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Measure Development Process

For its 2016-2017 cycle, KCQA will focus on a framework for Patient-Reported Outcomes for patients with ESRD; measure development per se will not be undertaken.

Cycle 3: Patient-Reported Outcomes Framework

As the National Quality Forum notes, “patients remain an untapped resource in assessing the quality of healthcare and of long-term support services. Patients are a valuable and, arguably, the authoritative source of information on outcomes beyond experience with care. These include health-related quality of life, functional status, symptom and symptom burden, and health behaviors.” With increased focus on patient-centered care, policymakers have become interested in using patient-reported outcome measures in public reporting and value-based purchasing programs.

For 2016-2017, KCQA has undertaken an initiative focused on a framework (e.g., principles, domains and subdomains, possible priorities, etc.) related to patient-reported outcomes (PROs), patient-reported outcome measures (PROMs), and patient reported outcome performance measures (PRO-PMs) for patients with ESRD.

KCQA PRO Initiative Final Report:

On September 13, KCQA released it’s final report, Patient Reported Outcomes for End-Stage Renal Disease: A Framework and Priorities for Measurement.

KCQA PRO Initiative In-Person Meeting:

On May 16, KCQA convened an in-person meeting in Washington, DC to discuss the recommendations of two commissioned papers and the findings of the environmental scan, interviews, and survey prioritization. The meeting documents and meeting summary are, as follow:

KCQA Calls and Materials:

KCQA kicked off its Cycle 3 work in July 2016 and held its first call on August 23.

KCQA Conference Call: August 23, 2016 * Meeting Materials and Call Summary

Cycle 2: Medication Management

For Cycle 2, the KCQA chose Medication Management as its focus for measure development because:

Nationwide, medication management (particularly adverse drug events), is a serious public health problem. According to the Centers for Disease Control and Prevention, each year adverse drug events result in 700,000 emergency department visits and 120,000 hospitalizations, and at least 40% of the costs for adverse drug events in ambulatory settings are preventable (CDC).
Medication management is a critical safety issue for ESRD patients, who often require 10 or more medications, have multiple comorbid conditions, have several health care providers and prescribers, and undergo frequent medication regimen changes.
Medication-related problems contribute significantly to the approximately $40 billion in public and private funds spent annually on ESRD care in the United States. The cost per preventable adverse drug event in dialysis patients was estimated to be $1,983 in 2000, with a national annual cost of $887 million (Parker and Cardone; NIDDK).
A significant proportion of medication-related problems in hospitalized dialysis patients are attributed to an information gap that occurs during transitions between health care settings and are preventable.

Measure Specifications and Testing

The KCQA Steering Committee appointed a 11-member Measure Feasibility/Testing Workgroup to identify 4-5, Medication Mangement measure concepts, which will ultimately result in KCQA testing 1-2 related measures.

KCQA Calls and Materials:

KCQA kicked off its Cycle 2 development activities in August 2015. On October 19, members approved Medication Management as its next priority for measure development.

KCQA Conference Call: April 18, 2016 * Meeting Materials and Call Summary
KCQA Conference Call: January 8, 2016 * Meeting Materials and Call Summary
KCQA Conference Call: December 16, 2015 * Meeting Materials and Call Summary
KCQA Conference Call: October 19, 2015 * Meeting Materials and Call Summary
KCQA Conference Call: September 9, 2015 * Meeting Materials and Call Summary

Current Specifications

In response to testing, the draft specifications were further modified. At this time, only MM-2 —Medication Management for Patients Receiving Care at Dialysis Facilities — has been submitted to NQF for endorsement consideration. The current specifications may be accessed here.

Draft Specifications Available for Comment

On January 4, 2016, the Steering Committee concurred with the Workgroup’s recommendation to advance two medication reconciliation measures MM-2: Medication Reconciliation for Patients Receiving Care at Dialysis Facilities and MM-3: Medication Reconciliation at Care Transitions for Patients Receiving Care at Dialysis Facilities—to the testing phase and reviewed this decision with all KCQA members on January 8. The draft specifications for all measures are available here for review and comment through 6 pm ET, January 22, 2016.

Conference calls are open to KCQA members and the public; interested parties may contact Lisa McGonigal, MD, MPH at lmcgon@msn.com for dial-in information. Comments on the draft specifications also may be directed to Dr. McGonigal via e-mail; please ensure the subject line reads KCQA Specification Comments.

Cycle 1: Fluid Management

KCQA began its 2014 measure development process with an environmental scan to identify the universe of current ESRD measures, including those being used for internal quality improvement purposes. KCQA also identified gaps in the existing measure set. Following this scan, all KCQA members participated in a modified Delphi process, using KCP’s Strategic Quality Blueprint as the starting point, to prioritize the measure development areas that could be most influential in improving patient outcomes and potentially, through care improvement, reducing costs, with the end goal to improve the existing measure set available for potential inclusion in the QIP. The top five measurement areas identified, in priority ranking order, were Fluid Management; Rehospitalization; Vascular Access; Nutrition; and Health-Associated Infections.

The KCQA chose Fluid Management (FM) as the top 2014 priority because:

FM is a crucial aspect of high-quality dialysis care.
A 2010 study published in the Clinical Journal of the American Society of Nephrology (CJASN) involving 25,291 dialysis patients tracked 41,699 care episodes that resulted in inpatient hospitalization, observations or emergency room (ER) visits due to complications primarily from fluid overload, at a cost to the Medicare system of $6,372 per patient or $266 million.
FM involves a very delicate balance managed by skilled clinicians working closely with patients and dialysis staff during and between dialysis treatments. This balance involves limiting salt and water intake between dialysis treatments. Excess accumulation of fluid leads to heart attacks, high blood pressure, fluid in the lungs and even cardiac arrest.
Surprisingly, there are no current evidence-based clinical practice guidelines for FM in the dialysis patient.
More effective FM will improve patient survival, result in fewer hospital admissions and readmissions and less ER use, improve patient quality of life, and reduce health care spending by lessening the burden on the Medicare program and the American taxpayer.

Measure Specifications and Testing

The KCQA Steering Committee appointed a 14-member Measure Feasibility/Testing Workgroup to identify 4-5 FM measure concepts, which will ultimately result in KCQA testing 1-2 related measures.

The specifications for the two fluid management measures—Post-Dialysis Weight Above or Below Target Weight and Avoidance of Utilization of High Ultrafiltration Rate (>13 ml/kg/hour)—submitted to NQF for endorsement consideration may be accessed here.