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  • Measure Summary
  • NQMC:009910
  • Apr 2014

End stage renal disease (ESRD): percentage of a facility's ESRD patients aged 18 years and older with medical record documentation of a discussion of renal replacement therapy modalities at least once during the 12-month reporting period.

Kidney Care Quality Alliance. KCQA performance measures: detailed technical specifications. Washington (DC): Kidney Care Quality Alliance; 2014 Apr 29. 2 p.

This is the current release of the measure.

This measure updates a previous version: Kidney Care Quality Alliance. KCQA patient education awareness: detailed technical specifications (facility level). Washington (DC): Kidney Care Quality Alliance; 2010. 1 p.

The measure developer reaffirmed the currency of this measure in April 2016.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of a facility's end stage renal disease (ESRD) patients aged 18 years and older with medical record documentation of a discussion of renal replacement therapy modalities (including hemodialysis [HD], peritoneal dialysis [PD], home HD, transplants and identification of potential living donors, and no/cessation of renal replacement therapy) at least once during the 12-month reporting period.

Rationale

Shared decision making is the recognized preferred model for medical decision making because it addresses the ethical need to fully inform patients about the risks and benefits of treatments and ensures that patients' values and preferences are considered. It is based on a common understanding of the goals of treatment and the risks and benefits of the chosen course compared with any reasonable alternative. However, observational evidence indicates that shared decision making, especially the legal requirements for full disclosure and informed decisions, is often not achieved in the dialysis setting. Many patients initiating dialysis receive or perceive inadequate information and may not understand the information they do receive, despite the fact that the diagnosis of progressive renal disease is known well before the actual need for dialysis arises.

Evidence for Rationale

Kidney Care Quality Alliance, Kidney Care Partners. National Quality Measures Clearinghouse (NQMC) measure submission form: end stage renal disease (ESRD) performance measurement set: patient education awareness (facility). 2010 Feb 3.  20 p.

Primary Health Components

End stage renal disease (ESRD); renal replacement therapy; patient education

Denominator Description

All end stage renal disease (ESRD) patients aged 18 years and older

Numerator Description

Number of patients from the denominator with medical record documentation of a discussion of renal replacement therapy modalities (including hemodialysis [HD], peritoneal dialysis [PD], home HD, transplants and identification of potential living donors, and no/cessation of renal replacement therapy) at least once during the 12-month reporting period

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
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences

Additional Information Supporting Need for the Measure

  • In 2008, the adjusted incident rate of end stage renal disease (ESRD) cases in the United States (U.S.) was 350.8 per million population, and the adjusted rate of prevalent cases rose 1.9 percent to 1,699 per million population. This rate is nearly 20 percent greater than that seen in 2000, and the annual rate of increase has remained between 1.9 and 2.3 percent since 2003.
  • The disease burden of ESRD disproportionately affects minority populations, in particular African American and Latino populations. The rate of ESRD in minority patients ranges from 1.5 to 4 times those of age-adjusted Caucasian patients.
  • Kidney disease is a major cause of morbidity and is the ninth leading cause of death in the U.S. Nearly 85,000 Americans die with kidney failure each year, with adjusted rates of all-cause mortality 6.4 to 7.8 times higher for dialysis patients than for individuals in the general population. The mortality rate is highest within the first six months of initiating dialysis at approximately 30 percent. The rate then declines over the next six months before increasing gradually again over the next four years.
  • Resource utilization by ESRD patients is substantial. For instance, in 2008 nearly 92% of the 112,476 incident U.S. ESRD patients were being treated via hemodialysis. Of these, 98.5% were being dialyzed three or more times per week at three or more hours per session. Additionally, the risk of hospitalization is 1.25 times greater in ESRD patients than in patients without, and adjusted hospital admission rates for dialysis patients have fallen only 1.5 percent since 1993.
  • Total Medicare costs rose nearly 11 percent in 2008—up from a 7 percent rise the previous year—to $454 billion. ESRD costs rose 13.2 percent to $26.8 billion, and accounted for 5.9 percent of the Medicare budget.

Evidence for Additional Information Supporting Need for the Measure

U.S. Renal Data System. USRDS 2010 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. Bethesda (MD): National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2010.

Extent of Measure Testing

Testing Protocol
The Kidney Care Quality Alliance (KCQA) tested its end stage renal disease (ESRD) measures through a prospective cohort study on a nationally drawn sample of 53 dialysis facilities containing a mix of for-profit and not-for-profit providers; hospital-affiliated and freestanding facilities within large, small, and independent dialysis organizations; urban, suburban, and rural settings; and facilities both with and without electronic health records (EHRs). Approximately 25 patients per facility were sought, resulting in a final sample size of 1,115 patients. Both facility and patient samples were structured to be generally representative of the national industry profile as identified by the United States Renal Data Systems (USRDS) 2007 Annual Data Report. Facility records were used as the data source, and standardized, paper-based data collection sheets constructed from the endorsed specifications were employed during data collection (see also the "Companion Documents" field for the data collection form).

Following the year-long data collection period, on-site data-integrity audits were performed at 11 of the 53 facilities (21%). Audit sites were selected to provide a cross-section of facilities reflective of the sample profile. Selection criteria included geographic location, facility type (e.g., for-profit vs. not-for-profit, urban vs. rural), and EHR use. Pertinent data were reabstracted from the patients' medical records and were compared to the information submitted by the facility throughout the pilot to assess the measure's reliability.

Testing Results
Performance: Patient education data were provided for all 1,115 patients in the study sample. The performance rate for the measure was calculated as follows:

Performance Rate =

(Pts educated on all modalities* - Pts educated but without documentation)
Total ESRD Pts Aged ≥ 18 Years

= (185 - 2) / 1,115 = 16.4%

Performance for each individual facility ranged from 0% to 100%, demonstrating a performance gap. 

Reliability: Inter-rater reliability and the reliability percentage were assessed during on-site data integrity audits through a direct comparison of data submitted by the facilities throughout the pilot to data reabstracted by the auditor(s). Results were quantitatively summarized using Cohen's Kappa with confidence intervals and were provided to the National Quality Forum, which then converted the measure from time-limited to full endorsement. Results indicated that the measure can be reliability collected, but it was recognized that clarification in the instructions as to what constitutes patient education on end-of-life care as defined by the measure was needed.

*Patient must be educated on all renal replacement modalities to receive credit for the measure.

Evidence for Extent of Measure Testing

Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977 Mar;33(1):159-74. PubMed External Web Site Policy

U.S. Renal Data System. USRDS 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda (MD): National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2007.

State of Use

Current routine use

Current Use

Internal quality improvement

Monitoring and planning

Measurement Setting

Ambulatory/Office-based Care

Ambulatory Procedure/Imaging Center

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Nurses

Physician Assistants

Physicians

Social Workers

Least Aggregated Level of Services Delivery Addressed

Clinical Practice or Public Health Sites

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Person- and Family-centered Care
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Living with Illness

IOM Domain

Effectiveness

Patient-centeredness

Case Finding Period

12 month reporting period

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All end stage renal disease (ESRD) patients aged 18 years and older

Exclusions
None

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of patients from the denominator with medical record documentation of a discussion of renal replacement therapy modalities (including hemodialysis [HD], peritoneal dialysis [PD], home HD, transplants and identification of potential living donors, and no/cessation of renal replacement therapy) at least once during the 12-month reporting period

Exclusions
None

Numerator Search Strategy

Fixed time period or point in time

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

Kidney Care Quality Alliance (KCQA) Patient Education Data Collection Form: Patient Education Awareness, Facility Level

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

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Patient education awareness (facility).

Measure Collection Name

End Stage Renal Disease (ESRD) Performance Measures

Submitter

Kidney Care Quality Alliance - Clinical Specialty Collaboration

Developer

Kidney Care Quality Alliance - Clinical Specialty Collaboration

Funding Source(s)

Kidney Care Partners

Composition of the Group that Developed the Measure

Kidney Care Quality Alliance Steering Committee Members:

  • Raymond M. Hakim, MD, PhD (Co-Chair)—Fresenius Medical Care
  • Gail S. Wick, BSN, RN, CNN (Co-Chair)—American Nephrology Nurses Association
  • Dolph Chianchiano, JD—National Kidney Foundation
  • Richard S. Goldman, MD—Renal Physicians Association
  • Barbara Fivush, MD—American Society of Pediatric Nephrology
  • Maureen Michael, BSN, MBA—National Renal Administrators Association
  • Allen Nissenson, MD—DaVita
  • Barry M. Straube, MD—Centers for Medicare and Medicaid Services (Liaison Member) 

Financial Disclosures/Other Potential Conflicts of Interest

None

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2014 Apr

Measure Maintenance

Annually

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates a previous version: Kidney Care Quality Alliance. KCQA patient education awareness: detailed technical specifications (facility level). Washington (DC): Kidney Care Quality Alliance; 2010. 1 p.

The measure developer reaffirmed the currency of this measure in April 2016.

Source(s)

Kidney Care Quality Alliance. KCQA performance measures: detailed technical specifications. Washington (DC): Kidney Care Quality Alliance; 2014 Apr 29. 2 p.

Measure Availability

Source not available electronically.

For more information, contact Kidney Care Partners at 2550 M Street, NW, Washington, DC 20037; Phone: 703-830-9192; Web site: www.kidneycarepartners.com External Web Site Policy.

Companion Documents

The following is available:

  • Kidney Care Quality Alliance. Attachment A: KCQA patient education data collection form. Patient education awareness, facility level. Washington (DC): Kidney Care Quality Alliance; 2010. 1 p.

For more information, contact Kidney Care Partners at 2550 M Street, NW, Washington, DC 20037; Phone: 703-830-9192; Web site: www.kidneycarepartners.com External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on November 8, 2011. The information was verified by the measure developer on December 8, 2011.

This NQMC summary was updated by ECRI Institute on June 10, 2015. The information was verified by the measure developer on July 13, 2015.

The information was reaffirmed by the measure developer on April 7, 2016.

Copyright Statement

© 2014 Kidney Care Quality Alliance. All Rights Reserved.

Full measure specifications for the individual measure, "ESRD: Patient Education Awareness (Facility)," are available from the Kidney Care Partners Web Site (www.kidneycarepartners.com External Web Site Policy). Check the Kidney Care Partners Web Site regularly for the most recent version of the specifications.

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