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  • Measure Summary
  • NQMC:010643
  • Jan 2015
  • NQF-Endorsed Measure

Perinatal care: proportion of infants with gestational age between 22 and 29 completed weeks who were screened for retinopathy of prematurity (ROP).

Vermont Oxford Network. Proportion of infants with gestational age between 22 and 29 completed weeks who were screened for ROP. Burlington (VT): Vermont Oxford Network; 2015. 3 p.

This is the current release of the measure.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the proportion of infants with gestational age between 22 and 29 completed weeks who received a screening exam for retinopathy of prematurity (ROP) at the recommended post menstrual age.

Rationale

Retinopathy of prematurity (ROP) is a pathologic process occurring only in immature retinal tissue and can progress to tractional retinal detachment, leading to functional or complete blindness. Recent development of peripheral retinal ablative therapy using laser photocoagulation has resulted in the possibility of markedly decreasing the incidence of this poor visual outcome, but the sequential nature of ROP creates a requirement that at-risk preterm infants be examined at proper times to detect the changes of ROP before they become permanently destructive. As such, the American Academy of Pediatrics Section on Ophthalmology, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists issued a clinical guideline for the appropriate timing of initial screening for ROP based on an infant's gestational age (Fierson et al., 2013). The percentage of infants screened at the appropriate postmenstrual age is an important measure of the quality of care delivered to neonates.

Evidence for Rationale

Fierson WM, American Academy of Pediatrics Section on Ophthalmology, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Association of Certified Orthoptists. Screening examination of premature infants for retinopathy of prematurity. Pediatrics. 2013 Jan;131(1):189-95. PubMed External Web Site Policy

Vermont Oxford Network. Proportion of infants with gestational age between 22 and 29 completed weeks who were screened for ROP. Burlington (VT): Vermont Oxford Network; 2015. 3 p.

Primary Health Components

Perinatal care; retinopathy of prematurity (ROP); screening; infants

Denominator Description

All eligible infants whose gestational age is between 22 weeks, 0 days, and 29 weeks, 6 days, who are admitted to inpatient care at the reporting hospital within 28 days of birth without having been discharged home and who are still hospitalized at the postnatal age at which the first retinal screening exam is recommended by the American Academy of Pediatrics (AAP) guidelines (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of infants who had a retinal examination prior to discharge (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Collaborative inter-organizational quality improvement

Internal quality improvement

Quality of care research

Measurement Setting

Hospital Inpatient

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Physician Assistants

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Gestational age between 22 and 29 completed weeks

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness

Case Finding Period

Calendar year (January 1 through December 31)

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Institutionalization

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Time window precedes index event

Denominator Inclusions/Exclusions

Inclusions
All eligible infants whose gestational age is between 22 weeks, 0 days, and 29 weeks, 6 days, who are admitted to inpatient care at the reporting hospital within 28 days of birth without having been discharged home and who are still hospitalized at the postnatal age at which the first retinal screening exam is recommended by the American Academy of Pediatrics (AAP) guidelines

Population: Any infant who is admitted to inpatient care at the reporting hospital and whose gestational age is between 22 weeks, 0 days and 29 weeks, 6 days should be included, regardless of where in the hospital the infant receives care.

Note: Refer to the original measure documentation for calculation instructions and data item definitions. For administrative coding and additional data item information, refer to the 2016 Manual of Operations: Part 2 Data Definitions & Infant Data Forms (see the "Companion Documents" field).

Exclusions

  • Infants outside the gestational age range of 22 to 29 weeks
  • Infants admitted more than 28 days after birth
  • Infants who have been home prior to admission
  • Infants who die in delivery and are not admitted to inpatient care

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of infants who had a retinal examination prior to discharge

Note: Refer to the original measure documentation for additional information.

Exclusions
Unspecified

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Electronic health/medical record

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Analysis by subgroup (stratification by individual factors, geographic factors, etc.)

Description of Allowance for Patient or Population Factors

Gestational age, birth weight, inborn/outborn status

Standard of Comparison

External comparison of time trends

Internal time comparison

Original Title

Proportion of infants with gestational age between 22 and 29 completed weeks who were screened for ROP.

Measure Collection Name

Perinatal Care Measures

Submitter

Vermont Oxford Network - Health Care Quality Collaboration

Developer

Vermont Oxford Network - Health Care Quality Collaboration

Funding Source(s)

None

Composition of the Group that Developed the Measure

Neonatologists

Financial Disclosures/Other Potential Conflicts of Interest

None

Endorser

National Quality Forum

NQF Number

0483

Date of Endorsement

2014 Nov 3

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Jan

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

2016 May 2

Measure Status

This is the current release of the measure.

Source(s)

Vermont Oxford Network. Proportion of infants with gestational age between 22 and 29 completed weeks who were screened for ROP. Burlington (VT): Vermont Oxford Network; 2015. 3 p.

Measure Availability

Source not available electronically.

For more information, contact the Vermont Oxford Network, 33 Kilburn Street, Burlington, Vermont, 05401; Phone: 802-865-4814; Fax: 802-865-9613; Email: mail@vtoxford.org; Web site: https://public.vtoxford.org/ External Web Site Policy.

Companion Documents

The following is available:

  • Vermont Oxford Network. 2016 manual of operations: part 2 data definitions & infant data forms. Release 20.0. Burlington (VT): Vermont Oxford Network; 2015 Oct. 93 p. This document is available from the Vermont Oxford Network Web site External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on February 2, 2016. The information was verified by the measure developer on March 16, 2016.

Copyright Statement

No copyright restrictions apply.

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