Quality Priorities

April 29, 2008

MINUTES
Kidney Care Quality Alliance Steering Committee
April 29, 2008
Conference Call

Attendees

Summary
Ms. Lester opened the call and introduced and welcomed Drs. Nishimi and McGonigal as new staff for the KCQA. Dr. Nishimi then noted that the purpose of the call is to update the Steering Committee on the following items:

1. CMS’ proposed Clinical Performance Measures (CPMs);

2. NQF’s Immunization Steering Committee measure harmonization recommendations and proposed modifications to KCQA’s Influenza Vaccination measure specifications; and

3. Potential KCQA-AMA collaboration for testing of measures with time-limited NQF-753-8 endorsement.

The KCQA Steering Committee discussed which, if any, of the NQF-recommended modifications will be incorporated into the Influenza Vaccination measure and will continue its deliberations with the receipt of additional information from Drs. Nishimi and McGonigal. The Steering Committee will likewise await a proposal from the Iowa Foundation for Medical Care for projected costs for data element specification of the five KCQA measures, as well as additional information on prospects for collaboration with the AMA on measure testing.

CMS’ Proposed Clinical Performance Measures
Ms. Lester provided an overview of CMS’ CPMs. Specifically, CMS recently published a list of 26 measures it may use in the future: five anemia management; five hemodialysis adequacy; two peritoneal dialysis adequacy; two mineral metabolism; five vascular access; two influenza vaccination; one patient survival; and four patient education, perception of care, and quality of life measures. The Steering Committee noted that six of the above measures – three of the anemia management measures, the patient survival measure, and one of the hemodialysis adequacy measures – have not yet received NQF endorsement and queried Dr. Straube as to whether CMS plans to use these unendorsed measures in Dialysis Facility Compare. Dr. Straube indicated that the notice was broader than the NQF’s endorsed set so as to preserve CMS’s options in the future.

NQF Immunization Steering Committee Recommendations
Dr. Nishimi next reported that NQF’s recently convened Immunization Steering Committee had expressed concern that the numerous influenza vaccination measures that have received NQFendorsement are inconsistent in their numerators, denominators, and exclusions, and the NQF Committee ultimately recommended that the indicators be replaced by a single measure applicable to most populations. Notably, NQF’s Committee acknowledged that as the ESRD population is particularly vulnerable; a measure applying specifically to these patients is both necessary and appropriate. However, it was recommended that the “time-limited endorsement” status of KCQA’s Influenza Vaccination measure be made contingent upon a number of modifications (see below).

Dr. Fivush addressed the NQF Committee’s recommendation to expand the denominator age group from  18 years of age to  6 months of age. She expressed concern that there is both a lack of evidence-based data and considerable professional controversy regarding the use of the live vaccine in children with chronic renal disease. She advised that this and other such nuances particular to this vulnerable pediatric population is sufficient grounds to justify excluding these patients from the measure. Dr. Fivush noted that she will forward to the KCQA Steering Committee the ACIP and CDC guidelines supporting the avoidance of the live attenuated vaccine in children and dialysis patients.

Dr. McGonigal then relayed to the Committee the specific modifications recommended by NQF’s Immunization Steering Committee. Specifically, she noted that the NQF Committee recommends a 3-part numerator that will capture patients who 1) receive the vaccine, 2) were counseled but refuse the vaccine, and 3) have medical contraindications to the vaccine (e.g., hypersensitivity). (N.B. KCQA’s numerator currently includes only those patients who receive the vaccine.) In addition, it is recommended that the denominator be expanded to include all patients over the age of 6 months (see discussion above) and that there be an exclusion for patient encounters when providers’ vaccine supply is in order by has not yet been received.

KCQA Steering Committee members expressed concern over the potential for increased administrative burden with the expansion of the numerator, as chart review will likely be required to capture the necessary data elements. Moreover, as there is ongoing controversy regarding the use of the live attenuated vaccine in ESRD patients – regardless of age – the Committee debated whether this vaccine type should be exluded from the measure. However, Dr. Nishimi advised the Committee against modifying the measure beyond what has been recommended by NQF’s Steering Committee, as this would necessitate further NQF review and might ultimately jeopardize its endorsement status.

Drs. Nishimi and McGonigal will contact the AMA to determine whether it intends to incorporate the recommended changes into its ESRD influenza vaccination measure. They also will further investigate whether the additional data elements could be collected electronically and, based on their findings, will ultimately formulate a recommendation to the Steering Committee on what, if any, of the recommended changes should be adopted.

Update on Potential KCQA-AMA Collaboration
Finally, Dr. Nishimi updated the Steering Committee on the potential for KCQA-AMA collaboration for the testing of measures with time-limited NQF-endorsement. She noted that she and Dr. McGonigal have been in contact with the AMA regarding this matter, and that the AMA has made substantial progress towards fielding its measures. Specifically, it has contracted with the Iowa Foundation for Medical Care for specification of the necessary data elements and data collection. Dr. Nishimi reported that as there was no objection from the AMA, Dr. McGonigal has contacted the Iowa Foundation and has requested it draft a proposal specifying expected costs for data element specification for the five KCQA measures. The proposal is expected by the end of the week.

Dr. Nishimi also noted that as it is likely that the AMA will require facility data during the testing of its measures, the potential for collaboration with the KCQA exists. She and Dr. McGonigal will continue their communications with the AMA and update the Steering Committee with progress.

Next Steps
The course of action for the Steering Committee on 1) modification of the Influenza Vaccination measure, 2) AMA collaboration, and 3) contracting with the Iowa Foundation for Medical Care for data element specification is dependant upon the receipt of additional information to be provided by Drs. Nishimi and McGonigal

Dr. Nishimi also stated that she would like to reinstitute regularly scheduled calls and so will be working with KCQA Steering Committee members to identify a time for such calls.