ABIM Chronic Kidney Disease (CKD) PIM™ Practice Improvement Module Measures Catalogue

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American Board of Internal Medicine- Measures (2) This PIM examines the care you provide to your patients by addressing key processes and outcomes of chronic kidney disease care based on recommendations of the National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF KDOQI), and Kidney Disease: Improving Global Outcomes (KDIGO).
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ABIM Chronic Kidney Disease (CKD) PIM™ Practice Improvement Module Measures Catalogue

  1. 1. ABIM Chronic Kidney Disease (CKD) PIM™ Practice Improvement Module Measures Catalogue
  2. 2. Chronic Kidney Disease (CKD) Measures Catalogue May 2011 TABLE OF CONTENTS Introduction .............................................................................................................................................................. 3 Outcomes of Care ................................................................................................................................................... 5 Processes of Care Patient Evaluation................................................................................................................................................. 8 Diagnostic Testing.............................................................................................................................................. 11 Treatment: Medication ....................................................................................................................................... 17 Treatment: Other................................................................................................................................................. 21 Preventive Care ................................................................................................................................................. 25 Coordination of Care ........................................................................................................................................ 26 End of Life Care ................................................................................................................................................ 28Chronic Kidney Disease Measure Catalog May 2011 Page 2 of 28
  3. 3. IntroductionThis catalogue provides information related to the American Board of Internal Medicine’s Chronic Kidney Disease (CKD)Practice Improvement Module®. It is written in language that addresses the physician who might choose to complete thismodule, and it details the specifics of the module. Included is information regarding: • Purpose and structuring of the module • Patient inclusion criteria • Detailed description of the measuresThis PIM examines the care you provide to your patients by addressing key processes and outcomes of chronic kidney disease carebased on recommendations of the National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF KDOQI), andKidney Disease: Improving Global Outcomes (KDIGO)..The PIM is divided into three parts, with multiple sections in each part.Part 1 -Performance DataProvide baseline data about your practices current performance by: • Reviewing your charts • Assessing your practice systemsThe 68 chart review measures are summarized below. ABIM requires a minimum of 25 chart reviews. The practice systemsassessment comprises questions covering various aspects of practice structure and protocols.Patients can be included in this module if all of the following are true: 1. Patients are between the ages of 18 and 85 (inclusive); 2. Patient’s GFR is <30 mL/min/1.73 m2 for three months or longer; 3. Management decisions regarding their chronic kidney disease are made primarily by providers in the practice; 4. They have been patients in the practice for at least one year; AND 5. They have been seen by the practice within the past 12 months.Chronic Kidney Disease Measure Catalog May 2011 Page 3 of 28
  4. 4. Patients should be excluded from this module if any of the following are true: 1. They are on dialysis or have received a kidney transplant OR 2. They have late stage cancer, are currently receiving chemotherapy, or are in hospice.Part 2 - Quality Improvement (QI) PlanDevelop a plan for improving one aspect of your practice after reviewing the analysis of your current performance data. The analysiswill include many aspects of care you provide to your patients. Ultimately, you will target only one of these to use in this qualityimprovement (QI) cycle.Part 3 - RemeasurementRemeasure your performance data after you have implemented your QI plan to see if you achieved your goal. Then, you will reflect onthe process of developing and implementing a QI plan.You may claim CME credit for completing this activity. The University of Pennsylvania School of Medicine designates thiseducational activity for a maximum of 20 AMA PRA Category 1 Credit(s)TM.Chronic Kidney Disease Measure Catalog May 2011 Page 4 of 28
  5. 5. CKD - OUTCOMES OF CAREClinical OutcomesMeasure Title Description Numerator Denominator RationaleMost recent blood Patients in the sample Number of patients in the sample Number of patients Studies show that reducing blood pressurepressure < 130/80 mm whose blood pressure whose blood pressure in the sample. in people with CKD reduces the rate ofHg measurement at the most measurement at the most recent deterioration of their kidney function whether recent visit was less than visit was less than 130/80 mm or not they have hypertension or diabetes. 130/80 mm Hg. Hg. Randomized controlled trials conclusively demonstrate the benefit of lowering blood pressure to <140 mm Hg systolic and <80 mm Hg diastolic in patients. Epidemiologic studies show that the risk of CVD begins at blood pressures of >115/75 mm Hg. Experts have therefore agreed that <130/80 mm Hg is a reasonable target for blood pressure control in patients.Hemoglobin >=10 g/dL in Patients in the sample not Number of patients in the sample Number of patients Multiple studies have shown thatpatients not receiving an receiving an ESA whose not receiving an ESA whose in the sample. maintaining a hemoglobin >= 10 g/dL resultsESA and Hemoglobin 10 most recent Hemoglobin most recent Hemoglobin value in improvement in quality of life. Severalto 12 g/dL in patients value was greater than or was greater than or equal to 10 studies have shown a trend toward greaterreceiving an ESA equal to 10 g/dL or patients g/dL or patients in the sample cardiovascular events in dialysis and in the sample receiving an receiving an ESA whose most nondialysis patients assigned to Hgb targets ESA whose most recent recent Hemoglobin value was greater than 13.0 g/dL. Hemoglobin value was greater than or equal to 10 and greater than or equal to 10 less than or equal to 12 g/dL. and less than or equal to 12 Hemoglobin test must have been g/dL. done within the specified abstraction period (for patients not receiving an ESA, it should be within 12 months of the visit date, with a three month grace period; for patients receiving an ESA, it should be within three months of the visit date, with a one month grace period).Hemoglobin > 12g/dL at Patients in the sample Number of patients in the sample Number of patients Studies have shown that a hemoglobintime of last ESA whose hemoglobin was > whose hemoglobin was > 12g/dL in the sample greater than 13g/dL is associated withadministration (Overuse) 12g/dL at time of last ESA at time of last ESA receiving ESA. increased mortality and frequency of administration administration. cardiovascular events. The clinical recommendation regarding Hgb levels for CKD patients receiving ESA therapy is thatChronic Kidney Disease Measure Catalog May 2011 Page 5 of 28
  6. 6. Clinical OutcomesMeasure Title Description Numerator Denominator Rationale Hgb levels should generally be in the range of 11.0 to 12.0 g/dL. Additionally, these patients should also have their Hgb level checked at least monthly. The initial ESA dose and the ESA dose adjustments should be determined by the patient’s Hgb level, the target Hgb level, the observed rate of increase in Hgb level, and clinical circumstances.Serum phosphorus in Patients in the sample Number of patients in the sample Number of patients A number of different observational studiesnormal range (3.0-5.5 whose most recent serum whose most recent serum in the sample. in dialysis patients have demonstrated anmg/dL), tested within six phosphorus was in normal phosphorus was in normal range association between elevated serummonths of visit range (3.0-5.5 mg/dL). (3.0-5.5 mg/dL). Phosphorus phosphorus and mortality, cardiovascular measurement must have been events, and hospitalization. The relative risk done within the specified of mortality increased with serum abstraction period (within six phosphorus levels >6.5 mg/dL. Serum months of the visit date, with a phosphorus levels <2.5 mg/dL may be one month grace period). associated with abnormalities in bone mineralization such as osteomalacia. Serum phosphorus should be checked at least annually in patients with eGFR < 45 ml/min/1.73 m2 and at least every six months if abnormal.Serum bicarbonate < 20 Patients in the sample Number of patients in the sample Number of patients Low serum bicarbonate levels have beenmEq/L, tested within six whose most recent serum whose most recent serum in the sample. associated with changes in bonemonths of visit bicarbonate measurement bicarbonate measurement was < histomorphometry among populations with was < 20 mEq/L. 20 mEq/L. Serum bicarbonate differing glomerular filtration rates (GFRs). measurement must have been Patients with CKD are susceptible to done within the specified developing acidosis. Acidosis may cause abstraction period (within six increased risk for bone disease as well as months of the visit date, with a multiple other complications (i.e., one month grace period). cardiovascular disease and malnutrition). It is presumed that correction of serum bicarbonate leads to prevention of bone disease and preservation of bone buffering.Chronic Kidney Disease Measure Catalog May 2011 Page 6 of 28
  7. 7. Clinical OutcomesMeasure Title Description Numerator Denominator RationaleSerum LDL cholesterol Patients in the sample Number of patients in the sample Number of patients Continuing evidence shows that lowering<100 mg/dL, tested within whose most recent LDL whose most recent LDL in the sample. LDL in patients with CKD may retard the12 months of visit cholesterol level was <100 cholesterol level was <100 progression of kidney disease. It has been mg/dL. mg/dL. LDL measurement must recommended that the levels of LDL be have been done within the measured every year. specified abstraction period (within 12 months of the visit date, with a three month grace period).Serum HDL cholesterol Patients in the sample Number of patients in the sample Number of patients Strong epidemiological evidence links low>= 40 mg/dL for men; >= whose most recent HDL whose most recent HDL in the sample. levels of serum HDL cholesterol to50 mg/dL for women, cholesterol level was >= 40 cholesterol level was >= 40 increased CHD morbidity and mortality.tested within 12 months mg/dL for men and >= 50 mg/dL for men and >= 50 mg/dL Epidemiological studies consistently showof visit mg/dL for women. for women. HDL measurement low HDL cholesterol to be an independent must have been done within the risk factor for CHD. A low HDL level specified abstraction period correlates with the presence of other (within 12 months of the visit atherogenic factors. Prospective studies date, with a three month grace have shown that a high HDL cholesterol is period). associated with reduced risk for CHD.Serum triglycerides < 150 Patients in the sample Number of patients in the sample Number of patients Many prospective epidemiological studiesmg/dL, tested within 12 whose most recent whose most recent triglyceride in the sample. have reported a positive relationshipmonths of visit triglyceride level was <150 level was <150 mg/dL. between serum triglyceride levels and mg/dL. Triglyceride measurement must incidence of CHD. Elevated triglycerides are have been done within the widely recognized as a marker for increased specified abstraction period risk for CHD. (within 12 months of the visit date, with a three month grace period).Hemoglobin A1C > 9.0% Patients in the sample with Number of patients in the Number of patients Although aggressive control of glucose to(poor control), tested diabetes whose most recent sample with diabetes whose in the sample with near normal levels may not be appropriatewithin six months of visit A1C level was greater than most recent A1C level was diabetes. for all patients, including those who are frail, 9.0%, reflecting poor greater than 9.0%, OR who did have a history of severe hypoglycemia, or glucose control. In this not have A1C measurement who have longstanding and severe measure, lower percentages done or documented during the cardiovascular disease, most experts agree are better. specified abstraction period that all patients can benefit from glucose (within six months of the visit control that lowers A1C to < 9%, a level date, with a one month grace above which patients are at high risk for period). complications related to hyperglycemia.Chronic Kidney Disease Measure Catalog May 2011 Page 7 of 28
  8. 8. CKD - PROCESSES OF CAREPatient EvaluationMeasure Title Description Numerator Denominator RationaleHeight Patients in the sample with Number of patients in the sample Number of patients It is recommended that the physical height documented. who have height documented. in the sample. examination should include the height, weight and body mass index. Accurate measurements of height and weight are important to determine signs of malnutrition.Weight from most recent Patients in the sample with Number of patients in the sample Number of patients It is recommended that the physicaloffice visit documented weight documented from who have weight documented in the sample. examination should include the height, most recent office visit. from most recent office visit. weight and body mass index. Accurate measurements of height and weight are important to determine signs of malnutrition. Additionally, increased weight may indicate volume overload.Weight from last three Patients in the sample with Number of patients in the sample Number of patients Serial weights are important in assessingvisits documented weight documented at each with weight documented at each in the sample, both volume status and adequacy of of the last three office visits. of the last three office visits. excluding patients nutrition. Weight should be documented at who have had less every visit. than three office visits.Blood pressure Patients in the sample Number of patients in the Number of patients Recent research has shown that duringmeasured at most recent whose blood pressure sample whose blood pressure in the sample. office visits, approximately 20% to 30% ofvisit (systolic / diastolic) was (systolic/diastolic) was CKD patients do not have their blood measured at the most recent measured at the most recent pressure measured. Patients with CKD visit. visit. should have their blood pressure measured at each office visit so that changes can be identified and treatment initiated as soon as it is necessary. Blood pressure control is important in slowing the progression of chronic kidney disease. By slowing the progression of the disease, quality of life isChronic Kidney Disease Measure Catalog May 2011 Page 8 of 28
  9. 9. Patient EvaluationMeasure Title Description Numerator Denominator Rationale improved for the patient, and it results in a longer period of time before a patient requires renal replacement therapy.Blood pressure Patients in the sample Number of patients in the sample Number of patients Recent research has shown that duringmeasured at last three whose blood pressure whose blood pressure in the sample, office visits, approximately 20% to 30% ofoffice visits (systolic/diastolic) was (systolic/diastolic) was measured excluding patients CKD patients do not have their blood measured at the last three at the last three office visits. who have had less pressure measured. Patients with CKD office visits. than three office should have their blood pressure measured visits. at each office visit so that changes can be identified and treatment initiated as soon as it is necessary. Blood pressure control is important in slowing the progression of chronic kidney disease. By slowing the progression of the disease, quality of life is improved for the patient, and it results in a longer period of time before a patient requires renal replacement therapy.Most recent blood Patients in the sample with Number of patients in the sample Number of patients Patients with CKD should have their bloodpressure >=130/80 mm most recent blood pressure with most recent blood pressure in the sample pressure measured at each office visit soHg with documented measurement >= 130/80 measurement >= 130/80 mm Hg whose most recent that changes can be identified and treatmentblood pressure mm Hg who were reported who were reported as having a blood pressure initiated as soon as it is necessary. Bloodmanagement plan of care as having a documented documented blood pressure measurement was pressure control is important in slowing the blood pressure management management plan of care. >= 130/80 mm Hg, progression of chronic kidney disease. plan of care. regardless the date Patients with chronic kidney disease should of the blood have a target blood pressure of <130/80. pressure Treatment of high blood pressure in CKD measurement. should include identification of target blood pressure levels, nonpharmacologic therapy, and specific antihypertensive agents for the prevention of progression of kidney disease and development of cardiovascular disease.CKD diagnosis Patients in the sample with a Number of patients in the sample Number of patients Identification and diagnosis of CKD isdocumented chart documentation of who were reported as having in the sample. important to optimize clinical management current diagnosis of CKD. current diagnosis of CKD recommendations for this complex patient documented. population. All individuals with GFR < 60 mL/min/1.73 m2 for three months are classified as having chronic kidney disease, irrespective of the presence or absence of kidney damage.Chronic Kidney Disease Measure Catalog May 2011 Page 9 of 28
  10. 10. Patient EvaluationMeasure Title Description Numerator Denominator RationaleCKD stage documented Patients in the sample with a Number of patients in the sample Number of patients Staging of CKD may facilitate the application chart documentation of who were reported as having in the sample. of clinical practice guidelines (CPG), clinical current stage of CKD. stage of CKD documented. performance measures, and quality improvement efforts to the evaluation and management of CKD.Medications reviewed at Patients in the sample who Number of patients in the sample Number of patients A number of drugs can be associated withmost recent office visit were reported as having who were reported as having in the sample. chronic kidney damage, so a thorough current medications current medications reviewed at review of the medication list (including reviewed at most recent most recent office visit. prescribed medications, over-the-counter office visit. medications, “nontraditional” medications, vitamins and supplements, herbs, and drugs of abuse) is vital. Severe kidney impairment may alter volume of distribution and protein binding, prompting dosage adjustments. In patients with CKD, medications that are renally excreted may require a lower initial dose or an increase in the interval between doses.Chronic Kidney Disease Measure Catalog May 2011 Page 10 of 28
  11. 11. Diagnostic TestingMeasure Title Description Numerator Denominator RationaleeGFR assessment, Patients in the sample who were Number of patients in the sample Number of patients Estimated glomerular filtration ratewithin six months of reported as having eGFR who were reported as having in the sample. (eGFR) has become the “goldvisit assessment during the six month eGFR assessment during the six standard” test for the measurement period prior to the visit date, with month period prior to the visit of kidney function. A variety of a one month grace period. date, with a one month grace different prediction equations have period. been developed including the MDRD (4- and 6-variable) and Cockroft-Gault Formulas. While estimates of eGFR may be unreliable at the extremes of age, muscle mass and weight, and at eGFR levels above 60 ml/min/1.73m2, eGFR is reasonably accurate measure of true GFR in most patients with moderate or more severe CKD.UPC ratio or UACR, Patients in the sample who had Number of patients in the sample Number of patients Protein excretion in the urine is antested within six months testing for UPC ratio or UACR who had testing for UPC ratio or in the sample. indicator of abnormal kidneyof visit done during the six month period UACR done during the six month function and should be assessed in prior to the visit date, with a one period prior to the visit date, with all patients with CKD. Proteinuria is month grace period. a one month grace period. not only a marker of kidney damage, it is also a guide to the differential diagnosis, prognosis, and therapy of chronic kidney disease.Hemoglobin, tested as Patients in the sample not Number of patients in the sample Number of patients Observational studies show that (inper guidelines receiving ESA who were not receiving ESA who were in the sample. the absence of ESA therapy) the reported as having hemoglobin reported as having hemoglobin natural history of anemia in patients testing done during the 12 month testing done during the 12 month with CKD is a gradual decline in period prior to the visit date, with period prior to the visit date, with Hgb levels over time. The a three month grace period, OR a three month grace period, OR recommendation is that patients be patients in the sample receiving patients in the sample receiving evaluated at least annually. ESA who were reported as ESA who were reported as Hemoglobin is the preferred test for having hemoglobin testing done having hemoglobin testing done evaluation of anemia. A complete during the three month period during the three month period blood count can help determine prior to the visit date, with a one prior to the visit date, with a one whether anemia is present, how month grace period. month grace period. severe the anemia is and whether the patient would benefit from treatment. Patients receiving anChronic Kidney Disease Measure Catalog May 2011 Page 11 of 28
  12. 12. Diagnostic TestingMeasure Title Description Numerator Denominator Rationale ESA should have their hemoglobin level checked at least monthly.Documented plan of Patients in the sample receiving Number of patients in the sample Number of patients Studies have shown that acare to reduce an ESA and with the most recent receiving an ESA and with the in the sample hemoglobin greater than 13 g/dL ishemoglobin in patients Hemoglobin value greater than most recent Hemoglobin value receiving an ESA associated with increased mortalityreceiving an ESA and or equal to 13g/dL who were greater than or equal to 13g/dL and with the most and frequency of cardiovascularwith Hemoglobin reported as having a who were reported as having a recent Hemoglobin events. The clinical>=13g/dL documented plan of care to documented plan of care to value greater than or recommendation regarding Hgb reduce hemoglobin. reduce hemoglobin. equal to 13g/dL. . levels for CKD patients receiving ESA therapy is that Hgb levels should generally be in the range of 11.0 to 12.0 g/dL. Additionally, these patients should also have their Hgb level checked at least monthly. The initial ESA dose and the ESA dose adjustments should be determined by the patient’s Hgb level, the target Hgb level, the observed rate of increase in Hgb level, and clinical circumstances.Serum ferritin, tested Patients in the sample receiving Number of patients in the sample Number of patients Serum ferritin level is the onlyper guidelines an ESA who were reported as receiving an ESA who were in the sample with available blood marker of storage having serum ferritin testing done reported as having serum ferritin anemia. Anemia is iron. It is recommended that during the six month period prior testing done during the six month defined as a hemoglobin, ferritin, and TSAT be to the visit date, with a one period prior to the visit date, with documented tested together because the month grace period, OR patients a one month grace period, OR diagnose of anemia, combination provides important in the sample with anemia who patients in the sample with or if their most recent insight into external iron balance were not receiving an ESA and anemia who were not receiving hemoglobin is < 13 and internal iron distribution. Iron who were reported as having an ESA and who were reported g/dL for men and < status tests provide reasonable serum ferritin testing done during as having serum ferritin testing 12 g/dL for women, markers to detect iron deficiencies. the 12 month period prior to the done during the 12 month period or hemoglobin has visit date, with a three month prior to the visit date, with a three been <10 g/dL in the grace period. month grace period. last 12 months.Chronic Kidney Disease Measure Catalog May 2011 Page 12 of 28
  13. 13. Diagnostic TestingMeasure Title Description Numerator Denominator RationaleTsat, tested as per Patients in the sample receiving Number of patients in the sample Number of patients TSAT is a measure of the adequacyguidelines an ESA who were reported as receiving an ESA who were in the sample with of iron supply for erythropoiesis. It having Tsat testing done during reported as having Tsat testing anemia. Anemia is is recommended that hemoglobin, the six month period prior to the done during the six month period defined as a ferritin, and TSAT be tested visit date, with a one month prior to the visit date, with a one documented together because the combination grace period, OR patients in the month grace period, OR patients diagnose of anemia, provides important insight into sample with anemia who were in the sample with anemia who or if their most recent external iron balance and internal not receiving an ESA and who were not receiving an ESA and hemoglobin is < 13 iron distribution. Iron status tests were reported as having Tsat who were reported as having g/dL for men and < provide reasonable markers to testing done during the 12 month Tsat testing done during the 12 12 g/dL for women, detect iron deficiencies. period prior to the visit date, with month period prior to the visit or hemoglobin has a three month grace period. date, with a three month grace been <10 g/dL in the period. last 12 months.Hemoglobin A1C, Patients in the sample with Number of patients in the sample Number of patients Studies have repeatedly shown thattested within six months diabetes who had A1C testing with diabetes who had A1C in the sample with out-of-control diabetes results inof visit done during the six month period testing done during the six month diabetes. complications from the disease. prior to the visit date, with a one period prior to the visit date, with Hemoglobin A1C is thought to month grace period. a one month grace period. reflect average glycemia over several months, and has strong predictive value for diabetes complications. Patients with stable glycemia well within target may do well with testing only twice per year, while unstable or highly intensively managed patients (e.g., pregnant type 1 women) may need testing more frequently.Serum calcium, tested Patients in the sample who had Number of patients in the sample Number of patients As kidney function declines, there iswithin six months of visit serum calcium testing done who had serum calcium testing in the sample. a progressive deterioration in during the six month period prior done during the six month period mineral homeostasis, with a to the visit date, with a one prior to the visit date, with a one disruption of normal serum and month grace period. month grace period. tissue concentrations of phosphorus and calcium. The laboratory diagnosis of CKD–MBD includes the use of laboratory testing of serum PTH, calcium, and phosphorus. Serum phosphorus, calcium, and intact PTH should be checked at least annually in patients with eGFR < 45 ml/min/1.73 m2 and at least every six months if abnormal.Chronic Kidney Disease Measure Catalog May 2011 Page 13 of 28
  14. 14. Diagnostic TestingMeasure Title Description Numerator Denominator RationaleSerum phosphorus, Patients in the sample who had Number of patients in the sample Number of patients As kidney function declines, there istested within six months serum phosphorus testing done who had serum phosphorus in the sample. a progressive deterioration inof visit during the six month period prior testing done during the six month mineral homeostasis, with a to the visit date, with a one period prior to the visit date, with disruption of normal serum and month grace period. a one month grace period. tissue concentrations of phosphorus and calcium. The laboratory diagnosis of CKD–MBD includes the use of laboratory testing of serum PTH, calcium, and phosphorus. Serum phosphorus, calcium, and intact PTH should be checked at least annually in patients with eGFR < 45 ml/min/1.73 m2 and at least every six months if abnormal.Serum bicarbonate, Patients in the sample who had Number of patients in the sample Number of patientstested within six months serum bicarbonate testing done who had serum bicarbonate in the sample. Patients with CKD are susceptibleof visit during the six-month period prior testing done during the six-month to developing acidosis. Acidosis to the visit date, with a one- period prior to the visit date, with may cause increased risk for bone month grace period. a one-month grace period. disease as well as multiple other complications (i.e., cardiovascular disease and malnutrition). Since the serum bicarbonate level can fluctuate over days or weeks, frequent monitoring is warranted.Serum potassium, Patients in the sample who had Number of patients in the sample Number of patients Disorders of potassium homeostasistested within six months serum potassium testing done who had serum potassium in the sample. (both high and low potassiumof visit during the six month period prior testing done during the six month levels) may result in preventable to the visit date, with a one period prior to the visit date, with morbidity and mortality. Potassium month grace period. a one month grace period. levels should be checked periodically in patients with kidney disease.Chronic Kidney Disease Measure Catalog May 2011 Page 14 of 28
  15. 15. Diagnostic TestingMeasure Title Description Numerator Denominator RationaleSerum intact PTH, Patients in the sample who had Number of patients in the sample Number of patients Renal osteodystrophy is a complextested within 12 months serum intact PTH testing done who had serum intact PTH in the sample. and multifaceted disease processof visit during the 12 month period prior testing done during the 12 month that begins early in the course of to the visit date, with a three period prior to the visit date, with chronic kidney disease (CKD) and is month grace period. a three month grace period. a major, long-term complication associated with high rates of morbidity. Experimental and clinical research has shown an increased risk for hyperparathyroidism (HPTH) with hypocalcemia and hyperphosphatemia that often accompanies CKD. HPTH reflected by high immunoreactive parathyroid hormone (iPTH) levels may exist in the face of normal serum calcium and phosphorus. Serum phosphorus, calcium, and intact PTH should be checked at least annually in patients with eGFR < 45 ml/min/1.73 m2 and at least every six months if abnormal.Serum 25- Patients in the sample who had Number of patients in the sample Number of patients Beginning in CKD stage 3, thehydroxyvitamin D serum 25-hydroxyvitamin D who had serum 25- in the sample. ability of the kidneys to(calcidiol), tested within (calcidiol) testing done during the hydroxyvitamin D (calcidiol) appropriately excrete a phosphate12 months of visit 12 month period prior to the visit testing done during the 12 month load is diminished. This leads to an date, with a three month grace period prior to the visit date, with impairment in the conversion of period. a three month grace period. 25(OH)D to 1,25(OH)2D reducing intestinal calcium absorption and increasing PTH. Vitamin D deficiency and insufficiency may have a role in the pathogenesis of secondary hyperparathyroidism (HPT). Studies have shown that there is an association of low 25(OH)D levels with mortality.Serum LDL cholesterol Patients in the sample who had Number of patients in the sample Number of patients Continuing evidence shows thattested within 12 months LDL cholesterol testing done who had LDL cholesterol testing in the sample. lowering LDL in patients with CKDof visit during the 12-month period prior done during the specified may retard the progression of to the visit date, with a three abstraction period (within 12 kidney disease. It has been month grace period. months of the visit date, with a recommended that the levels of LDLChronic Kidney Disease Measure Catalog May 2011 Page 15 of 28
  16. 16. Diagnostic TestingMeasure Title Description Numerator Denominator Rationale three month grace period). be measured every year. It has been recommended that all patients with CKD should be evaluated for dyslipidemias annually. The assessment of dyslipidemias should include a complete fasting lipid profile with total cholesterol, low- density lipoprotein (LDL), high- density lipoprotein (HDL), and triglycerides.Serum HDL cholesterol Patients in the sample who had Number of patients in the sample Number of patients It has been recommended that alltested within 12 months HDL cholesterol testing done who had HDL cholesterol testing in the sample. patients with CKD should beof visit during the 12-month period prior done during the specified evaluated for dyslipidemias to the visit date, with a three abstraction period (within 12 annually. The assessment of month grace period. months of the visit date, with a dyslipidemias should include a three month grace period). complete fasting lipid profile with total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides.Serum triglycerides Patients in the sample who had Number of patients in the sample Number of patients It has been recommended that alltested within 12 months triglyceride testing done during who had triglyceride testing done in the sample. patients with CKD should beof visit the 12-month period prior to the during the specified abstraction evaluated for dyslipidemias visit date, with a three month period (within 12 months of the annually. The assessment of grace period. visit date, with a three month dyslipidemias should include a grace period). complete fasting lipid profile with total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides.Chronic Kidney Disease Measure Catalog May 2011 Page 16 of 28
  17. 17. Treatment: MedicationMeasure Title Description Numerator Denominator RationaleACE inhibitor or ARB Patients in the sample with Number of patients in the Number of patients in Numerous randomized, controlled hypertension and proteinuria sample with hypertension and the sample with clinical trials have demonstrated that who are currently receiving ACE proteinuria who are currently hypertension and the use of angiotensin converting inhibitor or ARB. receiving ACE inhibitor or ARB. proteinuria (proteinuria is enzyme (ACE) inhibitors and Proteinuria is defined as UACR defined as UACR > 300 angiotensin receptor blockers (ARBs) > 300 mg/g or UPC ratio > 200 mg/g or UPC ratio > 200 as antihypertensive therapy is mg/g. mg/g). effective, and may help slow the progression of chronic kidney disease (CKD). These drugs help control hypertension and decrease proteinuria. ACE inhibition has also been shown to reduce mortality and cardiovascular events in patients with pre-existing coronary artery disease and patients with diabetes mellitus and at least one other coronary artery disease risk factor. The mortality benefit conferred by ACE inhibitors may be greater for patients with elevated serum creatinine compared to those with normal renal function. Patients with CKD are considered to be in the highest category for cardiac risk and are thus likely to derive benefit from ACE inhibition. ARBs have also been shown to reduce progression of chronic kidney disease in subjects with type II diabetes mellitus.Statin or other lipid- Patients in the sample who are Number of the patients in the Number of the patients Patients with CKD have increasedlowering drug potentially eligible for treatment sample who potentially eligible in the sample potentially coronary heart disease (CHD) risk with a statin or other lipid- for treatment with a statin or eligible for treatment (greater than 20% per 10 years) and lowering drug, and who are other lipid-lowering drug, and with a statin or other should be considered to be in the currently receiving this therapy. who are currently receiving this lipid-lowering drug. highest risk category for Patients were considered therapy. Patients were Patients were atherosclerotic cardiovascular disease potentially eligible for treatment considered potentially eligible considered potentially (ACVD). Multiple clinical trials with a statin or other lipid- for treatment with a statin or eligible for treatment demonstrated significant effects of lowering drug if the chart other lipid-lowering drug if the with a statin or other pharmacologic (primarily statin) documented that they had chart documented that they had lipid-lowering drug if the therapy on CVD outcomes in subjects elevated LDL cholesterol or are elevated LDL cholesterol or are chart documented that with CHD and for primary CVDChronic Kidney Disease Measure Catalog May 2011 Page 17 of 28
  18. 18. Treatment: MedicationMeasure Title Description Numerator Denominator Rationale on LDL-lowering medication, or on LDL-lowering medication, or they had elevated LDL prevention. A higher frequency of if their most recent LDL if their most recent LDL cholesterol or are on adverse events has been reported cholesterol was 100 mg/dL or cholesterol was 100 mg/dL or LDL-lowering with statin therapy in patients with higher. higher. medication, or if their CKD so careful monitoring is most recent LDL warranted. Lower statin doses may be cholesterol was 100 necessary to reduce the risk of mg/dL or higher. myopathy.Aspirin Patients in the sample Number of patients in the Number of male patients One large meta-analysis and several potentially eligible for sample potentially eligible for age 45 and over, and clinical trials demonstrate the efficacy antiplatelet/anticoagulant antiplatelet/anticoagulant female patients age 55 of using aspirin as a preventive therapy who are currently therapy who are currently and over in the sample, measure for cardiovascular events, receiving this therapy. Patients receiving this therapy. Patients excluding patients who including stroke and myocardial were considered potentially were considered potentially have medical infarction. The net benefit of aspirin eligible if they were male eligible if they were male contraindications. depends on the initial risks for stroke patients age 45 and over, or patients age 45 and over, or and gastrointestinal bleeding. Thus, female patients age 55 and female patients age 55 and decisions about aspirin therapy should over, excluding patients who over, excluding patients who consider the overall risk for stroke and have medical contraindications have medical contraindications. gastrointestinal bleeding. The optimum dose of aspirin for preventing cardiovascular disease events is not known. Primary prevention trials have demonstrated benefits with various regimens, including dosages of 75 and 100 mg/d and 100 and 325 mg every other day. A dosage of approximately 75 mg/d seems as effective as higher dosages. The risk for gastrointestinal bleeding may increase with dose.Metformin (a marker of Number of patients in the Number of patients in the Number of patients in Metformin should not be given topoor care) sample with diabetes who are sample with diabetes who are the sample with diabetic patients with CKD because it currently receiving Metformin currently receiving Metformin diabetes. is cleared by the kidneys and may therapy. It is a marker of poor therapy. It is a marker of poor build up with even modest impairment care. care. of kidney function, putting patients at risk of lactic acidosis.Chronic Kidney Disease Measure Catalog May 2011 Page 18 of 28
  19. 19. Treatment: MedicationMeasure Title Description Numerator Denominator RationaleESA Patients in the sample Number of patients in the Number of patients in As kidney function declines, the potentially eligible for treatment sample potentially eligible for the sample with likelihood of anemia associated with with ESA who are currently treatment with ESA who are hemoglobin <10 g/dL EPO deficiency increases because the receiving this therapy. Patients currently receiving this therapy. currently or in the last 12 diseased kidneys are unable to were considered potentially Patients were considered months. produce sufficient quantities of EPO. eligible for treatment with ESA if potentially eligible for treatment In patients with CKD not requiring the chart documented that they with ESA if the chart dialysis, untreated anemia increases had a hemoglobin <10 g/dL documented that they had a cardiovascular risk, hospitalization, currently or in the last 12 hemoglobin <10 g/dL currently and all-cause mortality, and months. or in the last 12 months. diminishes health-related quality of life. Heightened risk for progression of kidney failure has also been linked to untreated anemia of CKD. ESA agents will not work to their maximal potential in patients with iron deficiency anemia. Several interventional studies have shown that treating anemia of CKD with erythropoietic agents may reduce or reverse cardiac complications and retard the rate of CKD progression.Iron supplements for Patients in the sample with iron Number of patients in the Number of patients inpatients with iron deficiency anemia who are sample with iron deficiency the sample with iron Anemia is common in patients withdeficiency anemia currently receiving iron anemia who are currently deficiency anemia. advanced CKD and can lead to a supplements. receiving iron supplements. Anemia is defined as a variety of detrimental effects. In Anemia is defined as a documented diagnose of addition to the direct effects of anemia documented diagnose of anemia, or if their most on performance and ischemic anemia, or if their most recent recent hemoglobin is < symptoms, it has also been suggested hemoglobin is < 13 g/dL for 13 g/dL for men and < that mortality and major complications men and < 12 g/dL for women, 12 g/dL for women, or during end-stage renal disease or hemoglobin has been <10 hemoglobin has been (ESRD) are associated with anemia g/dL in the last 12 months. Iron <10 g/dL in the last 12 that develops early in the course of deficiency is defined as serum months. Iron deficiency CDK. Correcting anemia before the ferritin < 100 ng/mL or Tsat < is defined as serum initiation of renal replacement therapy 20%. ferritin < 100 ng/mL or (RRT) may improve health outcomes. Tsat < 20%. Iron deficiency is treatable and failure to replete iron stores may result in resistance to erythropoietin.Chronic Kidney Disease Measure Catalog May 2011 Page 19 of 28
  20. 20. Treatment: MedicationMeasure Title Description Numerator Denominator RationalePhosphate binders Patients in the sample who are Number of patients in the Number of patients in Treatment and prevention of bone currently receiving phosphate sample who are currently the sample. disease in patients with CKD is binders. receiving phosphate binders. directed at treating the elevated serum phosphorus with phosphate binders and dietary phosphate restriction, and providing the active form of vitamin D with a medication. Almost all patients with CKD will require dietary phosphorus restriction and/or phosphate binders to maintain serum phosphorus levels within the target range. Several prospective randomized, controlled trials have shown that therapy is safe and effective.Alkalinization therapy Patients in the sample who are Number of patients in the Number of patients in Experimental studies in animals and currently receiving alkalinization sample who are currently the sample. clinical studies in patients with CKD therapy. receiving alkalinization therapy. have identified several potential adverse consequences of acidosis, including muscle wasting, induction of a catabolic state, exacerbation of renal osteodystrophy, and accelerating the progression of kidney disease. Correction of metabolic acidosis lessens renal osteodystrophy and improves protein metabolism.Vitamin D supplement Patients in the sample who are Number of patients in the Number of patients in Vitamin D deficiency is a major currently receiving Vitamin D sample who are currently the sample. complication in patients with CKD and supplement. receiving Vitamin D facilitates the pathogenesis of supplement. hyperparathyroidism. Several studies have shown that administering active vitamin D leads to significant reduction in mortality in CKD patients. In all CKD patients receiving vitamin D therapy, continued surveillance is needed, and hypercalcemia must be avoided.Chronic Kidney Disease Measure Catalog May 2011 Page 20 of 28

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