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End-Stage Renal Disease (ESRD)

National Coordinating Center (NCC)

ESRD NCC Data QIP Kt/V Process Guideline (PGL) v.1.0HHMS – 500 – 2015 – NW00XC

Task 3.A, Support QIP QIA Activities, QIP Dialysis Adequacy (Kt/V)

Task 4.A, ESRD Data Warehouse

as of Thursday, March 9th, 2017

ESRD NCC Data Open Office Hours – QIP Kt/V QIA

HHMS – 500 – 2015 – NW00XC, Task 3.A, ESRD NCC Data Warehouse

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Benchmark

• 97.74•90th percentile

Performance Standard


Achievement Threshold


There were questions about the thresholds during the AIM 3 Workgroup

calls and how NCC reporting could assist in any comparisons.

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.





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BSO Data Batches

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.

Data Transformation

De-normalized

data is stored

Raw Data

Raw data is pulled from the CW clinical data

tables for the Kt/V questions and answers on the

patient clinical dialysis adequacy screen.

CROWNWeb

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.

Key Terms / Logic:

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.

CW Snapshot

The CROWNWeb (CROLPR14)

snapshot is refreshed nightly at

6:45PM with CROWNWeb data

through that time.

NCC Data Warehouse

Staging Database

NCC Data Warehouse

Clinical Database

QIPCriteria Applied

Baseline Data is stored

Kt/V Data

Data validation is per-

formed on the CW

Snapshot data to ensure

Data Accuracy &

Completeness (DAC).

NCC Data Warehouse

QIP Kt/V Database

Baseline Tables

The process of pulling, validating, & transforming CW data into usable, de-normalized data occurs for each clinical period in the three baseline average.

NCC Data Warehouse

QIP Kt/V Database

BL1 Tables

NCC Data Warehouse

QIP Kt/V Database

BL2 Tables

NCC Data Warehouse

QIP Kt/V Database

BL3 Tables

Patient De-dupe

Comp. BL data is stored

Data Validation

Pt. Elig. Ct

Pt. Kt/V Met Ct

Prev.Patients

HD Kt/V

PD Kt/V

Comp. Kt/V

Facility-Level

Data

NW-Level

DataBSO-Level

Data

Nat’l-Level

Data

Patient-Level

Data

ESRD NW

QIP Kt/V

Distribution Files

Data scripts are run on validation,

duplicate patient submissions and to

pull 3 mos into comprehensive data.

Data scripts are run to pull end-of-

baseline prevalence, and count the

eligible and ‘met’ months for each pt.

Data scripts are run to calculate the

baseline counts for patients for

Comprehensive, HD & PD Kt/V.

Data 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.

Data scripts are run to create

the ESRD NW Distribution files

for QIP Kt/V.





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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_Data BL2_Raw_Data BL3_Raw_Data CROWN_Facility Baseline_Patient_Detail Baseline_Facility_Detail Baseline_Network_Detail Baseline_BSO_Detail Baseline_National_Detail

The BL Raw Data 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.





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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.

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.





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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.

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.





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The QIP Kt/V Network Detail Table gives the total patient count as of the end of the baseline period.



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 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 shows the Baseline Comprehensive Rate, and also gives the Baseline HD and PD Rates at the National level.





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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 Data 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.

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