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  • Measure Summary
  • NQMC:011395
  • Sep 2015
  • NQF-Endorsed Measure

End stage renal disease (ESRD): percentage of all peritoneal dialysis and hemodialysis patient-months with serum or plasma phosphorus measured at least once within the month.

Centers for Medicare & Medicaid Services (CMS). Measure information form: mineral and bone disorder. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2015 Sep 25. 5 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 all peritoneal dialysis and hemodialysis patient-months with serum or plasma phosphorus measured at least once within the month.

Rationale

Consistent monitoring of phosphorus levels helps ensure regulation of patient morbidity and mortality, including stabilization of bone density, decreased bone pain, fracture prevention and decreased rates of arteriosclerosis and related conditions (e.g., stroke, heart attack). Routine blood tests will also aid in detection of and monitoring for abnormal states phosphorus balance in this especially vulnerable population.

Evidence for Rationale

National Quality Forum measure information form: measurement of phosphorus concentration. Washington (DC): National Quality Forum (NQF); 2016 Dec 16. various p.

Primary Health Components

End stage renal disease (ESRD); hemodialysis (HD); peritoneal dialysis (PD); serum or plasma phosphorus

Denominator Description

Number of patient-months among in-center hemodialysis, home hemodialysis, or peritoneal dialysis patients under the care of the dialysis facility for the entire reporting month (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of dialysis patient-months in the denominator with serum or plasma phosphorus measured at least once within 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 2013–December 2013 CROWNWeb data to calculate facility level monthly and annual performance scores. 5,951 facilities that had at least 11 eligible patients and included 517,762 patients in total were included in the testing.

The developer assessed reliability by calculating facility-level Pearson correlation coefficients between the current performance month and the preceding month for reporting months during January 2013–December 2013.

In addition, the developer calculated inter-unit reliability (IUR) for each reporting month and the overall 12 months. The monthly based measure was a simple average across individuals in the facility. The National Quality Forum (NQF)-recommended approach for determining measure reliability is a one-way analysis of variance (ANOVA), in which the between and within facility variation in the measure is determined. The IUR measures the proportion of the measure variability that is attributable to the between-facility variance. The yearly based measure, however, is not a simple average and the developer instead estimates the IUR using a bootstrap approach, which uses a resampling scheme to estimate the within facility variation that cannot be directly estimated by ANOVA.

Statistical Results from Reliability Testing

The Pearson correlation coefficients of each pair of the current and the preceding months ranged from 0.72 to 0.90, and were all statistically significant (p less than 0.0001), indicating this measure is reliable over time.

The monthly IURs ranged from 0.95 to 0.97, which indicates that at least 95% of the variation in the measure calculated at the monthly level can be attributed to the between facility differences and 5% to within facility variation. The annual IUR across the 12 reporting months was 0.98, which indicates that 98% of the variation in the measure calculated at the yearly level can be attributed to the between facility variation.

Interpretation

The IURs provide evidence of reliability in that most of the variation can be attributed to the between facility variation. The IUR suggest this measure is reliable. However, since the distribution of performance scores is skewed, the IUR value should be interpreted with some caution.

The results of the Pearson correlations indicate the measure is reliable over time.

Validity Testing

Method of Validity Testing

The developer used January 2013–December 2013 CROWNWeb data to calculate facility level monthly and annual performance scores. 5,951 facilities that had at least 11 eligible patients and included 517,762 patients in total were included in the testing.

The developer assessed validity using Poisson regression models to identify the predictive strength of facility level performance scores for the measure, on an NQF-endorsed standardized mortality rate, using the 2013 standardized mortality ratio (SMR) (NQF 0369).

Statistical Results from Validity Testing

Poisson regression modeling was used to assess the predictive strength of facility level performance scores for the measure, on mortality, using the 2013 NQF-endorsed SMR. The results suggest the measure performance scores were predictive of the standardized mortality rate, as measured by the SMR. For instance, the facility-level relative risk of mortality for a 10% increase in the performance score is 0.98 (p less than 0.0001).

Interpretation

The results of the Poisson regression suggest that facilities with a higher percentage of patient-months with phosphorous measured, have a lower standardized mortality rate relative to facilities with a lower percentage of patient-months with phosphorous measured. The direction of the relationship is as expected.

Evidence for Extent of Measure Testing

National Quality Forum measure information form: measurement of phosphorus concentration. Washington (DC): National Quality Forum (NQF); 2016 Dec 16. various p.

State of Use

Current routine use

Current Use

External oversight/Medicare

Internal quality improvement

Pay-for-performance

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

Specified

Target Population Age

Unspecified

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

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Number of patient-months among in-center hemodialysis, home hemodialysis, or peritoneal dialysis patients under the care of the dialysis facility for the entire reporting month

The denominator comprises all patient-months for patients during the 1-month study period, where patients have an "Admit Date" prior or equal to the first day of the month; whose "Discharge Date" is blank or greater than or equal to the last day of the month; whose "Primary Type of Treatment" = 'Hemodialysis,' 'CAPD' or 'CCPD' on the last day of the study period; and whose "Primary Dialysis Setting" = 'Dialysis Facility/Center' on the last day of the Study Period.

Exclusions
Exclusions that are implicit in the denominator definition include all patients who have not been in the facility the entire reporting month.

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of dialysis patient-months in the denominator with serum or plasma phosphorus measured at least once within the reporting month

The numerator comprises all eligible patient-months during the 1-month study period with a non-missing value for serum or plasma phosphorus.

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

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

Does not apply to this measure

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

Measurement of phosphorus concentration.

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

The Centers for Medicare & Medicaid Services (CMS) has contracted with the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) to develop measures of mineral and bone disorder in end stage renal disease (ESRD) patients.

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Endorser

National Quality Forum

NQF Number

255

Date of Endorsement

2016 Apr 14

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Sep

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: mineral and bone disorder. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2015 Sep 25. 5 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.

Copyright Statement

No copyright restrictions apply.

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