Measure Description
The number of newly initiated patients on dialysis in a practitioner group who are under the age of 75 and were either listed on the kidney or kidney-pancreas transplant waitlist or received a living donor transplant within the first year of initiating dialysis. The practitioner group is inclusive of physicians and advanced practice providers. The measure is the ratio-observed number of waitlist events in a practitioner group to its expected number of waitlist events. The measure uses the expected waitlist events calculated from a Cox model, which is adjusted for age, patient comorbidities, and other risk factors at the time of dialysis.
Instructions
This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. This measure is intended to reflect the quality of services provided for patients within the first year of following initiation of dialysis. This measure may only be submitted by Merit-based Incentive Payment System (MIPS) eligible clinician groups who provide the measure-specific denominator coding. This measure is not intended to be reported by individual clinicians.
Unique to this measure is the Minimum Process of Care Performance Threshold Requirement. This measure-based threshold requires that at least 90% of all eligible patients have an outcome documented by the end of the performance period. Therefore, if the performance rate for Submission Criteria 1 is below 90%, the MIPS eligible clinician would not be able to meet the denominator of the Submission Criteria 2 and this measure CANNOT BE SUBMITTED. CMS anticipates the performance rate for Submission Criteria 2 will be calculated using all denominator eligible patients for Submission Criteria 1.
This measure contains two submission criteria which together ensure capture of the full patient population and assessment of timely listing to the kidney or kidney-pancreas transplant waitlist or receipt of a living donor transplant. Submission Criteria 1 ensures a complete patient population is being assessed and measure requirements are being met. Submission Criteria 2 evaluates the expected number of waitlist events for observed events. For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 2 is used for performance. For the purposes of submitting this measure, use the Data Completeness determined in Submission Criteria 1.
Technical notes describing the statistical methods used to calculate the measure, including model details, can be found on the following publicly available webpage: https://dialysisdata.org/content/MIPS. Please refer to the technical notes when calculating this measure.
NOTE: Eligible Cases for this measure conducted via telehealth are not allowable.
Measure Submission Type:
Measure data may be submitted by MIPS eligible groups or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible groups or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:
1) Percentage of patients in their first year of dialysis who had documentation of waitlist status at the end of the performance period
AND
2) Ratio of the observed number of waitlist events to the number of expected waitlist events
DENOMINATOR (SUBMISSION CRITERIA 1):
Patients aged 75 years of age or less who have initiated dialysis during January 1st – December 31st of the previous performance period
DENOMINATOR NOTE: If a dialysis practitioner group has fewer than 11 patients, then the dialysis practitioner group is excluded from reporting outcomes. The Nursing Home Minimum Dataset (MDS) and the Questions 16u and 22 on CMS Medical Evidence Form 2728 may be used to identify patients in skilled nursing facilities.
For the purposes of this measure, the transplant program or Organ Procurement and Transplant Network (OPTN) can be utilized as the data source for the numerator as well as patients on the kidney/kidney-pancreas waitlist prior to the initiation of dialysis.
For the purposes of determining age, utilize the date of birth given on the completed CMS Medical Evidence Form 2728 for all ESRD dialysis patients.
Denominator Criteria (Eligible Cases):
Patients aged <75 years on date of dialysis initiation during January 1st – December 31st of the previous performance period
AND
CMS Medical Evidence Form 2728 for dialysis patients: Initial form completed: M1265
AND NOT
DENOMINATOR EXCLUSIONS:
Patients admitted to a skilled nursing facility (SNF): M1266
OR
Patients in hospice on their initiation of dialysis date or during the month of evaluation: M1263
OR
Patients that were on the kidney or kidney-pancreas waitlist prior to initiation of dialysis: M1261
OR
Patients who had a transplant prior to initiation of dialysis: M1262
NUMERATOR (SUBMISSION CRITERIA 1):
Patients who initiated dialysis and had documentation of status at the end of the first year after initiating dialysis
NUMERATOR NOTE: Documentation of the patient’s status should indicate if denominator eligible patients were either added or not added to the kidney or kidney-pancreas transplant waitlist or if they received a living donor transplant. Patients who do not have documentation of their status at the end of the first year after initiating dialysis would be reporting as a performance not met. Documentation within the medical record doesn’t have to occur on the last day of the first year, however, for the purposes of this measure the status used to determine performance should reflect status on the last day of the first year after initiating dialysis.
Numerator Options:
Performance Met: Patient status documented within the first year of initiating dialysis (M1259)
OR
Performance Not Met: Patient status not documented within the first year of initiating dialysis (M1260)
DENOMINATOR (SUBMISSION CRITERIA 2):
The denominator for the First Year Standardized Waitlist Ratio (FYSWR) is the total number of patients under the age of 75 in the practitioner group according to each patient's treatment history for patients within the first year following initiation of dialysis
DENOMINATOR NOTE: If a dialysis practitioner group has fewer than 11 patients or 2 expected waitlist events, then the dialysis practitioner group is excluded from reporting outcomes. The Nursing Home Minimum Dataset (MDS) and the Questions 16u and 22 on CMS Medical Evidence Form 2728 may be used to identify patients in skilled nursing facilities
For the purposes of this measure, the transplant program or Organ Procurement and Transplant Network (OPTN) can be utilized as the data source for the numerator as well as patients on the kidney/kidney-pancreas waitlist prior to the initiation of dialysis.
For the purposes of determining age, utilize the date of birth given on the completed CMS Medical Evidence Form 2728 for all ESRD dialysis patients.
Denominator Criteria (Eligible Cases):
Minimum Process of Care Threshold Requirement: At least 90% of all eligible patients had documentation indicating their status as of the last day for the first year after initializing dialysis (M1259 submitted for Submission Criteria 1)
AND
Patients aged <75 years on date of dialysis initiation during January 1st – December 31st of the previous performance period
AND
CMS Medical Evidence Form 2728 for dialysis patients: Initial form completed: M1265
AND NOT
DENOMINATOR EXCLUSIONS:
Patients admitted to a skilled nursing facility (SNF): M1266
OR
Patients in hospice on their initiation of dialysis date or during the month of evaluation: M1263
OR
Patients that were on the kidney or kidney-pancreas waitlist prior to initiation of dialysis: M1261
OR
Patients who had a transplant prior to initiation of dialysis: M1262
NUMERATOR (SUBMISSION CRITERIA 2):
The ratio of the observed number of waitlist events in a practitioner group to the model-based expected number of waitlist events
Definitions:
Expected Waitlist Event – A model-based expected number of waitlist events that is calculated from a Cox model, adjusting for age, incident comorbidities, dual Medicare-Medicaid eligibility, Area Deprivation Index (from patient's residence zip code) and transplant center characteristics. The number of days at risk (time from start of dialysis to the earliest of being placed on the waitlist, receiving a living donor transplant, death, or one year from start of dialysis) for each patient is used to calculate the expected waitlist or living donor transplant events.
Observed Waitlist Event – The number of patients placed on the kidney or kidney-pancreas waitlist or who received a living donor transplant within one year from start of dialysis.
NUMERATOR NOTE: For the purposes of this measure, the transplant program or Organ Procurement and Transplant Network (OPTN) can be utilized as the data source for the numerator.
Calculations for the ratio measures are detailed below, but for more information on how to calculate FYWSR, please see Technical Notes on the Merit-based Incentive Payment System Clinical Quality Measure (MIPS CQM) for First Year Standardized Waitlist Ratio (FYSWR) found at https://dialysisdata.org/content/MIPS.
- Step One: Calculate days at risk. Days at risk is calculated as the time between the start of ESRD and date of listing on the kidney or kidney-pancreas transplant waitlist; date of receiving a living donor transplant; date of death; or 365 days after the start of ESRD dialysis treatment, whichever comes first.
- Step Two: For each patient period, calculate the linear prediction using the Model Coefficients table in the FYSWR_ModelInfo.xlsx Excel file located at https://dialysisdata.org/content/MIPS. Table 2 shows these details for the example. Note the calculations can be affected by rounding. For this calculation example, we show only four decimal places for ease of display.
- Step Three: Use the Excel file to find the baseline cumulative hazard, by finding the corresponding hazard value given the number of days at risk in the patient period. Table 3 shows these details for the example. Again, note the baseline cumulative hazard values are shown to four decimal places in this example.
- Step Four: Using the linear prediction and baseline cumulative hazard in Tables 2 and 3, compute the expected number of waitlists for each of these patients by calculating the exponentiation of the linear prediction and multiplying by the baseline cumulative hazard.
- The expected number of waitlists of a patient is calculated as:
Expected number of waitlists
= exp(Linear prediction)*(Baseline cumulative hazard)
- The expected number of waitlists of a patient is calculated as:
- Step Five: Calculate the total expected number of waitlists by adding each patient’s expected number of waitlists for all the patients.
- Step Six: Finally, calculate FYSWR by dividing the total number of observed events (waitlists or living donor transplants) by the total number of expected waitlists
FYWSR = Sum observed waitlist / Sum expected waitlist
Rationale
A measure focusing on the outcome of waitlisting is appropriate for several reasons. First, in preparing patients for suitability for waitlisting, dialysis practitioners optimize their health and functional status, improving their overall health state. Second, waitlisting is a necessary step prior to potential receipt of a deceased donor kidney transplant (receipt of a living donor kidney is also accounted for in the measure), which is known to be beneficial for survival and quality of life [1]. Third, dialysis practitioners exert substantial control over the processes that result in waitlisting. This includes proper education of dialysis patients on the option for transplant, referral of appropriate patients to a transplant center for evaluation, and assisting patients with completion of the transplant evaluation process in order to increase their candidacy for transplant waitlisting. These types of activities are included as part of the conditions for coverage for Medicare certification of ESRD dialysis facilities. Finally, wide regional and facility variations in waitlisting rates highlight substantial room for improvement for this measure [2-5].
Additionally, this measure focuses specifically on the population of patients incident to dialysis, examining for waitlist or living donor transplant events occurring within a year of dialysis initiation. This will evaluate and encourage rapid attention from dialysis practitioner groups to the optimization of health of patients to ensure early access to the waitlist, which has been demonstrated to be particularly beneficial [6-9]. This measure contrasts with the other proposed waitlisting measures, which focus on a prevalent population of dialysis patients and encourage maintenance of patients on the waitlist (Percent of Prevalent Patients Waitlisted and Percent of Prevalent Patients Waitlisted in Active Status).
References
1. Tonelli M, Wiebe N, Knoll G, et al. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. American Journal of Transplantation 2011;11:2093-2109.
2. Ashby VB, Kalbfleisch JD, Wolfe RA, et al. Geographic variability in access to primary kidney transplantation in the United States, 1996-2005. American Journal of Transplantation 2007; 7 (5 Part 2):1412-1423
3. Satayathum S, Pisoni RL, McCullough KP, et al. Kidney transplantation and wait-listing rates from the international Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney Intl 2005 Jul; 68 (1):330-337.
4. Patzer RE, Plantinga L, Krisher J, Pastan SO. Dialysis facility and network factors associated with low kidney transplantation rates among United States dialysis facilities. Am J Transplant. 2014 Jul; 14(7):1562-72.
5. Melanson TA, Gander JC, Rossi A, et al. Variation in Waitlisting Rates at the Dialysis Facility Level in the Context of Goals for Improving Kidney Health in the United States. Kidney International Reports 2021;6:1965-1968.
6. Meier-Kriesche, Herwig-Ulf, and Bruce Kaplan. "Waiting time on dialysis as the strongest modifiable risk factor for renal transplant outcomes: A Paired Donor Kidney Analysis." Transplantation 74.10 (2002): 1377-1381.
7. Meier-Kriesche, H. U., Port, F. K., Ojo, A. O., Rudich, S. M., Hanson, J. A., Cibrik, D. M., ... & Kaplan, B. (2000). Effect of waiting time on renal transplant outcome. Kidney international, 58(3), 1311-1317.
8. Schold JD, Huml AM, Poggio ED et al. Patients with High Priority for Kidney Transplant Who Are Not Given Expedited Placement on the Transplant Waiting List Represent Lost Opportunities. J Am Soc Nephrol 2021;32:1733-1746.
9. Schold J and Meier-Kreische HU. Which Renal Transplant Candidates Should Accept Marginal Kidneys in Exchange for a Shorter Waiting Time on Dialysis? Clin J Am Soc Nephrol 2006;1:532-538.
Clinical Recommendation Statements
Empirical support for the value of waitlisting to patients comes from a published study reporting on a large survey of 409 patients or family members who agreed to receiving emails from the National Kidney Foundation [1]. Participants included both patients with advanced chronic kidney disease prior to transplant, and recipients of transplants, who were asked about their priorities in choice of a transplant center. Notably, participants were most likely (a plurality of participants) to rank waitlisting characteristics (such as ease of getting on the waitlist) as the most important feature, in contrast to other transplant center characteristics such as post-transplant outcomes and practical considerations (e.g., distance to center).
National or large regional studies provide strong empirical support for the association between processes under dialysis practitioner control and subsequent waitlisting. In one large regional study conducted on facilities in the state of Georgia, a standardized dialysis facility referral ratio was developed, adjusted for age, demographics and comorbidities [2]. There was substantial variability across dialysis facilities in referral rates, and a Spearman correlation performed between ranking on the referral ratio and dialysis facility waitlist rates was highly significant (r=0.35, p3) transplant education strategies (e.g., provision of brochures, referral to formal transplant education program, distribution of transplant center contact information) had 36% higher waitlist rates compared to facilities employing fewer strategies.
References
1. Husain SA, Brennan C, Michelson A, Tsapepas D, Patzer RE, Schold JD, Mohan S. Patients prioritize waitlist over posttransplant outcomes when evaluating kidney transplant centers. Am J Transplant. 2018 Nov;18(11):2781-2790.
2. Paul S, Plantinga LC, Pastan SO, Gander JC, Mohan S, Patzer RE. Standardized Transplantation Referral Ratio to Assess Performance of Transplant Referral among Dialysis Facilities. Clin J Am Soc Nephrol. 2018 Feb 7;13(2):282-289.
3. Kucirka LM, Grams ME, Balhara KS, Jaar BG, Segev DL. Disparities in provision of transplant information affect access to kidney transplantation. Am J Transplant. 2012 Feb;12(2):351-7.
4. Salter ML, Orandi B, McAdams-DeMarco MA, Law A, Meoni LA, Jaar BG, Sozio SM, Kao WH, Parekh RS, Segev DL. Patient- and provider-reported information about transplantation and subsequent waitlisting. J Am Soc Nephrol. 2014 Dec;25(12):2871-7.
5. Waterman AD, Peipert JD, Goalby CJ, Dinkel KM, Xiao H, Lentine KL. Assessing Transplant Education Practices in Dialysis Centers: Comparing Educator Reported and Medicare Data. Clin J Am Soc Nephrol. 2015 Sep 4;10(9):1617-25.