      This measure, which focuses on cardiovascular disease (CVD) risk assessment during pregnancy and postpartum, directly contributes to the advancement of health equity by standardizing CVD risk assessment and follow-up across racial/ethnic groups. There are significant disparities in the prevalence and treatment of CVD among pregnant/postpartum patients, which are largely due to systemic racism and implicit provider bias. These disparities impact low-income, Black, Native American, Latinx, and Asian/Pacific Islander communities. Targeting a significant healthcare disparity: the high risk of mortality among Black birthing people due to pre-existing CVD, hypertensive disorders of pregnancy (HDP), and peripartum cardiomyopathy (PPCM). Studies have found that black women are not monitored as carefully as white women, and their complaints are often dismissed.1 Data consistently show that Black birthing individuals have a 3-12 times higher risk of mortality compared to those from other racial/ethnic groups, marking them as the racial-ethnic group with the highest pregnancy-related mortality ratio. Additionally, Pacific Islanders, Native American and Alaskan Islanders (AN/AI) have an increased risk of maternal mortality when compared to non-Hispanic white women.2 In fact, since 1999, AN/AI has had the largest increase maternal mortality.  Furthermore, low-income birthing individuals, regardless of their racial or ethnic background, face elevated risks of post-delivery complications, including hospitalization, readmission, and emergency department visits within 90 days of delivery.3

       

      1. Louis JM, Menard MK, Gee RE. Racial and Ethnic Disparities in Maternal Morbidity and Mortality. Obstetrics & Gynecology. 2015;125(3):690-694. doi:https://doi.org/10.1097/aog.0000000000000704
      2. Fleszar LG, Bryant AS, Johnson CO, et al. Trends in State-Level Maternal Mortality by Racial and Ethnic Group in the United States. JAMA. 2023;330(1):52-61. doi:https://doi.org/10.1001/jama.2023.9043
      3. Howell EA, Zeitlin J. Improving hospital quality to reduce disparities in severe maternal morbidity and mortality. Seminars in Perinatology. 2017;41(5):266-272. doi:10.1053/j.semperi.2017.04.002
    • 6.2.1 Actions of Measured Entities to Improve Performance

      Hospital networks can use the measure to identify clinics or individual clinicians with low risk assessment rates. To enhance performance on this measure, entities must prioritize comprehensive clinician training, proactive leadership involvement, and the structured onboarding of new medical residents. Additionally, integrating the measure into the orientation of incoming residents and new hires, supported by mentorship from experienced clinicians, ensures its consistent application in the future. In addition to identifying clinics with low performance, clinics can review whether certain patient groups are less likely to be tested and monitored for CVD risk (minorities, postpartum patients or patients entering late prenatal care), in which case corrective action steps could be unconscious bias training or changes in clinic flow.  

    • Submitted by Sophie Hameed (not verified) on Mon, 05/27/2024 - 23:59

      Permalink

      I strongly endorse this measure for screening pregnant patients for CVD. This will greatly enhance healthcare and save many lives.

      Organization
      USC

      Submitted by Sara (not verified) on Tue, 05/28/2024 - 06:36

      Permalink

      Very helpful for testing pregnant women for CVD, should be implemented. 

      Submitted by perla prado (not verified) on Tue, 05/28/2024 - 18:27

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      I am pleased to support the implementation of the CVD risk assessment measure developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, significantly reduces maternal mortality, and improves healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.
       

      Submitted by Dawn Lombardo DO, MS (not verified) on Tue, 05/28/2024 - 18:57

      Permalink


      I am pleased to support the implementation of the CVD risk assessment measure developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, significantly reduces maternal mortality, and improves healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.
       

      Organization
      University of California, Irvine

      Submitted by Breanna Castanon (not verified) on Tue, 05/28/2024 - 19:28

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, significantly reduces maternal mortality, and improves healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.

      Organization
      Providence St Jude Medical Center main Hospital

      Submitted by Breanna Castanon (not verified) on Tue, 05/28/2024 - 19:28

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, significantly reduces maternal mortality, and improves healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.

      Organization
      Providence St Jude Medical Center main Hospital

      Submitted by lissette cortes (not verified) on Tue, 05/28/2024 - 19:48

      Permalink

      I think this is a great extra measure to take with pregnancy. It could significantly reduce the death rate in pregnant women and  overall healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. 

      Submitted by Tabetha Harken (not verified) on Tue, 05/28/2024 - 19:52

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, significantly reduces maternal mortality, and improves healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.

      Organization
      UCI

      Submitted by Christine Kim, MD (not verified) on Tue, 05/28/2024 - 20:00

      Permalink

      I support the implementation of the CVD risk assessment measure developed by UCI.  As CVD is one of the big contributors to maternal morbidity and mortality, we should be using this tool to identify patients at risk to provide better care.  

      Organization
      UCI Health

      Submitted by Christy McCain (not verified) on Tue, 05/28/2024 - 20:08

      Permalink

      As a research scientist working in the field of maternal mortality for over 15 years, I can attest to the large proportion of lives that may have been saved if this CVD risk assessment had been available at the time. This tool was developed in collaboration with our (California's) pregnancy-associated mortality review team and it is exciting to see how integrating it into the EHR system has been piloted and implemented by UCI. This measure helps clinicians to diagnose CVD early and accurately in pregnant and postpartum individuals. It will reduce maternal mortality among those racial/ethnic groups most impacted by pregnancy-related CVD and will improve the quality of care significantly. By identifying and managing CVD risk factors early, we can significantly reduce adverse health pregnancy outcomes among young birthing populations and ultimately lower healthcare costs. I strongly advocate for the implementation of the CVD risk assessment measure developed by UCI. 

      Organization
      Public Health Institute

      Submitted by Roxana Ghashghaei (not verified) on Tue, 05/28/2024 - 20:18

      Permalink

      I am excited to endorse the implementation of the CVD risk assessment measure developed by UCI. This tool is crucial for identifying high-risk cardiovascular conditions in pregnant and postpartum patients, enabling timely and effective interventions. By integrating this measure into the EHR system, we have streamlined the process, ensuring comprehensive screening and improved patient outcomes. This initiative enhances diagnostic accuracy, significantly reduces maternal mortality, and elevates healthcare quality. Early identification and management of CVD risk factors can greatly decrease adverse pregnancy events and reduce healthcare costs. This measure has immense potential in combating maternal mortality.

      Organization
      UCI

      Submitted by Rebecca Post (not verified) on Tue, 05/28/2024 - 20:52

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, significantly reduces maternal mortality, and improves healthcare quality. By identifying and managing cardiovascular disease risk factors early, we can significantly reduce the number of adverse pregnancy events for both pregnant individuals and their unborn babies, and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.

      Organization
      University of California Irvine

      Submitted by Komal Suryawala (not verified) on Wed, 05/29/2024 - 08:52

      Permalink

      I am pleased to support UCI in CVD risk management during pregnancy. We come across many pregnant patients who can use more education and support on how to manage the risk associated with Cvd during pregnancy. 

      Organization
      St. Jude Medical Center

      Submitted by Komal Suryawala (not verified) on Wed, 05/29/2024 - 08:52

      Permalink

      I am pleased to support UCI in CVD risk management during pregnancy. We come across many pregnant patients who can use more education and support on how to manage the risk associated with Cvd during pregnancy. 

      Organization
      St. Jude Medical Center

      Submitted by Malissa Wood (not verified) on Wed, 05/29/2024 - 12:26

      Permalink

      I am strongly support the implementation of the CVD risk assessment measure developed by UCI. This  innovation will provide guidance and structure to the process of identifying individuals at high risk of experiencing cardiovascular complications during pregnancy.   This early identification will lead to earlier implementation of effective interventions.   Utilizing the EHR as the vehicle by which individuals undergo this risk assessment has significantly reduced barriers to identification of  cardiac risk during pregnancy and enhances diagnostic accuracy, significantly reduces maternal mortality, and improves healthcare quality.  This innovation will lead to improve outcomes and reduced maternal cardiovascular morbidity and mortality associated with pregnancy.  

      Organization
      Lee Health

      Submitted by Dariush H Tonkaboni (not verified) on Wed, 05/29/2024 - 13:11

      Permalink

      It gives me great pleasure to assist the application of the UCI-developed CVD risk assessment tool. This intervention increases the quality of healthcare, lowers maternal mortality dramatically, and improves diagnostic accuracy. The number of unfavorable pregnancy events can be greatly decreased, and healthcare expenses can be decreased, by early detection and management of CVD risk factors. 

      Organization
      UCI

      Submitted by Jasmine Patel (not verified) on Wed, 05/29/2024 - 14:55

      Permalink

      I am in full support of implementation of the CVD risk assessment measure developed by UCI. I have used this tool and it has been instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, significantly reduces maternal mortality, and improves healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality. I recommend its integration into every health system!

      Organization
      University of California Irvine

      Submitted by Elena Rhoads (not verified) on Wed, 05/29/2024 - 17:53

      Permalink

      I support the implementation of the CVD risk assessment measure. It is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, which can lead to timely and effective interventions. Its integration into the EHR system has streamlined the process. This measure enhances diagnostic accuracy and improves healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.

      Organization
      UCI

      Submitted by Dongbao CHEN (not verified) on Wed, 05/29/2024 - 19:03

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure developed by the team led by Professor Afshan Hameed at UCI. The assessment protocol is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Integrating this versatile approach into the EHR system has stratified the process, ensuring comprehensive screening for more diagnostic accuracy. This measurement allows identification of CVD early to inform an "early window" for managing CVD risk factors, offering a great promise to improve patient outcomes and to reduce maternal mortality. Overall, this assessment tool holds an immense potential in the combat of CVDs in pregnant women especially these having had a complicated pregnacy.

      Organization
      UCI

      Submitted by Jennifer Xu (not verified) on Wed, 05/29/2024 - 19:15

      Permalink

      I fully endorse this tool for screening pregnant patients with cardiovascular disease. As clinicians with varying experience with this patient population this offers a streamlined way to identify high risk patients at the right moment for interventions

      Organization
      UCI Health

      Submitted by Julia Bregand-White (not verified) on Thu, 05/30/2024 - 16:56

      Permalink

      The CVD screen provides reassurance that our patients are receiving a combination of individualized clinical assessment and EMR parameter monitoring to identify those at high risk for CVD with options to pursue further workup or evaluation seamlessly integrated into the patient's chart.  

      Organization
      UCI Health

      Submitted by Courtney Brewington (not verified) on Thu, 05/30/2024 - 18:22

      Permalink

      I want to support the implementation of the CVD risk assessment. This measure significantly reduces maternal mortality, and improves healthcare quality.  

      Organization
      Tennessee Maternal Fetal Medicine

      Submitted by Talia Moreno (not verified) on Fri, 05/31/2024 - 18:28

      Permalink

      As a patient who has experienced the benefits of the CVD risk assessment measure developed by UCI, I am pleased to support its implementation. Identifying and managing CVD risk factors early, significantly reduces the amount of stress and other negative outcomes during pregnancy and postpartum periods. This measure holds immense potential in the fight against maternal mortality, benefiting many patients like myself.

      Organization
      University of California, Irvine (UCI)

      Submitted by Abha Khandelwal (not verified) on Sun, 06/02/2024 - 22:39

      Permalink

      This is a fantastic measure. I am pleased to support the implementation of the CVD risk assessment measure being developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, highly likely to reduce maternal mortality, and improve healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality. It has my full support.

      Organization
      Stanford University

      Submitted by Amir Shamshirsaz (not verified) on Sun, 06/02/2024 - 22:42

      Permalink

      University of California Irvine's groundbreaking initiative to support cardiovascular risk assessment among pregnancy and postpartum is a game-changer in women's health. By emphasizing the importance of monitoring cardiovascular health during and after pregnancy, this initiative addresses a critical gap in current healthcare practices. Pregnancy and the postpartum period pose unique challenges to a woman's cardiovascular system, and effective risk assessment can lead to timely interventions and improved outcomes for both mothers and babies. This proactive approach highlights UC Irvine's commitment to advancing maternal health and enhancing the standard of care for all women. By focusing on early detection and personalized care, this initiative has the potential to revolutionize how we approach cardiovascular health in the maternal population, setting a new standard for healthcare institutions worldwide. I applaud UC Irvine for taking a proactive stance on this vital issue and look forward to the positive impact it will have on the health and well-being of mothers everywhere.

      Organization
      Baylor College of Medicine

      Submitted by Nandita Scott (not verified) on Mon, 06/03/2024 - 07:26

      Permalink


      "I am pleased to support the implementation of the CVD risk assessment measure being developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, highly likely to reduce maternal mortality, and improve healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality."

      Organization
      Massachusetts General Hospitak

      Submitted by Ponnila Marinescu (not verified) on Mon, 06/03/2024 - 07:40

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure being developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, highly likely to reduce maternal mortality, and improve healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.

      Organization
      University of Rochester Medical Center

      Submitted by Emily Lau (not verified) on Mon, 06/03/2024 - 08:24

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure being developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, highly likely to reduce maternal mortality, and improve healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality."

      Organization
      Massachusetts General Hospital

      Submitted by Jordan Bloom (not verified) on Mon, 06/03/2024 - 09:49

      Permalink

      I strongly support the implementation of the CVD risk assessment measure.  This will save lives.

      Organization
      MGH

      Submitted by Andrew Combs (not verified) on Mon, 06/03/2024 - 10:30

      Permalink

      Very important measure - I stronglt favor endorsement.

      CVD is a major cause of pregnancy-related death.

      Most pregnancy-related CVD deaths are judged to have been preventable with prompt recognition and management.

      Screening will help to identify those with existing CVD.

      Organization
      Pediatrix

      Submitted by Marla Mendelson,MD (not verified) on Mon, 06/03/2024 - 10:43

      Permalink

      This is an extremely important study.  The way in which women have traditionally accessed health care has been documented to be sporadic during their lifetime.  But pregnancy is a time when women are more focused on their health and seek medical attention.  Not only could underlying cardiac disease complicate a pregnancy but CVD occurring in pregnancy can predict cardiovascular complications in the future. I fully and enthusiastically support this project.

      Organization
      Northwestern Medicine

      Submitted by Ailin Barseghian (not verified) on Mon, 06/03/2024 - 11:08

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure developed by UCI. In an era where US mortality in pregnancy is in the mainstream (newspaper articles, Netflix features, etc), it is especially important to demonstrate advancement in the current practice of risk assessment in pregnant women. 

       

      This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, significantly reduces maternal mortality, and improves healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality. 

      Organization
      University of California Irvine

      Submitted by Elliott Main, MD (not verified) on Mon, 06/03/2024 - 11:45

      Permalink

      This is an important step for identification of of cardiovascular morbidity which is now the leading cause of maternal  mortality in the US and for which we have no other promising approaches.  Integration into the EHR system has simplied implementation and made it practical for widespread use.  By identifying and managing CVD symptoms early, we can significantly reduce the number of adverse pregnancy events. This measure holds significant potential in the fight against maternal mortality.

      Organization
      Stanford University Dept OB GYN

      Submitted by Anna Bortnick (not verified) on Mon, 06/03/2024 - 12:19

      Permalink

      The CVD risk assessment measure being developed by UCI will be a key tool that could be broadly disseminated and incorporated into electronic medical records systems to identify cardiac disease in pregnancy and postpartum. We need to find the rare individuals at risk of maternal mortality and more commonly, those at risk of significant morbidity in pregnancy and peripartum. We need systematic approaches to do this and the CVD risk assessment does just that. Identifying these individuals could lead to better management, less adverse events and lower cost of care. 

      Organization
      Montefiore Medical Center and Albert Einstein College of Medicine

      Submitted by Jennifer Jolley (not verified) on Mon, 06/03/2024 - 12:40

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.

      Organization
      UC Irvine Medical Center

      Submitted by Harold B Collins (not verified) on Mon, 06/03/2024 - 14:22

      Permalink

      I enthusiastically support the implementation of the CVD risk assessment measure being developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, highly likely to reduce maternal mortality, and improve healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.

      Organization
      Tennessee Maternal Fetal Medicine, PLC

      Submitted by Maryam Tarsa MD MAS (not verified) on Mon, 06/03/2024 - 14:44

      Permalink

      It is time that we all stand to support this measure. Cardiovascular disease in pregnancy is the reality of our healthcare and needs to be addressed to decrease morbidity and mortality in our pregnant and postpartum patients. Public awareness, provider education, patient screening WILL SAVE LIVES!!! This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, significantly reduces maternal mortality, and improves healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.

      Organization
      University of California San Diego

      Submitted by Robin Bell (not verified) on Mon, 06/03/2024 - 15:30

      Permalink

      The CVD risk assessment measure is an invaluable tool in identifying high risk cardiovascular conditions in the pregnant and postpartum patients. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. Women's heart health is so important and being able to offer screening, further imaging, and management while the patient is still in the hospital, is a win.

      Organization
      tnmfm

      Submitted by Christine Mort… (not verified) on Mon, 06/03/2024 - 15:52

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure being developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, highly likely to reduce maternal mortality, and improve healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality and morbidity, as CVD is a leading cause of both.  It is long overdue to screen for this often fatal condition.  


       

      Organization
      CMQCC @ Stanford Medicine

      Submitted by Marla Seacrist (not verified) on Mon, 06/03/2024 - 16:22

      Permalink

      I agree with the details provided on this tool development for risk assessment. I believe this risk assessment tool can save countless lives of women who's symptoms are often overlooked. 

      Organization
      California State University Stanislaus

      Submitted by Dr. Molly Nune… (not verified) on Mon, 06/03/2024 - 16:51

      Permalink

      The implementation of the CVD risk assessment measure represents a significant advancement in maternal healthcare. By seamlessly integrating this tool into the EHR system, healthcare providers can more effectively screen for cardiovascular risks in pregnant and postpartum patients. This proactive approach not only improves patient outcomes but also contributes to the broader goal of reducing maternal mortality rates. Early identification and management of CVD risk factors are crucial steps towards minimizing adverse pregnancy events and optimizing healthcare resources. The potential of this measure to enhance healthcare quality and patient safety is indeed substantial.

      Organization
      UCI Health

      Submitted by Amy Sarma (not verified) on Mon, 06/03/2024 - 18:13

      Permalink

      Cardiovascular disease is the leading cause of morbidity and mortality among pregnant patients in the United States. Further, research consistently demonstrates that a high proportion of adverse cardiovascular events among pregnant patients are preventable and primarily due to provider-related factors including failure of timely recognition of cardiovascular complications and diagnoses. Use of this simple tool embedded within a widely utilized medical record system will be an incredibly important step toward earlier identification of at-risk patients and holds the promise to significant reduce maternal mortality in the United States.

      Organization
      Massachusetts General Hospital

      Submitted by Arthur Jason Vaught (not verified) on Mon, 06/03/2024 - 18:44

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure being developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, highly likely to reduce maternal mortality, and improve healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality

      Organization
      Johns Hopkins University

      Submitted by Kimberly A Durdin (not verified) on Mon, 06/03/2024 - 21:12

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure being developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, highly likely to reduce maternal mortality, and improve healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.

      Organization
      KindredSpaceLA

      Submitted by Doreen DeFaria… (not verified) on Mon, 06/03/2024 - 22:08

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure being developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, highly likely to reduce maternal mortality, and improve healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.

      Organization
      Massachusetts General Hospital

      Submitted by Fayez M Bany-M… (not verified) on Tue, 06/04/2024 - 00:19

      Permalink

      I strongly support the implementation of the CVD risk assessment measure being developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, is likely to reduce maternal mortality, and improves healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against the rising maternal mortality rates in the US

      Organization
      UC Irvine Medical Center

      Submitted by Anonymous (not verified) on Tue, 06/04/2024 - 00:43

      Permalink

      "I enthusiastically support the implementation of the CVD risk assessment measure being developed by UCI. This is critical work. Identifying high-risk cardiovascular conditions in pregnant and postpartum patients results in timely and effective interventions ultimately reducing maternal mortality.

      Organization
      UCRiverside Women’s Health Center

      Submitted by Melinda Davis (not verified) on Tue, 06/04/2024 - 10:34

      Permalink

      I fully support the CVD risk assessment tool developed by UCI. Maternal morbidity and mortality is largely driven by delays in appropriate diagnosis and recognition of risk. This initiative has significant potential to save pregnant women and mothers, and can also improve neonatal outcomes. Early detection is essential for giving patients appropriate care. Since the majority of obstetric patients are generally low-risk, identification of high-risk patients is sometimes overlooked, which leads to significant morbidity, mortality, and health care costs. Integration into the EHR is an essential method to alert clinicians, improve screening, and reduce adverse outcomes. 

      Organization
      University of Michigan

      Submitted by Joshua George (not verified) on Tue, 06/04/2024 - 17:52

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure being developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, highly likely to reduce maternal mortality, and improve healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality

      Organization
      University of Michigan

      Submitted by Katherine W. A… (not verified) on Wed, 06/05/2024 - 10:22

      Permalink

      I support the implementation of the CVD risk assessment measure.  It will help identify high-risk cardiovascular conditions in pregnant and postpartum patients, which can lead to timely and effective interventions. 

      Organization
      Katherine W. Arendt, MD, Professor of Anesthesiology, Mayo Clinic

      Submitted by Jonathan G Steller (not verified) on Thu, 06/06/2024 - 18:25

      Permalink

      As CVD is one of the leading causes of maternal morbidity and mortality in the United States, I am thrilled with standardizing screening for CVD in pregnancy as not only may it help to reduce this risk during pregnancy, but may also trigger longitudinal preventative care that helps to keep women safe!

      Organization
      UC Irvine Health

      Submitted by Rachel M Bond, MD (not verified) on Sun, 06/09/2024 - 18:42

      Permalink

      I am pleased to support the implementation of the CVD risk assessment measure being developed by UCI. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, highly likely to reduce maternal mortality, and improve healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality.

      Organization
      Dignity Health Medical Group

      Submitted by Olivia on Tue, 06/11/2024 - 14:21

      Permalink

      Hi, I think the CVD risk assessment measure is important, in particular, because of individuals that are often at-risk for CVD are missed somehow during the birthing process and postpartum. And so, we have far too many deaths in our country, which aligns with some countries who have much less resources than we have. Being able to capture this is important. 

      Organization
      Janice Tufte

      Submitted by Olivia on Tue, 06/11/2024 - 14:25

      Permalink

      So, I appreciate that they'll be using this standardized tool, because hopefully, the information that's gathered will improve maternal health across the board for all diverse populations as well, because there are some populations that do have issues through maternal health. And I'm hoping that the data that's gathered will again improve maternal health across the board. So I support this measure here.

      Organization
      Florence Thicklin (Committee member for Management of Acute Events and Chronic Conditions)

      Submitted by Eleni Tsigas (not verified) on Wed, 06/12/2024 - 21:05

      Permalink

      As the patient advocacy organization representing the hundreds of thousands of women who develop hypertensive disorders of pregnancy and are thus at higher risk of CVD now and later in life, we are desperate for more standards of care that will address these health risks. We strongly support cardiovascular disease risk assessment in pregnant and postpartum patients to allow for early recognition of the disease.  Implementing routine CVD risk assessment as standard of care will lay the groundwork for further quality measures to focus on appropriate clinical care for patients who are identified to be at risk for CVD or with previously unknown CVD. The more we know - and do - the more we can prevent the senseless deaths and morbidity that imperil young families.

      Organization
      Preeclampsia Foundation

      Submitted by Joan Briller (not verified) on Fri, 06/14/2024 - 10:04

      Permalink

      Maternal morbidity and mortality continue to be major concerns in women’s cardiovascular health. Cardiac complications are frequently under diagnosed or diagnosed late and preventable. I strongly support use of validated screening tools will aid in early diagnosis to improve outcomes. 

      Organization
      University of Illinois Chicago

      Submitted by Koryn Rubin (not verified) on Fri, 06/14/2024 - 11:56

      Permalink

      The American Medical Association (AMA) remains committed to decreasing maternal morbidity and mortality and we support the intent of this measure. We ask for clarification on whether this measure is based on clinical guidelines, which would outline basis on how frequently the assessment should occur since CVD can develop at any point during the pregnancy. We also were unable to determine if a performance gap exists since that section was blank no were we able to determine whether the level at which the testing was performed aligns with the levels of analysis of clinician: individual and group/practice. We ask that the committee carefully review whether this submission meets the minimum requirements for endorsement. 

      Organization
      American Medical Association

      Submitted by Rebecca Abbott (not verified) on Fri, 06/14/2024 - 12:25

      Permalink

      Given the significant contributing role of cardiovascular conditions to maternal mortality and morbidity, particularly for Black birthing people, the Society for Maternal-Fetal Medicine (SMFM) supports cardiovascular disease (CVD) risk assessment in pregnant and postpartum patients. Such assessment allows for early recognition, optimal treatment, and improved outcomes for patients. Ideally, the proposed measure could ultimately be paired with one that assesses timely follow-up of those patients who screen positive.

       

      SMFM notes that the proposed measure requires use of a standardized CVD risk assessment tool. As noted in the measure application, the California Maternal Quality Care Collaborative (CMQCC) tool is the only standardized tool currently available. SMFM supports allowing those implementing the measure to modify the CQMCC risk assessment tool with additional data on CVD risk assessment, or using an alternative method when available. Further, SMFM notes that the CQMCC tool includes African American race as a variable, which is a proxy for implicit bias rather than a biological variable. 

       

      SMFM appreciates the opportunity to comment. Any follow-up questions can be sent to [email protected].

      Organization
      Society for Maternal-Fetal Medicine

      Submitted by Lee Brian Padove (not verified) on Sun, 06/16/2024 - 22:09

      Permalink

      Without reservation, I support the implementation of the  CVD Risk tool developed by UCI. Maternal mortality is a growing problem. This tool is instrumental in identifying high-risk cardiovascular conditions in pregnant and postpartum patients, leading to timely and effective interventions. Its integration into the EHR system has streamlined the process, ensuring comprehensive screening and better patient outcomes. This measure enhances diagnostic accuracy, highly likely to reduce maternal mortality, and improve healthcare quality. By identifying and managing CVD risk factors early, we can significantly reduce the number of adverse pregnancy events and lower healthcare costs. This measure holds immense potential in the fight against maternal mortality."

      Organization
      Northside Hospital Cardiovascular Care

    • Submitted by MPickering01 on Sun, 06/16/2024 - 15:31

      Permalink

      Importance

      Importance Rating
      Met
      Importance

      Strengths:

      • The logic model as well as the literature review provides ample evidence of the connection of CVD in prenatal and postpartum patients with a range of material health outcomes, and also shows how follow-up of positive risk assessment can reduce the chance of poor outcomes. Similar risk assessment tools have been shown to be able to retrospectively identify persons who died from CVD, and/or have been endorsed by organizations such as the American College of Obstetricians and Gynecologists (ACOG).

        The developer cites statistics regarding the role of CVD in maternal mortality, i.e., it is the leading cause of maternal mortality in the United States, it also accounts for increased maternal morbidity and utilization, and about a quarter of CVD pregnancy-related deaths are preventable. The risk assessment tool can distinguish between CVD risk and symptoms frequently reported in pregnant populations.

        The developer indicates that a measure assessing clinician performance in this area is lacking.

        The developer conducted in depth interviews with 10 patients who had experience with the screening tool. Themes drawn from their responses indicate that understanding their CVD risk is important to them and expressed interest in how to address modifiable behaviors. The developer reports adding another 3 patients with “lived CVD experience” to their TEP.

        In the Equity section, developer references research demonstrating disparities in maternal mortality in this population by race and disparities in post-delivery complications for low-income persons.

      Limitations:

      • The developer indicates that a measure assessing clinician performance in this area is lacking. It would be helpful to know what resources they reviewed before drawing this conclusion.

      Rationale:

      • The measure focus is well supported by empirical data from prenatal and postpartum populations, and similar assessments have been endorsed by clinician groups, including ACOG. CVD is the leading cause of maternal mortality and many of these cases are preventable.

        The developers do a thorough job of evaluating the importance of this measure focus to patients, and expanded their TEP to include patients with experience with CVD. In addition, the evidence base shows disparities in maternal mortality and post-delivery complications.

        The developer indicates that a measure assessing clinician performance in this area is lacking. It would be helpful to know what resources they reviewed before drawing this conclusion.

      Feasibility Acceptance

      Feasibility Rating
      Met
      Feasibility Acceptance

      Strengths:

      • The developer reports that feasibility for the measure is high because it can be abstracted from EHRs for those entities that have integrated the algorithm into their systems. For the electronic option, all needed data elements are available electronically.

        With training and EHR implementation, this measure can be generated in normal care processes.

        There are no fees associated with the measure.

      Limitations:

      • This measure was not classified as an eCQM because there is a paper option, but it is not clear whether the developer evaluated feasibility for the paper option, and no feasibility scorecard for the electronic option was provided (the feasibility scorecard is only required if the measure is an eCQM).

        The developer indicates that the measure needs to be integrated into the clinic workflow to avoid issues that may arise if someone other than the clinician documents the result of the assessment.

        The measure contains some limited proprietary code that the user must obtain licenses for. 

      Rationale:

      • The measure includes an algorithm to be integrated into EHRs, and once this is done the measure is easily generated, assuming clinicians receive appropriate training in using the assessment.

        While this is not categorized as an eCQM,the committee could consider whether this submission would benefit from more information regarding completeness of the data elements across EHR systems, and if the implementation guide is sufficient. The developer does not describe any feasibility assessment performed for the paper option.

        The measure contains some proprietary code but there are no fees associated with the measure.

      Scientific Acceptability

      Scientific Acceptability Reliability Rating
      Met
      Scientific Acceptability Reliability

      Strengths:

      • The measure is clear and well defined. 
        Entity level reliability testing is conducted on 2022 data across 20 entities using the empirical Bayes method (the measure is not risk-adjusted). Average entity level reliability is >0.6 for all entities (minimum reliability is 0.839).
        Patient or encounter level reliability testing is mentioned with a kappa of 1.0.

      Limitations:

      • Only 23 entities were included in the reliability testing.
        There is no description of the patient/encounter level reliability test methodology.

      Rationale:

      • The measure is well defined. Reliability was assessed at the entity level. Reliability statistics are above the established thresholds for all entities.
      Scientific Acceptability Validity Rating
      Met
      Scientific Acceptability Validity

      Strengths:

      • Accountable entity testing: The developer conducted empirical accountable entity-level validity testing by calculating the correlation between the measure score and percentage of confirmed CVD cases in a cohort of 10,860 patients. The developers hypothesized and observed a positive correlation with a resulting Pearson Correlation Coefficient of r=0.424. The developer observed that patients with a positive risk assessment result were significantly more likely to have an abnormal follow-up test result than those with a negative result. The developer also collected face validity feedback from a Technical Expert Panel, 100% of which agreed that the measure is consistent with CVD diagnosis.

        Face validity: For analysis of face validity, the developer reported that the TEP “unanimously agreed that the measure assesses the quality of CVD risk assessment.” 

      Limitations:

      • The developers do not report data element validity testing for this new measure or assessment of missing data, nor did they provide a feasibility scorecard (noting this is not required for measures not categorized as eCQM).

        The developer does not provide details regarding how face validity was established. They also refer to case report evaluations, but it is unclear whether the case reports referred to were among the sources cited in the Importance section.

      Rationale:

      • The developer conducted empirical accountable entity-level validity testing by calculating the correlation between the measure score and percentage of confirmed CVD cases in a cohort of 10,860 patients. The developers hypothesized and observed a positive correlation with a resulting Pearson Correlation Coefficient of r=0.424. The developer observed that patients with a positive risk assessment result were significantly more likely to have an abnormal follow-up test result than those with a negative result. The developer also collected face validity feedback from a Technical Expert Panel, 100% of which agreed that the measure is consistent with CVD diagnosis.

        The developer reported high (100%) face validity but provided no details regarding how this was assessed. No data element testing was reported for this new measure.

        While this criterion is scored as 'Met', the committee should consider requesting more information regarding the establishment of face validity for this measure. In addition, the committee should explore whether the performance characteristics of the instrument have been sufficiently evaluated.
         

      Equity

      Equity Rating
      Not met but addressable
      Equity

      Strengths:

      • For this new measure, the developer cites empirical research that establishes disparities by race in maternal morbidity and mortality, including CVD. 

      Limitations:

      • The developer did not report whether they explored potential disparities in their testing data.

      Rationale:

      • For this new measure, the developer cites empirical research that establishes disparities by race in maternal morbidity and mortality, including CVD. The developer did not report whether they explored potential disparities in their testing data.

      Use and Usability

      Use and Usability Rating
      Met
      Use and Usability

      Strengths:

      • The developer reports that the measure will be used in the 2024 Merit-based Incentive Payment (MIPS) Value Pathways (MVPs). No unexpected findings or performance improvements are reported for this new measure.

        The developer lists actions entities can take to improve performance, including identifying clinics or clinicians who underperform, prioritizing clinician training, and integrating training into onboarding residents and new hires, and mentorship from experienced clinicians

      Limitations:

      • Developers did not report on a method for collecting feedback or potential unintended consequences of the measure.

      Rationale:

      • The developer reports that the measure will be used in the 2024 MIPS MVPs.

        The developer lists actions entities can take to improve performance, including identifying clinics or clinicians who underperform, prioritizing clinician training, and integrating training into onboarding residents and new hires, and mentorship from experienced clinicians.

        Through staff assessment review process, the developer confirmed that the measure is currently in use in MIPS MVPs, and the committee should consider whether there is a system for collecting and acting on feedback about the measure, and if there have been any unintended consequences with its use.
         

    • Submitted by Tamaire Ojeda on Tue, 06/25/2024 - 16:03

      Permalink

      Importance

      Importance Rating
      Met
      Importance

      Agree with the Staff Preliminary Assessment. 

      The importance of this measure is well established by the developer as well as all the public comments. One death is too many. 

      Feasibility Acceptance

      Feasibility Rating
      Not met but addressable
      Feasibility Acceptance

      Disagree with Staff Preliminary Assessment. 

      The paper documentation path was not provided, even though it is an option. What is burden to small clinics with short staffing, if no electronic pathway is available? 

      Scientific Acceptability

      Scientific Acceptability Reliability Rating
      Met
      Scientific Acceptability Reliability

      Agree with Staff Preliminary Assessment.

      Scientific Acceptability Validity Rating
      Met
      Scientific Acceptability Validity

      Agree with Staff Preliminary Assessment.

      Equity

      Equity Rating
      Not met but addressable
      Equity

      Disagree with Staff Preliminary Assessment.

      Differences are pointed out, but it is not clear how this measure will help support equity amongst disadvantaged demographics. Especially those without insurance. If no insurance but with risk of CVD, what are the options?

      Use and Usability

      Use and Usability Rating
      Not met but addressable
      Use and Usability

      Disagree with Staff preliminary Assessment. 

      In the submission there is no discussion of how this measure will help with those that do not have health insurance. It also does not address the expected false negatives, what is the expectation, and how their impact on the patient and health system. This may not be a big deal, but I am unable to evaluate it. The burden on the systems and clinics that have patients with poor or no health insurance coverage is not discussed either. This is important to support both the patient and the clinics that do not have resources as big health systems do. 

      Summary

      One death is too many. However, this measure does not discuss the impacts of a false positive or the impact on the patient or the smaller clinics, when a patient has poor or no insurance coverage. Was that tested/evaluated? I would love to see this measure endorsed, because of what it stands for, but I would hate to see negative impacts from lack of thorough evaluation. 

      Submitted by Jean-Luc Tilly on Tue, 07/02/2024 - 14:28

      Permalink

      Importance

      Importance Rating
      Met
      Importance

      Agree with staff assessment. I would have preferred to see a performance gap definitively articulated; however, in reviewing the literature a performance gap is clear.

      Feasibility Acceptance

      Feasibility Rating
      Met
      Feasibility Acceptance

      Agree with staff assessment. No issues.

      Scientific Acceptability

      Scientific Acceptability Reliability Rating
      Met
      Scientific Acceptability Reliability

      Agree with staff assessment. Testing supports the reliability of the numerator and denominator. 

      Scientific Acceptability Validity Rating
      Met
      Scientific Acceptability Validity

      Agree with staff assessment. Testing supports the validity of the measure result.

      Equity

      Equity Rating
      Met
      Equity

      Agree with staff assessment. Disparities clearly demonstrated.

      Use and Usability

      Use and Usability Rating
      Met
      Use and Usability

      Agree with staff assessment. Measure currently in use.

      Summary

      This measure addresses an important performance gap in screening processes, with potential to save lives. Few issues were identified with the submission, and should not prevent endorsement.

      Submitted by Jennifer Bailit on Thu, 07/04/2024 - 11:40

      Permalink

      Importance

      Importance Rating
      Met
      Importance

      Very important topic

      Feasibility Acceptance

      Feasibility Rating
      Met
      Feasibility Acceptance

      measure has shown to be feasible in systems with some brands of EHR.  Further testing needed to assess collection burden when done manually.

      Scientific Acceptability

      Scientific Acceptability Reliability Rating
      Met
      Scientific Acceptability Reliability

      acceptable, the measure seems to measure what it intends.

      Scientific Acceptability Validity Rating
      Not Met
      Scientific Acceptability Validity

      The true test of a screening tool is whether it picks up cases that would not otherwise have been found.  From the data presented, I do not find this to be the case.  It is possible that further data exist that better demonstrate the developers supposition that the screening test adds value in finding cases of CVD.  Please see my interpretation of the data shown in the flow sheet below.

       

      Flow chart shows 13/5902 who were screened were found to have CVD (.22%).  11/4958 who were not screened had CVD (.22%).  This is not convincing that screening picked up additional cases of CVD over clinical care alone.  However the screened population had 4472/5902 =75.8% with testing.  Unscreened had 3192/4958 =64.4% with testing.  Thus, there were 11.4% higher rates of testing in the screened group without additional positive cases identified.  Screening tool may not be a large improvement over traditional care and may add additional time and worry burden as well as cost of testing for the patient.

      Equity

      Equity Rating
      Met
      Equity

      equity rating met

      Use and Usability

      Use and Usability Rating
      Not Met
      Use and Usability

      See summary comment

      Summary

      The topic is of critical importance and the measure seems reliable in what is sets out to measure. There are large equity issues in CVD in pregnancy and the measure could theoretically make a difference by eliminating provider bias if providers rely on an objective tool. The data presented showed there were 11.4% higher rates of testing in the screened group compared to the unscreened group without additional positive cases identified.  The screening tool may not be a large improvement over traditional care and may add additional time and worry burden as well as cost of testing for the patient. Further data (ideally randomized or cluster trial) is needed to show that screening a population with the measure picks up additional cases of CVD compared to not screening.  Trial should also look at cost of additional testing both monetarily and in terms of burden to the patient and the patient experience.  The data presented at present, are not convincing enough to roll out the measure on a national basis.  Additional testing in labor units that are nurse or laborist driven rather than residency driven would be important.  For the clinics that need to perform the tool manually, cost and time estimates added per additional case detected should be determined before widespread roll out.  In short, it is an important topic and the measure shows promise, but further testing of the measure is needed.

      Submitted by Kyle Campbell on Fri, 07/05/2024 - 11:33

      Permalink

      Importance

      Importance Rating
      Met
      Importance

      Agree with staff assessment. Important topic with clear linkage to outcomes. Would be helpful to know more about ACOG's endorsement of the tool. The developers indicate that the measure can be met with the use of any validated tool but the California Maternal Quality Care Collaborative (CMQCC) is the only tool available. Seems like specifications should be specific to this tool or results would not be comparable across institutions.

      Feasibility Acceptance

      Feasibility Rating
      Not met but addressable
      Feasibility Acceptance

      Disagree with staff assessment. It is not clear from the information provided that the feasibility of data elements was systematically addressed across all institutions. It was stated that all data were available in the EHR but also that sites could use a paper tool. For sites using the paper tool, is there an abstraction guide available?

      Scientific Acceptability

      Scientific Acceptability Reliability Rating
      Not met but addressable
      Scientific Acceptability Reliability

      Disagree with staff assessment. Accountable level entity reliability for clinics appears to be appropriate and well above established thresholds. Measure specifications indicate measure is specified at the individual clinician level but clinician level reliability does not appear to be assessed. Need to address precision of specifications. 

      Scientific Acceptability Validity Rating
      Met
      Scientific Acceptability Validity

      Agree with staff assessment. Additional information on face validity would be helpful.

      Equity

      Equity Rating
      Not met but addressable
      Equity

      Agree with staff assessment.

      Use and Usability

      Use and Usability Rating
      Met
      Use and Usability

      Agree with staff assessment.

      Summary

      Important measure concept. Additional information is needed to support as specified. 

      Submitted by Pat Merryweath… on Fri, 07/05/2024 - 21:30

      Permalink

      Importance

      Importance Rating
      Met
      Importance

      Highly important in reducing mortality among pregnant and post partum women.  Definitely would serve to reduce disparities among Black women and other non-Black women if conducted on all women.

       

      Feasibility Acceptance

      Feasibility Rating
      Met
      Feasibility Acceptance

      If women knew it would reduce their risk of death, they would take it.  Ideally it should be included in testing of all pregnant and post-partum women.  

       

      Scientific Acceptability

      Scientific Acceptability Reliability Rating
      Met
      Scientific Acceptability Reliability

      It has been utilzed in many academic settings and it was not clear to me if they were able to share the results of those tests in terms of identifying women at risk and saving their lives.

      Scientific Acceptability Validity Rating
      Met
      Scientific Acceptability Validity

      It is an evidence based initiative .

      Equity

      Equity Rating
      Met
      Equity

      Definitely is key to reducing the risks among Black women and non-Black women.  All it takes is for this test to be administered with analysis of results -- and interventions provided for women at risk.

      Use and Usability

      Use and Usability Rating
      Met
      Use and Usability

      It appears to be usable if the results are reviewed and shared with all women -- not just non-Black women.

      Summary

      I strongly support this measure and look forward to the day when there is equity and a reduced number of deaths during pregnancy or post-partum.

      Submitted by Jill Blazier on Sun, 07/07/2024 - 21:17

      Permalink

      Importance

      Importance Rating
      Met
      Importance

      Agree with Staff Preliminary Assessment

       

      Feasibility Acceptance

      Feasibility Rating
      Not met but addressable
      Feasibility Acceptance

      Do not agree with Staff Preliminary Assessment. I believe this measure can be easily entered into maternal care workflows if clinics use an EMR that has this existing in the build, where data elements are already captured and the score can be calculated. However, I have concerns that there is need for limited proprietary code that the user must obtain licensing for.  Also, feasibility was not evaluated on the paper tool. What are the impacts to small clinics or clinics that do not use an EMR with the tool integrated?

      Scientific Acceptability

      Scientific Acceptability Reliability Rating
      Met
      Scientific Acceptability Reliability

      Agree with Staff Preliminary Assessment

      Scientific Acceptability Validity Rating
      Met
      Scientific Acceptability Validity

      Agree with Staff Preliminary Assessment

      Equity

      Equity Rating
      Not met but addressable
      Equity

      Agree with Staff Preliminary Assessment

      Use and Usability

      Use and Usability Rating
      Met
      Use and Usability

      Agree with Staff Preliminary Assessment

      Summary

      Needs a little more information on the Feasibility. I look forward to other thoughts and feedback in the discussion. 

      Submitted by Helen W Haskell on Sun, 07/07/2024 - 23:33

      Permalink

      Importance

      Importance Rating
      Met
      Importance

      Important measure addressing significant cause of patient harm.

      Feasibility Acceptance

      Feasibility Rating
      Met
      Feasibility Acceptance

      Agree with staff assessment

      Scientific Acceptability

      Scientific Acceptability Reliability Rating
      Met
      Scientific Acceptability Reliability

      Agree with staff assessment

      Scientific Acceptability Validity Rating
      Met
      Scientific Acceptability Validity

      Agree with staff assessment

      Equity

      Equity Rating
      Met
      Equity

      Addresses important source of harm for minority populations.While the measure does not single out any one population group, it is hard to see this as inequitable.

      Use and Usability

      Use and Usability Rating
      Met
      Use and Usability

      Agree with staff assessment

      Summary

      Important and well-constructed measure.

      Submitted by Greg Bocsi on Mon, 07/08/2024 - 03:29

      Permalink

      Importance

      Importance Rating
      Not met but addressable
      Importance

      Shouldn't the developer characterize a performance gap?

      Feasibility Acceptance

      Feasibility Rating
      Not met but addressable
      Feasibility Acceptance

      Thoughts about feasibility were included, but it wasn't a systematic assessment or a description of a strategy to make routine data capture feasible at the levels of analysis and settings listed

      Scientific Acceptability

      Scientific Acceptability Reliability Rating
      Met
      Scientific Acceptability Reliability

      agree with staff assessment

      Scientific Acceptability Validity Rating
      Not met but addressable
      Scientific Acceptability Validity

      I didn't see details of the the methodology that yielded a face validity estimate of 100%.  Did the TEP see the results of the empiric validity testing?  Seems like a very small number of cases and not the most impressive statistics.

      Equity

      Equity Rating
      Not met but addressable
      Equity

      There is a discussion of equity, but is the measure's anticipated contribution to equity only the intent to do this for everyone but without an ability to determine if it is actually done equally across groups?

      Use and Usability

      Use and Usability Rating
      Met
      Use and Usability

      appears usable, but that will have to be confirmed by seeing entities reporting this measure if/when available

      Summary

      A number of addressable issues, but need to see how they are addressed. Of course, we want to catch the true positives, but concerned about the costs and unintended consequences (incl. false positive screens) when searching for what may be few true positive cases.

      Submitted by Karen Johnson on Tue, 07/09/2024 - 08:33

      Permalink

      Importance

      Importance Rating
      Not met but addressable
      Importance

      Do not agree with staff assessment.  The evidence section did not describe studies demonstrating that doing the assessment led to the actions or outcomes listed in the conceptual model but instead appears to rely on concensus statements from professional organizations.  That section also did not provide estimates of current performance.  Per the former, the most I could find was included in the sample flowchart in the validity section, which suggests higher follow-up rates in those screened but not a higher rate of those with confirmed CVD compared to those not screened.   

      Feasibility Acceptance

      Feasibility Rating
      Met
      Feasibility Acceptance

      Agree with staff assessment.

      Scientific Acceptability

      Scientific Acceptability Reliability Rating
      Not Met
      Scientific Acceptability Reliability

      Do not agree with staff assessment. Entity level testing was not conducted at the individual level so measure cannot be endorsed for this level of analysis.  They also noted “eliminated clinics with a relatively large sample size”, which was concerning.

      Scientific Acceptability Validity Rating
      Not met but addressable
      Scientific Acceptability Validity

      Do not agree with staff assessment (at this time).  It seems like (of the 10,860 sample), 13 of those screened had confirmed CVD while 11 of those not screened had confirmed CVD (i.e., the same rate), although admittedly the follow-up test percentage was higher in the screened group.  (NOTE: this may be patient-level testing?).  The entity-level testing described appears to be for groups, not individuals (although this is not clear).  While they did conduct a face validity assessment, it appears they found agreement about the utility of the assessment tool itself, rather than whether use of the tool would differentiate poor vs. good quality care. 

      Equity

      Equity Rating
      Met
      Equity

      Agree with staff assessment.

      Use and Usability

      Use and Usability Rating
      Met
      Use and Usability

      Agree with staff assessment.  

      Summary

      Can likely change to support if evidence more clearly presented, if individual LoA removed.