NR 717 Week 4: sample paper, in real form

Severe Maternal Morbidity Across 4,180 Delivery Hospitalizations: A Population Outcome Measure Set and the Postpartum Coverage Mechanism Behind It

Student Name

College of Nursing, Chamberlain University

NR 717: Concepts in Population Health Outcomes and Health Policy

Professor Name

August 11, 2026

Population, Setting, and the Denominator

Riverbend Health is a composite three hospital safety net system serving a metropolitan county of 611,000 residents. Across the 12 months ending with the most recent complete fiscal year the system recorded 4,180 delivery hospitalizations, of which 2,341, or 56.0 percent, were financed by Medicaid. One site is a level III maternal care center and two are level I, so the system both delivers and receives transfers, which matters for any measure built from discharge records. The county carries a Black population share of 29 percent, and 41 percent of the delivery cohort lived in census tracts falling in the two most deprived quintiles of the Area Deprivation Index. These are the people the measures below are about.

The denominator for the outcome is delivery hospitalizations rather than live births, and the difference is not clerical. Live births exclude stillbirths and count infants rather than pregnancies, so a multiple gestation inflates the count while a fetal death removes a patient who may have been severely harmed. Delivery hospitalizations are also the unit the discharge abstract already produces, which keeps numerator and denominator inside one data system instead of two. Rates are therefore expressed per 10,000 delivery hospitalizations, the convention used in national reporting of severe maternal morbidity (Centers for Disease Control and Prevention, 2024).

Severe maternal morbidity is defined here by the 21 indicator algorithm applied to ICD-10-CM and ICD-10-PCS codes on the delivery discharge record, reported both with and without transfusion only cases, because transfusion coding drives a large share of the national rate and its use varies between hospitals (Centers for Disease Control and Prevention, 2024). Applied to the 4,180 delivery hospitalizations, the algorithm returned 61 cases including transfusion only and 29 excluding them, or 145.9 and 69.4 per 10,000. The window for the outcome is the delivery admission itself; the window for the postpartum measures that follow runs 12 months from the date of discharge.

The Measure Set

Four measures carry the work, each written as a numerator over a stated denominator. The outcome measure is the severe maternal morbidity rate per 10,000 delivery hospitalizations, with deliveries flagged by the indicator algorithm as numerator and all 4,180 as denominator. The first process measure is a documented blood pressure check within 7 to 10 days of discharge for every patient discharged with a hypertensive disorder of pregnancy, a denominator of 502 in the baseline year, which is the follow up interval the national postpartum care guidance recommends for that group (American College of Obstetricians and Gynecologists, 2018).

The second process measure is attendance at a postpartum visit between 7 and 84 days after delivery, taken from the prenatal and postpartum care measure that state Medicaid agencies report in the child core set, with a denominator restricted to the 2,341 Medicaid financed deliveries. The fourth measure is a coverage measure: the proportion of those 2,341 patients still continuously enrolled in Medicaid at 6 and at 12 months after delivery. Data sources are the discharge abstract for the outcome, the electronic record for the blood pressure check, and monthly Medicaid eligibility files for enrollment, linked on a system assigned identifier rather than on name and date of birth.

Every measure is reported stratified by patient reported race and ethnicity, by payer, and by Area Deprivation Index quintile, and no measure is reported only in aggregate. Aggregation is what hides the finding, since a system wide rate can improve while the gap inside it widens. A balancing measure sits alongside the four: emergency department visits within 42 days of delivery discharge, carried over the same denominators, which catches the case where earlier discharge or a tighter follow up schedule pushes care into the emergency department instead of preventing the need for it.

The Financing and Policy Mechanism

None of these measures move without a mechanism, and the mechanism here is coverage. Pregnancy related Medicaid eligibility historically ended 60 days after delivery, closing the payment source in the middle of the window when postpartum hypertension, infection and mental health crises present. Federal guidance opened a state plan option to extend that coverage to 12 months after delivery and set out the eligibility, benefit and implementation conditions for state agencies (Centers for Medicare & Medicaid Services, 2021). For Riverbend Health, state adoption of that option turns the 12 month coverage measure from an aspiration into a billable pathway for 2,341 patients a year.

A second mechanism attaches accountability to the measures themselves. Core set reporting by state Medicaid agencies has moved from voluntary to required, so the postpartum care measure now travels upward with the state's own performance attached to it (Centers for Medicare & Medicaid Services, 2024). That shifts the negotiating position of a safety net system, because a hospital able to produce stratified postpartum results holds something its state agency is obliged to report. The practical use of that position is a contract term: a perinatal quality incentive written into the managed care agreement and tied to the blood pressure follow up measure rather than to the morbidity rate.

Tying the incentive to a process measure rather than to the outcome is a deliberate choice, not a retreat. Severe maternal morbidity at this volume produces roughly 61 events a year, a count small enough that quarterly movement is mostly noise, and paying for a noisy outcome invites case selection rather than improvement. The blood pressure follow up measure has a denominator of 502, moves inside a quarter, and sits directly upstream of the outcome the system wants. The clinical content of the pathway is not invented here; it follows the severe hypertension in pregnancy safety bundle already published for maternal care units (Alliance for Innovation on Maternal Health, 2022).

Equity, Threats to Validity, and the Evaluation Design

Stratified baseline rates are the reason for the design. Severe maternal morbidity excluding transfusion only cases ran 69.4 per 10,000 across the system, and the rate among Black patients in the cohort was more than twice the rate among White patients, a ratio consistent in direction with national reporting of pregnancy related deaths (Petersen et al., 2019). Postpartum visit attendance moved the same way, lowest in the most deprived quintile. A system reporting one number for 4,180 deliveries can post an improvement while the group carrying the harm sees none, which is why the disparity ratio, and not the rate alone, is named as an outcome of record.

Three threats to validity belong on the page before any result is claimed. Coding intensity can move an ICD based indicator without any change in care, so every trend is read against the transfusion excluded definition as well as the full one. Transfers into the level III site concentrate severity at one hospital and make site level comparison misleading unless received cases are identified and analyzed separately. Eligibility files lag, so 12 month coverage cannot be evaluated until a full year after the last delivery in the cohort, and reporting it sooner would count patients whose enrollment had simply not yet been recorded.

Evaluation uses an interrupted time series with quarterly points, eight quarters before the coverage extension takes effect and eight after, with blood pressure follow up as the primary series and severe maternal morbidity as a secondary series read across the whole four year window rather than quarter by quarter. Success would look like a level change in follow up within two quarters, a narrowing disparity ratio, and no rise in the balancing measure. The design also states what would falsify the claim: follow up rising while emergency visits within 42 days rise alongside it would mean the pathway moved care rather than improved it.

References

Alliance for Innovation on Maternal Health. (2022). Severe hypertension in pregnancy patient safety bundle. American College of Obstetricians and Gynecologists. https://saferbirth.org/psbs/severe-hypertension-in-pregnancy/

American College of Obstetricians and Gynecologists. (2018). Optimizing postpartum care (ACOG Committee Opinion No. 736). Obstetrics and Gynecology, 131(5), e140-e150. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care

Centers for Disease Control and Prevention. (2024). Severe maternal morbidity in the United States. U.S. Department of Health and Human Services. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html

Centers for Medicare & Medicaid Services. (2021). Improving maternal health and extending Medicaid and CHIP postpartum coverage (State Health Official Letter No. 21-007). U.S. Department of Health and Human Services. https://www.medicaid.gov/federal-policy-guidance/downloads/sho21007.pdf

Centers for Medicare & Medicaid Services. (2024). Child and adult health care quality measures. Medicaid.gov. https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-and-child-health-care-quality-measures

Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Syverson, C., Seed, K., Shapiro-Mendoza, C., Callaghan, W. M., & Barfield, W. (2019). Racial and ethnic disparities in pregnancy related deaths: United States, 2007-2016. MMWR Morbidity and Mortality Weekly Report, 68(35), 762-765. https://doi.org/10.15585/mmwr.mm6835a3