Skip to main content

The AHRQ National Quality Measures Clearinghouse (NQMC, qualitymeasures.ahrq.gov) Web site will not be available after July 16, 2018 because federal funding
through AHRQ will no longer be available to support the NQMC as of that date. For additional information, read our full announcement.
  • Measure Summary
  • NQMC:011399
  • Sep 2015
  • NQF-Endorsed Measure

End stage renal disease (ESRD): percentage of patient-months of pediatric (less than 18 years) in-center hemodialysis patients (irrespective of frequency of dialysis) with documented monthly nPCR measurements.

Centers for Medicare & Medicaid Services (CMS). Measure information form: dialysis adequacy. 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 patient-months of pediatric (less than 18 years) in-center hemodialysis patients (irrespective of frequency of dialysis) with documented monthly normalized protein catabolic rate (nPCR) measurements.

Rationale

Normalized protein catabolic rate (nPCR) provides an estimate of dietary protein intake and has been shown to provide additional information to spKt/V. Studies have shown that in adolescent patients who achieved target spKt/V levels, nPCR was associated with nutritional status. Furthermore, there is evidence that nPCR less than 1 gram/kg/day is predictive of malnutrition and sustained weight loss among adolescent patients.

Evidence for Rationale

National Quality Forum measure information form: measurement of nPCR for pediatric hemodialysis patients. Washington (DC): National Quality Forum (NQF); 2018 Jan 25. various p.

Primary Health Components

End stage renal disease (ESRD); hemodialysis (HD); normalized protein catabolic rate (nPCR) measurement

Denominator Description

Number of all patient-months for pediatric (less than 18 years old) in-center hemodialysis patients (irrespective of frequency of dialysis) (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of patient-months in the denominator with monthly normalized protein catabolic rate (nPCR) measurements (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
  • 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 were used to calculate the inter-unit reliability (IUR) for the overall 12 months to assess the reliability of this measure. 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 IUR was estimated using a bootstrap approach, which uses a resampling scheme to estimate the within facility variation that cannot be directly estimated by ANOVA. The developer notes that the method for calculating the IUR was developed for measures that are approximately normally distributed across facilities. Since this measure is not normally distributed, the IUR value should be interpreted with some caution.

Statistical Results from Reliability Testing

The overall IUR was 0.985, which indicates that about 98.5% of the variation in the measure can be attributed to the between facility differences and 1.5% to within facility variation.

Interpretation

The IUR suggests this measure is reliable. However, since the distribution of performance scores is skewed, the IUR value should be interpreted with some caution.

Validity Testing

Method of Validity Testing

Concurrent validity was used as a method for testing the association between facility percentage of patients with normalized protein catabolic rate (nPCR) data elements and mean serum albumin. Although serum albumin is not a gold standard for nutritional assessment, it is a strong indicator of patient health and mortality in dialysis patients.

Using calendar year 2013 CROWNWeb data, average facility-mean albumin was compared between the two groups using a two-sided two-sample t-test, using facility percent of patients with nPCR data elements and mean serum albumin. Facilities were then categorized into one of two groups:

  1. Facilities with 100% reporting of nPCR among their pediatric patients;
  2. Facilities with less than 100% reporting of nPCR among their pediatric patients

nPCR values outside the range of [0.2, 1.8] were excluded.

This measure was also reviewed and approved by a clinical technical expert panel (TEP) in 2010.

Statistical Results from Validity Testing

Among facilities with at least 11 eligible pediatric patients with recorded nPCR values, facilities with 100% reporting of recorded nPCR values had a mean serum albumin of 3.77, while facilities with less than 100% reporting of recorded nPCR values had a mean serum albumin of 4.0. Using a t-test, these values were statistically significant (p-value 0.02).

Interpretation

These findings are somewhat unexpected, and in the opposite direction of analyses previously conducted. This difference may have resulted from a larger sample utilized for the current analyses (previous analyses were conducted over a limited timeframe). The developer speculates that the observed findings may have resulted if facilities are more likely to collect necessary data elements for nPCR assessment in patients for which nutritional concerns exist. These results therefore do not necessarily contradict the importance of evaluating nPCR.

Evidence for Extent of Measure Testing

National Quality Forum measure information form: measurement of nPCR for pediatric hemodialysis patients. Washington (DC): National Quality Forum (NQF); 2018 Jan 25. 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 less than 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
Number of all patient-months for pediatric (less than 18 years old) in-center hemodialysis patients (irrespective of frequency of dialysis)

The duration of hemodialysis treatment will be calculated as the difference between the first "Kt/V Collection Date" and "Date Regular Chronic Dialysis Began." The patient's age will be determined by subtracting the patient's date of birth from the first day of the reporting month. In-center hemodialysis patients are defined as follows: "Admit Date" to the specified facility is prior or equal to the first day of the study period, AND the patient has not been discharged ("Discharge Date" is null or blank), OR "Discharge Date" from the facility is greater than or equal to the last day of the study period AND "Treatment Dialysis Broad Start Date" is prior or equal to the first day of the study period, AND "Dialysis Broad Type of Treatment" = 'HD,' AND "Primary Dialysis Setting" = 'Dialysis Facility/Center' on the last day of the study period, AND "Date Regular Chronic Dialysis Began" is prior to the first day of the study period.

Exclusions
Exclusions that are implicit in the denominator definition include adult patients (greater than or equal to 18 years old), all patients who have not been in the facility for the entire reporting month, and all home hemodialysis patients. There are no additional exclusions for this measure.

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of patient-months in the denominator with monthly normalized protein catabolic rate (nPCR) measurements

The numerator will be determined by counting the patients in the denominator who meet one of the following criteria during the study month: nPCR is populated AND "Date nPCR Collected" is populated, OR "Kt/V Hemodialysis Collection Date" is populated, AND "BUN Pre-Dialysis" is populated, AND "BUN Post-Dialysis" is populated, AND "Pre-Dialysis Weight" is populated, AND "Pre-Dialysis Weight Unit of Measure" is populated, AND "Post-Dialysis Weight" is populated, AND "Post-Dialysis Weight Unit of Measure" is populated, AND "Delivered Minutes of BUN Hemodialysis Session" is populated AND "Interdialytic Time" is populated.

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

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

Internal time comparison

Original Title

Measurement of nPCR for pediatric hemodialysis patients.

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 dialysis adequacy in end stage renal disease (ESRD) patients.

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Endorser

National Quality Forum

NQF Number

1425

Date of Endorsement

2017 Jan 11

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: dialysis adequacy. 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.

NQMC Disclaimer

The National Quality Measures Clearinghouse™ (NQMC) does not develop, produce, approve, or endorse the measures represented on this site.

All measures summarized by NQMC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public and private organizations, other government agencies, health care organizations or plans, individuals, and similar entities.

Measures represented on the NQMC Web site are submitted by measure developers, and are screened solely to determine that they meet the NQMC Inclusion Criteria.

NQMC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or its reliability and/or validity of the quality measures and related materials represented on this site. Moreover, the views and opinions of developers or authors of measures represented on this site do not necessarily state or reflect those of NQMC, AHRQ, or its contractor, ECRI Institute, and inclusion or hosting of measures in NQMC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding measure content are directed to contact the measure developer.