June 24, 2006
MINUTES
Kidney Care Quality Initiative-Quality Care Measures Working Group
June 24, 2006
Meeting at Patton Boggs
Attendees:
Dr. William Haley
Dr. Jerry Lee
Dr. Charles McAllister
Dr. Rulan Parekh
Kathy Lester, Patton Boggs and Kidney Care Partners
Kathleen Strottman, Patton Boggs
Caitlin McCormick, Patton Boggs
Summary:
The Work Group discussed the current political environment. The group reviewed the materials provided by Dr. McAllister and responded to questions from Dr. Parekh. The Work Group ended their session by deciding that the grid should be finalized and distributed for final approval before it is sent to the Steering Committee on July 1.
Discussion of Political Environment:
The Work Group discussed concerns about measures that are purely process based rather than focused on outcomes. Dr. McAllister explained the need to keep in mind that the Kidney Care Partnership will need to get the Center for Medicare and Medicaid Services to agree to any measures
the Work Group might develop. The Work Group further discussed the important role that hard scientific facts plays in backing up the decisions of the Work Group in the face of political pressure.
Discussion of Data Collection among Physicians:
Dr. Haley raised concerns that while there is a system through which to use and collect these measures among facilities, there is no such system hrough which physicians can collect and report performance measures. Ms. Lester explained that the Steering Committee is considering establishing a data collection Work Group for Phase II of the Quality Initiative and that the P4P Work Group included a provision in the legislative specifications that would provide grants to help with information technology adoption.
Discussion of Global Elements:
The Work Group discussed concerns about establishing minimums for certain measures to ensure that independent care units are not penalized because they do not have sufficient numbers of patients to ensure appropriate evaluation of their performance. Because of this problem, the group agreed that facilities and physicians with less than 25 patients should be excluded from the P4P program.
Dr. Parekh asked if there will be an aggregate of facilities grouped by locality or if it will always be a single unit. The group agreed that facilities should report on a facility-by-facility basis.
The group then discussed the time-frame for taking the measurements. With the exception of adequacy of dialysis for PD (which will be 6 months), the group agreed the reporting period should be quarterly.
The group discussed the need to exclude patients that miss treatments. They agreed that if a patient misses one week out of the month there is no major concern, but that if a patient misses 3 or more treatments in a single month his/her physician and facility have lost the ability to significantly
influence outcomes for that individual. The group also agreed that to be counted patients must be present and on the same modality for the entire reporting period.
The group discussed process-based measures in the context of clinical practice and the need to examine what physicians can and cannot control. Dr. Haley noted that sometimes process-based measures are supported by hard scientific facts. He further addressed the need for effective measures to be both actionable and attributable. In addition to the measures selected, the Work Group discussed other potential measures and decided to consider them during the next phase of the Quality Initiative. These included bone and mineral metabolism, separate PD measures, referral for transplant, pneumococcal vaccination, and an upper limit for anemia management. The group concluded that there is not consensus as to
what constitutes “quality performance” for bone and mineral metabolism and separate PD measures. The group agreed that in terms of transplant referrals, there is already an expectation that every eligible patient will be offered the possibility of transplant under the conditions of coverage
for dialysis facilities.
Following these discussions, the Work Group agreed to set the threshold population at 25 patients, define facilities individually, set reporting time quarterly with an exception for PD kinetics which was set at 6 months, provide global exclusions for patients with less than one value per
month and patients missing more than three treatments in one month, define patient population as those patients present and using the same modality on the first and last day of the reporting period. To obtain the exclusion data, the group suggested Form 2728, facility co morbidity data, and medical and lab records as well as other relevant paper records. They also suggested that there be annual feedback reports to facilities.
Discussion of Performance Measures:
Anemia Management Performance Measures:
The group discussed the target goal for anemia. The group discussed using the CPMs and USRDS to set the target. The group agreed that for purposes of the starter set of measures should be set using the most recent USRDS. Dr. Parekh recommended USRDS, but said that we should confirm how they got their data and if they will be able to provide a yearly average.
Facility:
The group discussed how the measure would be calculated and decided to change the percentage of eligible patients with Hgb greater than eleven to 100 percent. They discussed the exclusion criteria and decided it was important to keep malignant diseases, including HIV and other chronic inflammatory /chronic infection diseases, separate from chemotherapy. They also decided to include patient refusal, hemoglobic anemia, other hematological disorders, and patients with a documented GI bleed during the reporting period.
Physician:
The group focused this measure on ensuring there is a plan of action in place rather than a specific result. The group agreed to use the most recent KDOQI actions and the same data sources that are used for access. The group also agreed to define the patient population in the same way a
facility defines their patient population. The group decided to set the numerator as the number of patients who do not have plan of action and set the denominator as the number of patients aggregated to the specific physician by MCP.
Dialysis Adequacy Measures:
The group agreed that the benchmarks for HD and PD would be the KDOQI guidelines They also decided to include in the exclusion criteria the general exclusions that were agreed upon in the anemia management measures, such as missed treatments and patient’s non compliance.
Physician:
The group agreed that the changes made for facility measures would also apply the physician measures. No other changes were made.
Influenza Vaccination Measures:
The Work Group discussed influenza vaccination. The group discussed the challenges related to ensuring that patients receive vaccinations and decided the measure should focus on whether the vaccination has been offered.
Facility:
The Work Group decided to set the numerator as the number of patients in facilities present between September 1st and December 1st who receive vaccination. The group also set the denominator as the number of patients in the facility between October 1st and December 1st. The Work Group decided to set the group as all ESRD patients treated at the facility during September, October, November, and December. The group then agreed to set the measure as the percentage of patients who were offered or recommended to take the vaccination to eliminate problems for smaller facilities who did not themselves administer vaccines but rather recommended vaccination by another provider. The group expanded the language of the exclusions to include patient attestation of a history of egg allergies as well as including patient who had gotten or said they had
gotten the vaccine between September and December of the current year. The group also agreed to put in a caveat for vaccine shortages.
Physician:
The group agreed that the exclusions would be the same as those for the facility measure. The group also removed language that had previously indicated that the vaccination must be done in the facility itself.
Prevalence of HD Patients with Catheters Measures:
Specifically, the group addressed the fistula first initiative. The group looked at whether referral of the patient for AV fistula is the best process to define or if there is a better process that could be actionable and attributable to the facility and would yield less people with catheters. The group agreed that the measure should be less than 10% catheters.
Facility:
The group decided to expand the language of the exclusion to specify patients who are maintained on hemodialysis for more then 90 days. The group also included patient refusal as an exclusion. The group agreed to set the benchmark at the current KDOQI guidelines and CPM.
Physician:
The group agreed to set the physician measure as the cumulative number of patients whom the physician receives the MCP. This change affects the numerator and denominator of the performance measure. The group further discussed the need for a system for collecting physician data.
Next Steps:
The group decided that the performance measures grid should be finalized to reflect today’s changes and to allow Work Group members to further comment on today’s decisions. Final comments from the group should be in by Friday, June 30th. Once all measures are finalized the measures will be submitted to the Steering Committee.
