DialysisReports.org

End Stage Renal Disease (ESRD) Quality Measures

Specifications for the Quality Measures and the Dialysis Facility Compare Measures
Arbor Research Collaborative for Health, in collaboration with the University of Michigan Kidney and Epidemiology Cost Center (UM-KECC), develop, maintain, and update the End Stage Renal Disease (ESRD) Quality Measures for the Centers for Medicare and Medicaid Services (CMS), under the Quality Measure Development and Maintenance contract with CMS. These include the Clinical Performance Measures (CPM), the Dialysis Facility Compare (DFC) Measures, and the development of new quality measures that will be implemented beginning in 2012. Several of CMS’s current and new Quality Measures will be used by CMS in the CMS ESRD Quality Incentive Program (QIP). In addition, Arbor Research and UM-KECC work with CMS’s Measures Management System (MMS) in the development, evaluation, and reporting of the current ESRD Quality Measures.

New measures, as well as those that are revised, go through the National Quality Forum (NQF) consensus endorsement process. Once measures are in use, CMS requires that they periodically be reevaluated. This is to determine, for example, whether revisions are necessary in response to new clinical evidence, or a change in clinical guidelines since the last cycle of review. The last cycle of measure development occurred in 2007. In the summer of 2008, the specifications for the ESRD Quality Measures were formally documented with the MMS through collaboration with another CMS contractor, the Health Services Advisory Group, Inc. (HSAG). Documentation forms with the detailed measure specifications were completed for each ESRD measure (listed below), and were prepared by Arbor Research and UM-KECC.

In September 2010, a new set of quality measures were submitted to CMS. The final NQF endorsed measures will be implemented by CMS at a later date after the conclusion of the NQF endorsement process.



Final Measure Specifications for the PY 2016 ESRD Quality Incentive Program (QIP)
This final rule containing measures for payment year 2016 was displayed by CMS on November 22, 2013.


Proposed Measure Specifications for the PY 2016 ESRD Quality Incentive Program (QIP)
This proposed rule containing proposed measures for payment year 2016 was posted by CMS on July 1, 2013.


Final Measure Specifications for the PY 2015 ESRD Quality Incentive Program (QIP)
This final rule containing measures for payment year 2015 was published by CMS on November 2, 2012.

Proposed Measure Specifications for the PY 2015 ESRD Quality Incentive Program (QIP)
This proposed rule containing proposed measures for payment year 2015 was posted by CMS on July 2, 2012.


2014 ESRD Quality Incentive Program (QIP) Performance Standards
Performance standards for payment year 2014 are calculated using data collected over a full year (July 1, 2010 through June 30, 2011) in accordance with the Final Rule published by CMS on November 1, 2011.

2014 Measure Specifications for the ESRD Quality Incentive Program (QIP) Final Rule
This final rule containing measures for payment year 2014 was published by CMS on November 1, 2011.

2014 Measure Specifications for the ESRD Quality Incentive Program (QIP) Notice of Proposed Rule Making (NPRM)
This proposed rule containing measures for payment year 2014 was published by CMS on July 1, 2011.


2013 Measure Specifications for the ESRD Quality Incentive Program (QIP) Final Rule
This final rule containing measures for payment year 2013 was published by CMS on November 1, 2011.



2013 Technical Expert Panel (TEP) Summary Report
These documents summarize the proceedings and recommendations of the ESRD Clinical Technical Expert Panels (TEPs) convened by Arbor Research Collaborative for Health, and the University of Michigan Kidney and Epidemiology Cost Center, April 16-17, 2013 in Baltimore, MD.

This meeting included three Clinical TEPs focusing on Hemodialysis Adequacy, Mineral & Bone Disorder, and Preventive Care that met in person in Baltimore.   In addition, the Pediatric Peritoneal Dialysis Adequacy TEP was convened via teleconference April 11 and 17, 2013.   Convening the Clinical TEPs was one important step in the quality measure development process.   However, these reports do not include CMS’s final determination on the direction of new proposed ESRD quality measures.

The Mineral & Bone Disorder TEP recommended to leave unchanged the Hypercalcemia measure, which was added to the ESRD QIP for PY 2016 as identified in the NPRM published by CMS on July 1, 2013.   To view the Mineral & Bone Disorder TEP summary report, click here .   To view the specifications for the Hypercalcemia measure included in the PY 2016 NPRM, please see above.

To view the Hemodialysis Adequacy, Pediatric Peritoneal Dialysis Adequacy, and Preventive Care TEP summary reports, please visit the CMS website.   The ESRD Quality Measures TEP Summary Reports zip file can be found in Downloads box at the bottom of the Technical Expert Panel page.

To view the Summary Report for the 2012 Technical Expert Panels that were convened in the areas of Anemia Management and Hospitalization, please click here.



Clinical Performance Measures (CPM)
Since February 1, 2009, these CPMs are included in Phase 1 of CROWNWeb.

Anemia Management

Hemodialysis (HD) Adequacy

Peritoneal Dialysis (PD) Adequacy

Mineral Metabolism

Vascular Access



Dialysis Facility Compare (DFC) Measures
These measures are reported on CMS’s Dialysis Facility Compare website.

Anemia Management, Facility Level

Dialysis Adequacy, Facility Level

Vascular Access, Facility Level

Mineral and Bone Disorders, Facility Level

Hospitalizations and Deaths, Facility Level

 

FOR DIALYSIS FACILITIES AND STATE SURVEYORS

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Important Dates
7/15/2014
2014 DFRs, QDFC-Preview for 10/14, and PY15 PSRs posted

7/15/2014 - 8/15/2014
Comment period for 2014 DFRs, QDFC-Preview for 10/14, and PY15 PSRs

7/17/2014
DFC website refresh

For a detailed list of dates, click here.
New for the Quarterly Dialysis Facility Compare (QDFC)
Measures that were reported in the QDFC-Preview for July 2014 report will be displayed on the DFC website on July 17, 2014.  Facilities may currently preview reports and submit comments about their QDFC-Preview for October 2014 reports through August 15, 2014 (5:00 PM ET).   An overall star rating of facilities will be added to the DFC website in October.   A preview of that rating, for your facility, is included in the QDFC-Preview for October 2014 report.
New for the Dialysis Facility Report (DFR)
The 2014 DFRs are currently available.  New Standardized Transfusion measure has been added to Table 6 and data from CROWNWeb is summarized in Table 14.   Facilities may currently preview their reports and submit comments for their State Surveyors through August 15, 2014 (5:00 PM ET).
New for the ESRD Quality Incentive Program
The Payment Year (PY) 2015 QIP Preview Performance Score Reports (PSRs) will be available on Tuesday, July 15, 2014. Facilities may submit comments and questions from July 15 through August 15, 2014 (5:00 PM ET).

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