The University of Michigan Kidney and Epidemiology Cost Center (UM-KECC), develops, maintains, and updates 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 Dialysis Facility Compare (DFC) Measures and the development of new quality measures that will be implemented in the future. Several of CMS’s current and new Quality Measures will be used by CMS in the CMS ESRD Quality Incentive Program (QIP). In addition, UM-KECC works with CMS’s Measures Management System (MMS) in the development, evaluation, and reporting of the current ESRD Quality Measures.
Measure Development and Implementation Activities
Summary of Public Comment on New Measures to be reported on Dialysis Facility Compare
In October 2017, CMS requested Public Comment on the inclusion of additional measures to Dialysis Facility Compare (DFC) measures in order to:
- Increase transparency in the process and selection criteria
- Allow for increased input from the community on candidate measures
- Increase opportunity for the inclusion of externally developed measures on DFC
Comments were accepted from October 25, 2017 thru December 31, 2017 via email to dialysisdata@umich.edu on the following measures:
Read the Public Comment Summary Report
Past Summary Reports
Read the Public Comment Summary from the 2015 comment period
Patient Reported Outcomes Report
The Centers for Medicare & Medicaid Services (CMS) tasked the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) with developing recommendations that investigate avenues for acquiring the evidence, data, and infrastructure necessary to implement patient-centered measures and patient reported outcomes. Read the Patient Reported Outcomes Report.
Patient Reported Outcomes Focus Group Summary Report
The Centers for Medicare & Medicaid Services (CMS) tasked the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) to convene focus groups to review draft questions on patient safety and patient life goals. The Patient Reported Outcomes Focus Group Summary Report summarizes the feedback received from both patient and provider specific focus groups on draft questions sets for patient safety and patient life goals. Read the Patient Reported Outcomes Focus Group Summary Report.
Technical Expert Panel Summary Reports
Access to Kidney Transplantation (April 2015)
Emergency Department Visits (May 2016)
- Documentation for proposed measure, Standardized Ratio of Emergency Department Encounters Occurring Within 30 Days of Hospital Discharge (ED30) for Dialysis Facilities
- Documentation for proposed measure, Standardized Emergency Department Encounter Ratio (SEDR) for Dialysis Facilities
DFC Star Ratings (February 2017)
Patient-Reported Outcomes (May 2017)
Medication Reconciliation and Management (July 2017)
Physician Level Measures (February 2018)
2014 Dry run of the Standardized Readmission Ratio (SRR) for Dialysis Facilities
The Centers for Medicare & Medicaid Services (CMS), through a contract with the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC), recently provided dialysis facilities with confidential reports of their results on the Standardized Readmission Ratio (SRR) for dialysis facilities through a national dry run held March 31 – May 2, 2014. Download the report.
Quality Measure Information
CMS and UM-KECC submitted 15 measures for NQF review in 2015, 11 of which received endorsement. The specifications for each measure are listed below. For information on how measures are implemented on DFC, please see the Guide to the Quarterly Dialysis Facility Compare Reports and the measure specifications on the Methodology page.
In addition, CMS and UM-KECC submitted 5 measures to NQF for review in 2016. Those measures are also included below.
Dialysis Adequacy
- Minimum Delivered Hemodialysis Dose (NQF # 0249 – reserve status)*
- Delivered Dose of Peritoneal Dialysis Above Minimum (NQF # 0318)*
- Minimum spKt/V for Pediatric HD Patients (NQF # 1423)*
- Measurement of nPCR for Pediatric HD Patients (NQF # 1425)*
- Minimum Delivered Peritoneal Dialysis Dose (NQF #2704)
- Pediatric Peritoneal Dialysis Adequacy: Achievement of Target Kt/V (NQF #2706)*
Vascular Access
- Hemodialysis Vascular Access- Maximizing Placement of Arterial Venous Fistula (NQF #0257)
- Hemodialysis Vascular Access- Minimizing use of catheters as Chronic Dialysis Access (NQF #0256)
- Hemodialysis Vascular Access: Long-term Catheter Rate (NQF #2978)*
- Hemodialysis Vascular Access: Standardized Fistula Rate (NQF #2977)*
Mineral and Bone Disorder
- Measurement of Serum Phosphorus Concentration (NQF # 0255 – reserve status)**
- Proportion of Patients with Hypercalcemia (NQF # 1454 – reserve status)*
Mortality
Hospitalization/Readmission
- Standardized Hospitalization Ratio for Dialysis Facilities (NQF #1463)*
- Standardized Readmission Ratio (NQF #2496)*
Anemia Management
- Monthly Hemoglobin Measurement for Pediatric Patients (NQF # 1424)**
- Standardized Transfusion Ratio for Dialysis Facilities (NQF #2979)*
*Currently publically reported on the Dialysis Facility Compare (DFC) Website
**Currently publically reported only in the DFC Downloadable Database on Data.Medicare.Gov