December 7, 2005
MINUTES
Kidney Care Quality Initiative Clinical Measures Work Group
December 7, 2005
Conference Call
Attendees:
Bill Haley, Facilitator Leader
John Burkart
Charlie McAllister
Jerry Yee
Lu Zawistowich, Patton Boggs
Kathy Lester, Patton Boggs and Kidney Care Partners
Not in Attendance:
Allan Collins
Summary
The Kidney Care Quality Initiative (KCQI) Clinical Measures Work Group reached consensus about vascular access, adequacy of hemodialysis, adequacy of peritoneal dialysis, anemia management, and immunization. The members also agreed to discuss potential advanced CKD measures related to hypertensive therapy, iron therapy for anemic, iron deficient, EPO or analogue treatment, vitamin D prescriptions, phosphate binder.
Discussion of Steering Committee Guiding Principles
The Work Group reviewed its charge to select from existing, evidence-based measures for adults that are appropriate measures of accountability and improvement. The members will propose a measurement set to the Steering Committee on December 12. As points of clarification, Dr. Haley indicated that the Work Group would not consider transplant patients, nor address morbidity or mortality.
These issues will be addressed in Phase II. Due to the timeframe, driven by Congressional interest in establishing a pay for performance system, no new measures will be created. Each of the members participating agreed that this approach was sensible, given that since Congress and CMS will act without input, it is better to develop a short-term proposal that is consistent with the current views of the kidney care community.
During Phase II, the Work Group will expand its discussion to include additional measures and sources, including the AMA physician consortium measures for physician accountability, CMS efforts for new vascular access and bone measures, as well as measures related to the number of patients on the waiting list for transplant.
Discussion of Development of Measures
Members discussed the purpose of clinical measures. They indicated that the KDOQI guidelines were not developed with the idea that measures could be derived from them. Measures should follow the condition and response form and evidence grades should be clear.
Functional specifications are necessary, meaning that when deriving measures from guidelines, the end goal is to produce something that improves care. Functional specifications require what is necessary and sufficient to be in place in order to achieve goal of care.
The final document from the Work Group will provide the set of measures and for each include: the measure’s name, clinical basis for it (including its evidence grade), and what is necessary to make the measure work.
Discussion of Clinical Measures
Using the draft measure chart as a tool to guide the discussion, the members discussed the following measures. They agreed that no measures will be considered for which there is not already consensus. The discussions focused on the work of CMS CPM Project, the Fistula First Initiative, the CMS G-codes for physicians, the 2000 and some of the 2006 KDOQI guidelines, among others.
Vascular Access
The members agreed recommend the CMS CPM I and II that seek to maximize the use of AV fistulae and minimize the use of catheters. Some members indicated concerns with the exact wording of the CMS CPMs. They agreed that monitoring measures remain controversial and, therefore, should not be included in Phase I.
Adequacy of Hemodialysis
The members agreed to consider further recommending a composite measure for the adequacy of hemodialysis that incorporates the CMS CPM I, II, and III (measurement of delivered dose, method of measurement of delivered dose, and the minimum delivered HD dose). They noted that the CMS G-codes mirror the CPMs.
Members also discussed whether or not it is appropriate to include this measure in a pay for performance program because many of the large dialysis (LDO) facilities already average 94 percent compliance with it. Some members indicated that although the measure may not distinguish between LDOs, it is still helpful at the individual facility or ESRD network level.
Adequacy of Peritoneal Dialysis
The members agreed to recommend a measure for the adequacy of peritoneal dialysis that incorporates the 2006 KDOQI guidelines (currently in review), which will establish the minimal delivered dose at peritoneal Kt/Vurea of at least 1.7 per week, rather than the previous target of 2.0. In addition, the members agreed that the dose should be measured once every four months.
One member suggested including blood pressure targets for the peritoneal dialysis population to encourage the community to pay more attention to its importance. The Work Group agreed that although a good idea, it would not be appropriate to include such a measure in Phase I because it is not mature enough. They agreed to consider it during Phase II.
Anemia Management
The members agreed to recommend a measure for a target hemoglobin level. They discussed whether the target should be as rigid as 11-12 g/dL or whether the target should be phrased with a focus on the negative, allowing only a certain percentage of patients to have documented hemoglobin levels less than 11. They concluded that this measure should be a process, rather than an outcome-based, measure and to develop appropriate wording to ensure that hemoglobin levels are maintained between 11 and 12 g/dL. The group agreed that hemoglobin levels over 12 g/dL are not beneficial.
The members agreed to recommend an iron-related measure as well. They agreed that worded with ferritin variables, current measures pose problems. They agreed to consider how to tailor a measure that eliminates ferritin and uses TSAT instead.
Immunization
The members agreed to recommend two process measures related to influenza and pneumonia immunizations. They asked Ms. Lester to explain congressional interest in such measures. She indicated that current agency activities, as well as language in pay for performance legislative proposals, seem to indicate that Congress would look favorably upon such measures.
CKD
The members agreed to consider during the next call the following measures related to advanced CKD (Stages 4 and 5), which have completed pilot testing: hypertension therapy, iron therapy for anemic patients, epoetin or analogue treatment, vitamin D prescription, and use of phosphate binders in CKD. The members agreed that lipid-lowering treatment measures were not yet mature enough to include. They, along with calcium, will be considered during Phase II.
Next Steps
Revised grids will be circulated, as will as draft recommendation summary that can be presented to the Steering Committee for review.
