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  • Measure Summary
  • NQMC:011397
  • May 2016
  • NQF-Endorsed Measure

End stage renal disease (ESRD): percentage of adult hemodialysis patient-months using a catheter continuously for three months or longer for vascular access.

Centers for Medicare & Medicaid Services (CMS). Measure information form: hemodialysis vascular access: long-term catheter rate. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2016 May. 35 p.

View the original measure documentation External Web Site Policy

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 percentage of adult hemodialysis patient-months using a catheter continuously for three months or longer for vascular access.

Rationale

Based upon data from the Centers for Medicare & Medicaid Services (CMS) Fistula First/Catheter Last initiative, a gradual trend towards lower catheter use has been observed among prevalent maintenance hemodialysis (HD) patients in the U.S., declining from approximately 28% in 2006 to approximately 18% by August 2015. Furthermore, the percentage of maintenance HD patients using a catheter for at least three months has declined as well over this time period from nearly 12% to 10.8%. Continued monitoring of chronic catheter use is needed to sustain this trend.

This measure is intended to be jointly reported with the Hemodialysis Vascular Access: Standardized Fistula Rate (see the related NQMC summary, End stage renal disease [ESRD]: adjusted percentage of adult hemodialysis patient-months using an autogenous arteriovenous fistula [AVF] as the sole means of vascular access). These two vascular access quality measures, when used together, consider AVF use as a positive outcome and prolonged use of a tunneled catheter as a negative outcome. With the growing recognition that some patients have exhausted options for an AVF, or have comorbidities that may limit the success of AVF creation, joint reporting of the measures accounts for all three vascular access options. The fistula measure adjusts for patient factors where fistula placement may be either more difficult or not appropriate and acknowledges that in certain circumstances an AV graft may be the best access option. This paired incentive structure that relies on both measures reflects consensus best practice, and supports maintenance of the gains in vascular access success achieved via the Fistula First/Catheter Last Project over the last decade.

Evidence for Rationale

National Quality Forum measure information form: hemodialysis vascular access: long-term catheter rate. Washington (DC): National Quality Forum (NQF); 2018 Feb 1. various p.

Primary Health Components

End stage renal disease (ESRD); hemodialysis (HD); long-term catheter use

Denominator Description

All patients at least 18 years old as of the first day of the reporting month who are determined to be maintenance hemodialysis (HD) patients (in-center and home HD) for the complete reporting month at the same facility (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

The numerator is the number of adult patient-months in the denominator who were on maintenance hemodialysis (HD) using a catheter continuously for three months or longer as of the last HD session of the reporting month (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
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

Reliability Testing

Method of Reliability Testing

The developer used January 2014–December 2014 CROWNWeb data to calculate facility-level annual performance scores. The National Quality Forum (NQF)-recommended approach for determining measure reliability is a one-way analysis of variance (ANOVA), in which the between-facility variation (σ_b^2) and the within-facility variation (σ_(t,w)^2) in the measure is determined. The inter-unit reliability (IUR) measures the proportion of the total variation of a measure (i.e., σ_b^2+σ_(t,w)^2) that is attributable to the between-facility variation, the true signal reflecting the differences across facilities. The developer assessed reliability by calculating IUR for the annual performance scores. If the measure were a simple average across individuals in the facility, the usual ANOVA approach would be used. The yearly based measure, however, is not a simple average and the developer instead estimate the IUR using a bootstrap approach, which uses a resampling scheme to estimate the within facility variation that cannot be directly estimated by ANOVA. A small IUR (near 0) reveals that most of the variation of the measures between facilities is driven by random noise, indicating the measure would not be a good characterization of the differences among facilities, whereas a large IUR (near 1) indicates that most of the variation between facilities is due to the real difference between facilities.

The reliability calculation only included facilities with at least 11 patients during the entire year.

Statistical Results from Reliability Testing

The IUR is 0.765, which indicates that 76.5% of the variation in the annual long-term catheter rate can be attributed to between-facility differences in performance (signal) and about 23.5% to the within-facility variation (noise).

Interpretation

The result of IUR testing suggests a high degree of reliability.

Validity Testing

Method of Validity Testing

Validity was assessed using Poisson regression models to measure the association between facility level quintiles of performance scores and the 2014 standardized mortality ratio (SMR, NQF 0369) and 2014 standardized hospitalization ratio (SHR, NQF 1463). Facility-level performance scores were divided into quintiles (Q1 to Q5), and the relative risk (RR) of mortality (and hospitalization, separately) was calculated for each quintile, using the combined Q1 and Q2 as the reference group. Thus, a RR greater than 1.0 would indicate a higher RR of mortality or hospitalization, compared to the lowest performance score quintiles.

In 2015, a vascular access technical expert panel (TEP) was convened to provide input on the development of access measures, and specifically input on exclusions for both catheter and fistula measures, and for fistula, risk adjustment factors to be considered. The TEP felt that minimizing catheter use is paramount and that while catheters may potentially be acceptable for some patients, they addressed this through identifying patient level exclusion criteria rather than risk adjustment. The candidate catheter measure was reviewed and validated by the TEP in 2015.

Statistical Results from Validity Testing

Quintiles of the performance scores were defined as follows:

  • Q1*: 0.0% - less than 6.24%
  • Q2*: 6.24% - less than 9.12%
  • Q3: 9.12% - less than 12.00%
  • Q4: 12.00% - less than 16.21%
  • Q5: 16.21% - less than 58.16%

*Q1 and Q2 as reference

Results from the Poisson model indicated that the percent of patient-months with a long-term catheter was significantly associated with the risks of mortality and hospitalization.

For the 2014 SMR, the RR of mortality increased as the performance measure quintile increased from the reference group (combined Q1 and Q2). For quintile 3, RR=1.03 (95% CI: 1.01, 1.05; p=0.006), quintile 4, RR=1.03 (95% CI: 1.01, 1.05; p=0.008), and quintile 5, RR=1.09 (95% CI: 1.07, 1.12; p less than 0.001).

Similarly for the 2014 SHR, the RR of hospitalization increased as the performance measure quintile increased from the reference group (combined Q1 and Q2). For quintile 3, RR=1.08 (95% CI: 1.08, 1.08; p less than 0.001), quintile 4, RR=1.10 (95% CI: 1.10, 1.10; p less than 0.001), and quintile 5, RR=1.16 (95% CI: 1.15, 1.16; p less than 0.001).

Interpretation

Results of the Poisson regression suggest the predictive relationship of higher catheter use with higher mortality and hospitalization, as measured by the respective standardized mortality and hospitalization rates, compared to facilities with a lower proportion of patients with a long-term catheter.

Evidence for Extent of Measure Testing

National Quality Forum measure information form: hemodialysis vascular access: long-term catheter rate. Washington (DC): National Quality Forum (NQF); 2018 Feb 1. various p.

State of Use

Current routine use

Current Use

External oversight/Medicare

Internal quality improvement

Measurement Setting

Ambulatory Procedure/Imaging Center

Hospital Outpatient

Managed Care Plans

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

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

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Living with Illness

IOM Domain

Effectiveness

Case Finding Period

The reporting month

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Patient/Individual (Consumer) Characteristic

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All patients at least 18 years old as of the first day of the reporting month who are determined to be maintenance hemodialysis (HD) patients (in-center and home HD) for the complete reporting month at the same facility

Patients are required to have been treated by the same facility for the complete month in order to be assigned to that facility for the reporting month.

The monthly patient count at a facility includes all eligible prevalent and incident patients. The number of patient-months over a time period is the sum of patients reported for the months covered by the time period. An individual patient may contribute up to 12 patient-months per year.

Exclusions
Exclusions that are implicit in the denominator definition include:

  • Pediatric patients (less than 18 years old)
  • Patients on peritoneal dialysis
  • Patient-months under in-center or home HD for less than a complete reporting month at the same facility

In addition, the following exclusions are applied to the denominator:

Patients with a catheter that have limited life expectancy:

  • Patients under hospice care in the current reporting month
  • Patients with metastatic cancer in the past 12 months
  • Patients with end stage liver disease in the past 12 months
  • Patients with coma or anoxic brain injury in the past 12 months

Exclusions/Exceptions

Medical factors addressed

Numerator Inclusions/Exclusions

Inclusions
The numerator is the number of adult patient-months in the denominator who were on maintenance hemodialysis (HD) using a catheter continuously for three months or longer as of the last HD session of the reporting month

The number of patient-months with a long-term catheter in use. Long-term catheter use is defined as using a catheter, at the same facility, for at least three consecutive complete months as of the last day of the reporting month.

For a given month, if any of the following CROWNWeb "Access Type IDs" (16,18,19,20,21,"·") has been recorded, a catheter is considered in use. If a catheter has been observed for three consecutive months (i.e., in the reporting month and the immediate two preceding months) at the same facility, the reporting month is counted in the numerator. Access Type ID "16" represents arteriovenous (AV) fistula combined with a catheter, "18" represents AV graft combined with a catheter, "19" represents catheter only, "20" represents port access only, "21" represents other/unknown, and "·" represents missing. If a patient changes dialysis facilities, the counting of the three consecutive complete months restarts at the new facility.

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Electronic health/medical record

Registry data

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Calculation Algorithm/Measure Logic Diagram: Hemodialysis Vascular Access: Long-term Catheter Rate

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a lower score

Allowance for Patient or Population Factors

Does not apply to this measure

Standard of Comparison

Internal time comparison

Original Title

Hemodialysis vascular access: long-term catheter rate.

Measure Collection Name

End Stage Renal Disease (ESRD) Quality Measures

Submitter

Centers for Medicare & Medicaid Services - Federal Government Agency [U.S.]

Developer

Centers for Medicare & Medicaid Services - Federal Government Agency [U.S.]

Funding Source(s)

Centers for Medicare & Medicaid Services (CMS)

Composition of the Group that Developed the Measure

Joseph Vassalotti, MD, FASN, FNKF
Chief Medical Officer, National Kidney Foundation
Associate Professor of Medicine, Division of Nephrology
Mount Sinai Medical Center
New York, NY

Monet Carnahan, RN, BSN, CDN
Renal Care Coordinator Program Manager
Fresenius Medical Center (FMC)
Franklin, TN
American Nephrology Nurses Association

Derek Forfang
Patient Leadership Committee Chair, ESRD Network 17
Board Member, Intermountain End State Renal Disease Network Inc.
Beneficiary Advisory Council (Vice Chair), The National Forum of ESRD Networks
Board Member, The National Forum of ERSD Networks
San Pablo, CA

Lee Kirskey, MD
Attending staff, Department of Vascular Surgery
Cleveland Clinic Foundation
Cleveland, OH

Nance Lehman
Board Member
Dialysis Patient Citizens (DPC)
Billings, MT

Charmaine Lok, MD, MSc, FRCPC (C)
Medical Director of Hemodialysis and Renal Management Clinics
University Health Network
Professor of Medicine
University of Toronto
Toronto, ON

Lynn Poole, FNP-BC, CNN NCC
Fistula First Catheter Last Project Clinical Lead
ESRD National Coordinating Center
Lake Success, NY

Rudy Valentini, MD
Chief Medical Officer
Children's Hospital of Michigan (CHM)
Professor of Pediatrics, Division of Nephrology
Wayne State University School of Medicine

Daniel Weiner, MD, MS
Nephrologist, Tufts Medical Center
Associate Medical Director, DCI Boston
Associate Professor of Medicine, Tufts University School of Medicine
Boston, MA

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Endorser

National Quality Forum

NQF Number

2978

Date of Endorsement

2016 Dec 9

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2016 May

Measure Maintenance

Annually

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

Source(s)

Centers for Medicare & Medicaid Services (CMS). Measure information form: hemodialysis vascular access: long-term catheter rate. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2016 May. 35 p.

Measure Availability

Source available from the Dialysis Data Web site External Web Site Policy.

For more information, contact Casey Parrotte at the Kidney Epidemiology and Cost Center, The University of Michigan, 1415 Washington Heights, Suite 3645 SPHI, Ann Arbor, MI 48109-2029; Phone: 734-763-6611; Fax: 734-763-4004; Email: parrotte@med.umich.edu.

NQMC Status

This NQMC summary was completed by ECRI Institute on May 22, 2018. The information was not verified by the measure developer.

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No copyright restrictions apply.

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