| eCQM Title | Exclusive Human Milk Feeding |
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|---|---|---|---|
| CMS ID | 9 | eCQM Version Number | 14.0.000 |
| CBE Number | Not Applicable | GUID | 7d374c6a-3821-4333-a1bc-4531005d77b8 |
| Measurement Period | January 1, 2026 through December 31, 2026 | ||
| Measure Steward | The Joint Commission | ||
| Measure Developer | The Joint Commission | ||
| Endorsed By | None | ||
| Description |
PC-05 Exclusive human milk feeding during the newborn's entire hospitalization. The measure is reported as an overall rate which includes all newborns that were exclusively fed human milk during the entire hospitalization. |
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| Copyright |
Measure specifications are in the Public Domain. LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. ICD-10 copyright 2024 World Health Organization. All Rights Reserved. |
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| Disclaimer |
These performance measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty. |
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| Measure Scoring | Proportion | ||
| Measure Type | Process | ||
| Stratification |
None |
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| Risk Adjustment |
None |
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| Rate Aggregation |
None |
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| Rationale |
Exclusive human milk feeding for the first 6 months of neonatal life has long been the expressed goal of World Health Organization [WHO], 2007, Department of Health and Human Services (DHHS), American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG). ACOG has recently reiterated its position (ACOG, 2018). A Cochrane review substantiates the benefits (Kramer & Kakuma, 2012). Much evidence has now focused on the prenatal and intrapartum period as critical for the success of exclusive (or any) human milk feeding (Centers for Disease Control and Prevention [CDC], 2020; McGuire, 2014). Exclusive human milk feeding rate during birth hospital stay has been calculated by the California Department of Public Health (2020) for the last several years using newborn genetic disease testing data. Healthy People 2020 (National Center for Health Statistics, 2021) and the CDC have also been active in promoting this goal. |
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| Clinical Recommendation Statement |
Exclusive human milk feeding for the first 6 months of neonatal life can result in numerous long-term health benefits for both mother and newborn (Feltner et al.,2018) and is recommended by a number of national and international organizations. Evidence suggests that the prenatal and intrapartum period is critical for the success of exclusive (or any) human milk feeding. Therefore, it is recommended that newborns are fed human milk only from birth to discharge. |
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| Improvement Notation |
Increased score indicates improvement |
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| Reference |
Reference Type: Citation Reference Text: 'ACOG Committee Opinion No. 756 Summary: Optimizing support for breastfeeding as part of obstetric practice. (2018). Obstetrics & Gynecology, 132(4), 1086-1088. https://doi.org/10.1097/AOG.0000000000002891' |
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| Reference |
Reference Type: Citation Reference Text: 'California Department of Public Health. (2020). In-hospital breastfeeding initiation data: Hospital of occurrence. Retrieved from https://www.cdph.ca.gov/Programs/CFH/DMCAH/Breastfeeding/Pages/Hospital-of-Occurrence-2020.aspx' |
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| Reference |
Reference Type: Citation Reference Text: 'Centers for Disease Control and Prevention. Division of Nutrition, Physical Activity, and Obesity. (2022). Breastfeeding report card. Retrieved from https://www.cdc.gov/breastfeeding-data/breastfeeding-report-card/?CDC_AAref_Val=https://www.cdc.gov/breastfeeding/data/reportcard.htm' |
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| Reference |
Reference Type: Citation Reference Text: 'Feltner, C., Weber, R.P., Stuebe, A., Grodensky, C.A., Orr, C., & Viswanathan, M. (2018). Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK525106/' |
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| Reference |
Reference Type: Citation Reference Text: 'Kramer, M. S., & Kakuma, R. (2012). Optimal duration of exclusive breastfeeding. Cochrane Database of Systematic Reviews, 2012(8). https://doi.org/10.1002/14651858.cd003517.pub2' |
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| Reference |
Reference Type: Citation Reference Text: 'McGuire, S. (2014). Centers for Disease Control and Prevention. 2013. Strategies to prevent obesity and other chronic diseases: The CDC guide to strategies to support breastfeeding mothers and babies. Atlanta, GA: U.S. Department of Health and Human Services, 2013. Advances in Nutrition, 5(3), 291–292. https://doi.org/10.3945/an.114.005900' |
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| Reference |
Reference Type: Citation Reference Text: 'Meek, J.Y., & Noble, L. (2022). Section on Breastfeeding. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics, 150 (1). https://doi.org/10.1542/peds.2022-057988' |
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| Reference |
Reference Type: Citation Reference Text: 'National Center for Health Statistics. (2021). Healthy People 2020 Final Review. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/nchs/healthy_people/hp2020-final-review.htm' |
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| Reference |
Reference Type: Citation Reference Text: 'World Health Organization. (2007). Indicators for assessing infant and young child feeding practices. Washington, DC, USA: World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/handle/10665/43895/9789241596664_eng.pdf' |
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| Definition |
None |
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| Guidance |
A discharge to a designated cancer center or children's hospital should be captured as a discharge to an acute care facility. Data show that the majority of newborns with gestational age 37 weeks or more have a birth weight 3000 grams or more. Birth weight 3000 grams or more is a proxy to capture term newborns without gestational age recorded in EHR system. Only one birth weight value should be recorded. In cases where there is conflicting data, use the document recording the birth weight closest to the start of encounter. If dextrose or glucose 40% gel is given, it is considered a medication not a feeding. This should be reflected as such in the newborn's EHR documentation. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the eCQI Resource Center (https://ecqi.healthit.gov/qdm) for more information on the QDM. |
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| Transmission Format |
TBD |
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| Initial Population |
Inpatient hospitalizations for single newborns who were born in the hospital with a discharge date during the measurement period and with either of the following conditions: - Gestational age at birth of >= 37 weeks. - Birth weight >= 3000 grams without gestational age at birth. |
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| Denominator |
Equals Initial Population |
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| Denominator Exclusions |
Inpatient hospitalizations for newborns who were with any of the following conditions: - Admitted/transferred to the Neonatal Intensive Care Unit (NICU) or admitted/transferred to a regular intensive care unit (ICU). - Transferred to an acute care facility, or other health care facility. - Expired during the hospitalization. - A diagnosis of galactosemia. - Subject to parenteral nutrition. |
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| Numerator |
Inpatient hospitalizations for newborns who were fed human milk only since birth |
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| Numerator Exclusions |
None |
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| Denominator Exceptions |
None |
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| Supplemental Data Elements |
For every patient evaluated by this measure also identify payer, race, ethnicity and sex |
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PCNewborn."Single Live Term Newborn Encounter"
"Initial Population"
"Single Live Term Newborn Encounter With NICU Or ICU Admission Or Selected Discharge Disposition"
union "Single Live Term Newborn Encounter With Galactosemia Or Parenteral Nutrition"
"Single Live Term Newborn Encounter With Newborn Fed Human Milk Only Since Birth"
None
None
None
"Initial Population"
"Single Live Term Newborn Encounter With NICU Or ICU Admission Or Selected Discharge Disposition"
union "Single Live Term Newborn Encounter With Galactosemia Or Parenteral Nutrition"
PCNewborn."Single Live Term Newborn Encounter"
"Single Live Term Newborn Encounter With Newborn Fed Human Milk Only Since Birth"
["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
where exists ( InpatientEncounter.diagnoses EncounterDiagnoses
where EncounterDiagnoses.code in "Single Live Born Newborn Born in Hospital"
)
and InpatientEncounter.relevantPeriod ends during day of "Measurement Period"
"Single Live Birth Encounter" SingleLiveBornEncounter
without ["Assessment, Performed": "Gestational age--at birth"] GestationalAge
such that Global."EarliestOf" ( GestationalAge.relevantDatetime, GestationalAge.relevantPeriod ) during SingleLiveBornEncounter.relevantPeriod
and GestationalAge.result is not null
where "FirstBirthWeight"(SingleLiveBornEncounter)>= 3000 'g'
"Single Live Birth Encounter" SingleLiveBornEncounter
with ["Assessment, Performed": "Gestational age--at birth"] GestationalAge
such that GestationalAge.result >= 37 weeks
and Global."EarliestOf" ( GestationalAge.relevantDatetime, GestationalAge.relevantPeriod ) during SingleLiveBornEncounter.relevantPeriod
( "Single Live Birth Encounter With Gestational Age 37 Weeks Or More"
union "Single Live Birth Encounter With Birth Weight 3000 Grams Or More Without Gestational Age"
)
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer Type"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "Federal Administrative Sex"]
( PCNewborn."Single Live Term Newborn Encounter" QualifyingEncounter
with ( ["Procedure, Performed": "Parenteral Nutrition"]
union ["Medication, Administered": "Total Parenteral Nutrition"] ) ParenteralNutrition
such that Global."NormalizeInterval" ( ParenteralNutrition.relevantDatetime, ParenteralNutrition.relevantPeriod ) starts during QualifyingEncounter.relevantPeriod
)
union ( PCNewborn."Single Live Term Newborn Encounter" QualifyingEncounter
where exists ( QualifyingEncounter.diagnoses BirthEncounterDiagnoses
where BirthEncounterDiagnoses.code in "Galactosemia"
)
)
PCNewborn."Single Live Term Newborn Encounter" QualifyingEncounter
with ["Substance, Administered": "Human Milk"] HumanMilkFeeding
such that Global."NormalizeInterval" ( HumanMilkFeeding.relevantDatetime, HumanMilkFeeding.relevantPeriod ) starts during QualifyingEncounter.relevantPeriod
without ["Substance, Administered": "Dietary Intake Other than Human Milk"] OtherFeeding
such that Global."NormalizeInterval" ( OtherFeeding.relevantDatetime, OtherFeeding.relevantPeriod ) starts during QualifyingEncounter.relevantPeriod
PCNewborn."Single Live Term Newborn Encounter" QualifyingEncounter
where exists ( QualifyingEncounter.facilityLocations Location
where Location.code in "Neonatal Intensive Care Unit"
or Location.code in "Intensive Care Unit" //in case newborn was transferred to regular Intensive Care Unit for special care.
)
or QualifyingEncounter.dischargeDisposition in "Patient Expired"
or QualifyingEncounter.dischargeDisposition in "Discharge To Acute Care Facility"
or QualifyingEncounter.dischargeDisposition in "Other Health Care Facility"
if ( HasStart(period)) then start of period
else
end of period
Earliest(NormalizeInterval(pointInTime, period))
not ( start of period is null
or start of period = minimum DateTime
)
if pointInTime is not null then Interval[pointInTime, pointInTime]
else if period is not null then period
else null as Interval<DateTime>
First(["Assessment, Performed": "Birth Weight"] BirthWeight
where Global."EarliestOf"(BirthWeight.relevantDatetime, BirthWeight.relevantPeriod)during Encounter.relevantPeriod
and BirthWeight.result is not null
sort by Global."EarliestOf"(relevantDatetime, relevantPeriod)
).result as Quantity
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer Type"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "Federal Administrative Sex"]
| Measure Set |
eMeasure Perinatal Care (ePC) |
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|---|---|---|---|