End-Stage Renal Disease (ESRD) National Coordinating Center (NCC) as of Thursday, March 9th, 2017 ESRD NCC QIP Kt/V Process Guideline (PGL) v.1.0 HHMS 500 2015 NW00XC Task 3.A, Support QIP QIA Activities, QIP Dialysis Adequacy (Kt/V) Task 4.A, ESRD Warehouse
Benchmark 97.74 90th percentile Performance Standard 93.08 50th percentile There were questions about the thresholds during the AIM 3 Workgroup calls and how NCC reporting could assist in any comparisons. Achievement Threshold 86.99 15th percentile The Kt/V project team determined that including the Performance Standard (93.08%) in the reports to measure against and to provide a variance calculation would help in data analysis and provide an easy reference point. Those reports that rollup at the Facility, NW, BSO, and National level have the threshold embedded in the report to show the comparison. ESRD NCC Open Office Hours QIP Kt/V QIA HHMS 500 2015 NW00XC, Task 3.A, ESRD NCC Warehouse 2
ESRD Facilities utilizing the CROWNWeb User Interface or Batch Submitting Organizations utilizing the CROWNWeb Batch Interface submit Patient, Form, Admit/Discharge, Facility, and Clinical data to the end of the CROWNWeb Clinical Period. ESRD Facilities & Batch Submitting Organizations typically have ~ 60 days to enter the data for the clinical month for the patient prior to the period closure. NCC Warehouse QIP Kt/V base Baseline Tables NCC Warehouse QIP Kt/V base BL1 Tables NCC Warehouse QIP Kt/V base BL2 Tables NCC Warehouse QIP Kt/V base BL3 Tables Kt/V BSO Batches QIP Criteria Applied Baseline is stored NCC Warehouse Clinical base Raw data is pulled from the CW clinical data tables for the Kt/V questions and answers on the patient clinical dialysis adequacy screen. Raw CROWNWeb Transformation Denormalized data is stored The CROWNWeb (CROLPR14) snapshot is refreshed nightly at 6:45PM with CROWNWeb data through that time. NCC Warehouse Staging base CW Snapshot The process of pulling, validating, & transforming CW data into usable, de-normalized data occurs for each clinical period in the three baseline average. Validation Patient De-dupe Comp. BL data is stored Prev. Patients Pt. Kt/V Met Ct Pt. Elig. Ct Comp. Kt/V scripts are run on validation, duplicate patient submissions and to pull 3 mos into comprehensive data. PD Kt/V HD Kt/V scripts are run to calculate the baseline counts for patients for Comprehensive, HD & PD Kt/V. scripts are run to pull end-ofbaseline prevalence, and count the eligible and met months for each pt. Patient-Level Facility-Level scripts are run to calculate the baseline elig & met counts for patients for Comprehensive, HD & PD Kt/V and place them in Pt, Fac, NW, BSO & Nat l level tables. NW-Level ESRD NW QIP Kt/V Distribution Files validation is performed on the CW Snapshot data to ensure Accuracy & Completeness (DAC). BSO-Level Nat l-level scripts are run to create the ESRD NW Distribution files for QIP Kt/V. Key Terms / Logic: Period Prevalence: each baseline month s period prevalence for all patients there the entire month. Point Prevalence (at end of baseline for the creation of the patient list for the NW file/facility attribution): patients that have open admits with no discharge date, and transient status is 0. Baseline Period: Q3-2016 (Jul = BL1, Aug = BL2, Sep = BL3) Numerator: Patient month counts meeting the Kt/V goal (HD >=1.2; PD >=1.7) across the baseline period. Patients w/ 9.99 or 8.88 do not meet the goal. Denominator: All HD and PD adult patient month counts meeting the eligible criteria to be measured for the QIP (All adult patients minus the exclusions) across the baseline period. Denominator Exclusions: Patients not dialyzing 3x/week Patients not on dialysis >= 90days Patients not at facility entire month Patients without either a CW record or submitted 2728 (need at least one) Rates: Comprehensive : The QIP requires a comprehensive total (across the baseline). This includes both HD, PD, and patients with no data submitted. Calculated using the total months met / total months eligible for each patient and rolled up to Fac, NW, BSO & Nat l HD: Patients that had a HD clinical submission or can be attributed to a HD modality; met / eligible PD: Patients that had PD clinical submission or can be attributed to a PD modality; met / eligible. NA: Patients that had NO clinical submission & can t be attributed to a modality; the counts are listed to show the difference in comprehensive eligibility and HD & PD eligibility. Note: Due to modality changes and the PD 4 month lookback, it is rare, but possible, for a patient to meet both HD & PD in a month and be in both rates. ESRD NCC Open Office Hours QIP Kt/V QIA HHMS 500 2015 NW00XC, Task 3.A, ESRD NCC Warehouse 3
The QIP Kt/V Baseline data will be delivered in a MS Access database on Server 39. The data will be delivered one time to begin the QIP Kt/V project and give the ESRD NWs the necessary data to start the review of facilities, perform RCAs and determine a list of facilities for the project. It will include: BL1_Raw_ BL2_Raw_ BL3_Raw_ CROWN_Facility Baseline_Patient_Detail Baseline_Facility_Detail Baseline_Network_Detail Baseline_BSO_Detail Baseline_National_Detail The BL Raw Tables include all of the affiliated CROWNWeb Kt/V data available, by patient. These are the foundation tables used to determine eligibility, goal met, and provide the basis for the Baseline Patient Detail table. One request made was for the raw data to not only show who was eligible, but that if the patient was INeligible, to show the reason why due to the exclusion criteria. This allows for easier navigation of the table during review and shows the reason in the data. ESRD NCC Open Office Hours QIP Kt/V QIA HHMS 500 2015 NW00XC, Task 3.A, ESRD NCC Warehouse 4
The QIP Kt/V Patient Detail Table takes the three baseline months and begins to prepare the data, by patient, to roll up to a facility rate. This table has both patient and facility demographics to show disparity and show the type of facility, location type and rural/urban status of a facility. It also shows the eligibility by each baseline month, and the total number of months the patient was eligible. This is important so that the denominator is correct in determining a fair and accurate comprehensive denominator. It also shows the reasons the patient was NOT eligible for that month due to the QIP exclusion criteria: The Patient Detail table also shows the KtV Met by month for each patient. If the patient was ineligible, that is carried forward into the Met columns for easy reference and showing why the patient didn t meet the month due to ineligibility. Additionally, the QIP Kt/V Patient Detail Table shows the actual Kt/V values, collection types (or lack of collection type) and makes referencing ineligible and if it was another type easier for reading. For instance, in the example to the right, if a patient is ineligible, it shows that in the field instead of just NULL. If there was no data submitted at all, the collection type shows N/A. If the patient has TWO Kt/V values for two collection types (the highlighted row) they are both counted towards the goal being met in in the HD or PD rates, but the patient is only counted once in the comprehensive rate. ESRD NCC Open Office Hours QIP Kt/V QIA HHMS 500 2015 NW00XC, Task 3.A, ESRD NCC Warehouse 5
The QIP Kt/V Facility Detail Table gives a patient count at the facility (this aids in comparing and validating the patient detail rows match the total in the table). It also shows the QIP Performance Standard as a static rate of comparison. It gives the variance between the QIP Performance Standard and the Baseline Comprehensive Rate. It shows the Baseline Comprehensive Rate, and also gives the Baseline HD and PD Rates. Additionally, the QIP Kt/V Facility Detail Table also shows the total eligible patient months for that facility and the total KtV met months to show the math behind the comprehensive rate. The HD and PD eligible months and the HD and PD met months are also shown to give the math behind the HD and PD rates requested. NA is also given, since there will be counts where patients had no data submitted and they are IN the comprehensive rate, but are not in either the HD or PD rate. Note: there are patients that also had both HD and PD for some months and these show those counts of patients. The HD + PD are not meant to equal the comprehensive. ESRD NCC Open Office Hours QIP Kt/V QIA HHMS 500 2015 NW00XC, Task 3.A, ESRD NCC Warehouse 6
The QIP Kt/V Network Detail Table gives the total patient count as of the end of the baseline period. It also shows the QIP Performance Standard as a static rate of comparison. It gives the variance between the QIP Performance Standard and the Baseline Comprehensive Rate. It shows the Baseline Comprehensive Rate, and also gives the Baseline HD and PD Rates at the Network level. The QIP Kt/V BSO Detail Table gives the total patient count (for that BSO in that Network) as of the end of the baseline period. It also shows the QIP Performance Standard as a static rate of comparison. It gives the variance between the QIP Performance Standard and the Baseline Comprehensive Rate. It shows the Baseline Comprehensive Rate, and also gives the Baseline HD and PD Rates at the Network s BSO level. The QIP Kt/V National Detail Table gives the total patient count as of the end of the baseline period. It also shows the QIP Performance Standard as a static rate of comparison. It gives the variance between the QIP Performance Standard and the Baseline Comprehensive Rate. It shows the Baseline Comprehensive Rate, and also gives the Baseline HD and PD Rates at the National level. ESRD NCC Open Office Hours QIP Kt/V QIA HHMS 500 2015 NW00XC, Task 3.A, ESRD NCC Warehouse 7
The QIP Kt/V Facility Detail Table will allow you to sort the data in various ways: You can order it by CCN to look for a particular facility, or you can order it by the comprehensive rate, to search for your lowest or highest performers, or you can sort by the variance from the Performance Standard. Click on the arrow on the column by which you wish to sort and the dialog box will appear. This allows you to filter on ranges, or do any sorting you wish. The QIP Kt/V Baseline does not require any DIF action. CMS has confirmed that before the DIF is engaged in this project, the baseline data must be received, reviewed, the RCAs performed and the facilities initiated into the QIA. Once those facilities are received by the NCC, filtered project data can be supplied and tracked for initiation and graduation to complete the monthly DIF for CMS. ESRD NCC Open Office Hours QIP Kt/V QIA HHMS 500 2015 NW00XC, Task 3.A, ESRD NCC Warehouse 8