eCQM Title

Diabetes: Medical Attention for Nephropathy

eCQM Identifier (Measure Authoring Tool)

134

eCQM Version Number

10.0.000

NQF Number

Not Applicable

GUID

7b2a9277-43da-4d99-9bee-6ac271a07747

Measurement Period

January 1, 20XX through December 31, 20XX

Measure Steward

National Committee for Quality Assurance

Measure Developer

National Committee for Quality Assurance

Endorsed By

None

Description

The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period

This Physician Performance Measure (Measure) and related data specifications are owned and were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2020 National Committee for Quality Assurance. All Rights Reserved.

Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2020 American Medical Association. LOINC(R) copyright 2004-2020 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2020 International Health Terminology Standards Development Organisation. ICD-10 copyright 2020 World Health Organization. All Rights Reserved.

Disclaimer

The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Measure Scoring

Proportion

Measure Type

Process

Stratification

None

Risk Adjustment

None

Rate Aggregation

None

Rationale

Diabetes is the seventh leading cause of death in the United States. In 2017, diabetes affected approximately 34 million Americans (10.5 percent of the U.S. population) and killed approximately 84,000 people (CDC, 2020a). Diabetes is a long-lasting disease marked by high blood glucose levels, resulting from the body's inability to produce or use insulin properly (CDC, 2020b). People with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney damage, and amputation of feet or legs (CDC, 2018). 

In 2017, diabetes cost the U.S. an estimated $327 billion: $237 billion in direct medical costs and $90 billion in reduced productivity. This is a 34 percent increase from the estimated $245 billion spent on diabetes in 2012 (American Diabetes Association [ADA], 2018).  

High blood sugar levels in patients with diabetes put them at a higher risk of damaging their kidneys and causing kidney disease (ADA, 2020a). Kidney disease is one of the most common adverse outcomes of diabetes, affecting 20-40 percent of patients with diabetes. Kidney Disease can lead to kidney failure and is the leading cause of end stage renal disease (ESRD) (ADA, 2020b). In 2013, there were more than 51,000 new cases of kidney failure among people with diabetes (National Kidney Foundation, 2016). In 2014, diabetes accounted for 44% of 118,000 new cases of ESRD (United States Renal Data System, 2016).

Clinical Recommendation Statement

American Diabetes Association (2020):
Screening
- At least once a year, assess urinary albumin (e.g., spot urinary albumin-to-creatinine ratio [UACR]) and estimated glomerular filtration rate (eGFR) in patients with type 1 diabetes with duration of >=5 years, and in all patients with type 2 diabetes, regardless of treatment. (Level of evidence: B)
- Patients with urinary albumin >30 mg/g creatinine and/or an eGFR <60 mL/min/1.73m2 should be monitored twice annually to guide therapy. (Level of evidence: C)

Treatment
- An angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) is not recommended for the primary prevention of chronic kidney disease in patients with diabetes who have normal blood pressure, normal UACR (<30 mg/g creatinine), and normal estimated glomerular filtration rate. (Level of evidence: B)
- In nonpregnant patients with diabetes and hypertension, either an ACE inhibitor or ARB is recommended for those with modestly elevated UACR (30-299 mg/g creatinine) (Level of evidence: B) and is strongly recommended for those with UACR >=300 mg/g creatinine and/or eGFR <60 mL/min/1.73.m2. (Level of evidence: A)
- Periodically monitor serum creatinine and potassium levels for the development of increased creatinine or changes in potassium when ACE inhibitors, ARB, or diuretics are used. (Level of evidence: B) 
-Patients should be referred for evaluation by a nephrologist if they have an eGFR <30 mL/min/1.73 m2. (Level of evidence: A)
-Promptly refer to a physician experienced in the care of kidney disease for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease. (Level of evidence: A)

American Association of Clinical Endocrinologists & American College of Endocrinology (2015): 
- Beginning 5 years after diagnosis in patients with type 1 diabetes (if diagnosed before age 30) or at diagnosis in patients with type 2 diabetes and those with type 1 diabetes diagnosed after age 30, annual assessment of serum creatinine to determine the estimated glomerular filtration rate (eGFR) and urine albumin excretion rate (AER) should be performed to identify, stage, and monitor progression of diabetic nephropathy. (Grade C; best evidence level 3) 
- Patients with nephropathy should be counseled regarding the need for optimal glycemic control, blood pressure control, dyslipidemia control, and smoking cessation. (Grade B; best evidence level 2)
- In addition, they should have routine monitoring of albuminuria, kidney function electrolytes, and lipids. (Grade B; best evidence level 2)
- Associated conditions such as anemia and bone and mineral disorders should be assessed as kidney function declines. (Grade D; best evidence level 4)
- Referral to a nephrologist is recommended well before the need for renal replacement therapy. (Grade D; best evidence level 4)

Improvement Notation

Higher score indicates better quality

Reference

Reference Type: CITATION

Reference Text: 'American Association of Clinical Endocrinologists And American College of Endocrinology. (2015). Clinical practice guidelines for developing a diabetes mellitus comprehensive care plan—2015. Endocrine Practice, 21(Suppl. 1). https://doi.org/10.4158/EP15672.GLSUPPL'

Reference

Reference Type: CITATION

Reference Text: 'American Diabetes Association. (2018). Economic costs of diabetes in the U.S. in 2017. Diabetes Care, 41, 917-928. Retrieved from http://care.diabetesjournals.org/content/early/2018/03/20/dci18-0007'

Reference

Reference Type: CITATION

Reference Text: 'American Diabetes Association. (2020). 11. Microvascular complications and foot care: Standards of Medical Care in Diabetes–2020. Diabetes Care 2020; 43(Suppl. 1):S135–S151. https://doi.org/10.2337/dc20-s011'

Reference

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention. (2018). Diabetes Report Card 2017. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services. Retrieved from https://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2017-508.pdf'

Reference

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention. (2020a). National Diabetes Statistics Report, 2020. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services. Retrieved from https://www.cdc.gov/diabetes/data/statistics-report/index.html'

Reference

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention. (2020b). Diabetes Basics. Retrieved from https://www.cdc.gov/diabetes/basics/diabetes.html'

Reference

Reference Type: CITATION

Reference Text: 'American Diabetes Association. (2020a). Kidney disease (nephropathy). Retrieved from https://diabetes.org/diabetes/complications/kidney-disease-nephropathy'

Reference

Reference Type: CITATION

Reference Text: 'National Kidney Foundation. (2016). Diabetes and Chronic Kidney Disease. Retrieved from https://www.kidney.org/news/newsroom/factsheets/Diabetes-And-CKD-states'

Reference

Reference Type: CITATION

Reference Text: 'United States Renal Data System. (2016). 2016 USRDS annual data report: Epidemiology of kidney disease in the United States. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.'

Definition

None

Guidance

Only patients with a diagnosis of Type 1 or Type 2 diabetes should be included in the denominator of this measure; patients with a diagnosis of secondary diabetes due to another condition should not be included.

This eCQM is a patient-based measure.
 
This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Transmission Format

TBD

Initial Population

Patients 18-75 years of age with diabetes with a visit during the measurement period

Denominator

Equals Initial Population

Denominator Exclusions

Exclude patients who are in hospice care for any part of the measurement period.

Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period. 

Exclude patients 66 and older with an indication of frailty for any part of the measurement period who meet any of the following criteria:
-	Advanced illness with two outpatient encounters during the measurement period or the year prior
-	OR advanced illness with one inpatient encounter during the measurement period or the year prior
-	OR taking dementia medications during the measurement period or the year prior

Exclude patients receiving palliative care during the measurement period.

Numerator

Patients with a screening for nephropathy or evidence of nephropathy during the measurement period

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Supplemental Data Elements

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Population Criteria
Definitions
Functions
Terminology
Data Criteria (QDM Data Elements)
Supplemental Data Elements
Risk Adjustment Variables

Population Criteria

Initial Population

exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) in Interval[18, 75 )
)
  and exists ( AdultOutpatientEncounters."Qualifying Encounters"
      union "Telehealth Services"
  )
  and exists ( ["Diagnosis": "Diabetes"] Diabetes
      where Diabetes.prevalencePeriod overlaps "Measurement Period"
  )

- Denominator
  - "Initial Population"

Denominator Exclusions

Hospice."Has Hospice"
  or FrailtyLTI."Advanced Illness and Frailty Exclusion Not Including Over Age 80"
  or ( exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate
      where ( Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 65 )
        and FrailtyLTI."Has Long Term Care Periods Longer Than 90 Consecutive Days"
        or PalliativeCare."Palliative Care in the Measurement Period"
  )

Numerator

exists ( "Active ACE or ARB Medications" )
  or exists ( "Nephropathy Diagnoses" )
  or exists ( "Nephropathy Screenings" )

- Numerator Exclusions
  - None

- Denominator Exceptions
  - None

- Stratification
  - None

Definitions

Active ACE or ARB Medications

["Medication, Active": "ACE Inhibitor or ARB or ARNI"] ACEorARBMedication
  where Global."NormalizeInterval" ( ACEorARBMedication.relevantDatetime, ACEorARBMedication.relevantPeriod ) overlaps "Measurement Period"

AdultOutpatientEncounters.Qualifying Encounters

( ["Encounter, Performed": "Office Visit"]
  union ["Encounter, Performed": "Annual Wellness Visit"]
  union ["Encounter, Performed": "Preventive Care Services - Established Office Visit, 18 and Up"]
  union ["Encounter, Performed": "Preventive Care Services-Initial Office Visit, 18 and Up"]
  union ["Encounter, Performed": "Home Healthcare Services"] ) ValidEncounter
  where ValidEncounter.relevantPeriod during "Measurement Period"

FrailtyLTI.Advanced Illness and Frailty Exclusion Not Including Over Age 80

exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 65
      and "Has Criteria Indicating Frailty"
      and ( exists "Two Outpatient Encounters with Advanced Illness on Different Dates of Service"
          or exists ( "Inpatient Encounter with Advanced Illness" )
          or exists "Dementia Medications In Year Before or During Measurement Period"
      )
)

FrailtyLTI.Dementia Medications In Year Before or During Measurement Period

["Medication, Active": "Dementia Medications"] DementiaMed
	where Global."NormalizeInterval"(DementiaMed.relevantDatetime, DementiaMed.relevantPeriod) overlaps Interval[( start of "Measurement Period" - 1 year ), 
	end of "Measurement Period"]

FrailtyLTI.Has Criteria Indicating Frailty

exists ( ["Device, Order": "Frailty Device"] FrailtyDeviceOrder
    where FrailtyDeviceOrder.authorDatetime during "Measurement Period"
)
  or exists ( ["Device, Applied": "Frailty Device"] FrailtyDeviceApplied
      where Global."NormalizeInterval" ( FrailtyDeviceApplied.relevantDatetime, FrailtyDeviceApplied.relevantPeriod ) overlaps "Measurement Period"
  )
  or exists ( ["Diagnosis": "Frailty Diagnosis"] FrailtyDiagnosis
      where FrailtyDiagnosis.prevalencePeriod overlaps "Measurement Period"
  )
  or exists ( ["Encounter, Performed": "Frailty Encounter"] FrailtyEncounter
      where FrailtyEncounter.relevantPeriod overlaps "Measurement Period"
  )
  or exists ( ["Symptom": "Frailty Symptom"] FrailtySymptom
      where FrailtySymptom.prevalencePeriod overlaps "Measurement Period"
  )

FrailtyLTI.Has Long Term Care Periods Longer Than 90 Consecutive Days
- - "Max Long Term Care Period Length" > 90

FrailtyLTI.Inpatient Encounter with Advanced Illness

["Encounter, Performed": "Acute Inpatient"] InpatientEncounter
  where exists ( InpatientEncounter.diagnoses Diagnosis
      where Diagnosis.code in "Advanced Illness"
  )
    and InpatientEncounter.relevantPeriod starts 2 years or less on or before 
    end of "Measurement Period"

FrailtyLTI.Long Term Care Adjacent Periods

from 
"Long Term Care Overlapping Periods" LTCPeriod1,
"Long Term Care Overlapping Periods" LTCPeriod2
where end of LTCPeriod1 within 1 day of start of LTCPeriod2
return Interval[start of LTCPeriod1, end of LTCPeriod2]

FrailtyLTI.Long Term Care Overlapping Periods

collapse("Long Term Care Periods During Measurement Period")

FrailtyLTI.Long Term Care Periods During Measurement Period

( ["Encounter, Performed": "Care Services in Long-Term Residential Facility"]
  union ["Encounter, Performed": "Nursing Facility Visit"] ) LongTermFacilityEncounter
  where LongTermFacilityEncounter.relevantPeriod overlaps "Measurement Period"
  return LongTermFacilityEncounter.relevantPeriod
    intersect "Measurement Period"

FrailtyLTI.Max Long Term Care Period Length

Max((collapse("Long Term Care Overlapping Periods"
      union "Long Term Care Adjacent Periods"
  ))LTCPeriods
    return duration in days of LTCPeriods
)

FrailtyLTI.Outpatient Encounters with Advanced Illness

( ["Encounter, Performed": "Outpatient"]
  union ["Encounter, Performed": "Observation"]
  union ["Encounter, Performed": "Emergency Department Visit"]
  union ["Encounter, Performed": "Nonacute Inpatient"] ) OutpatientEncounter
  where exists ( OutpatientEncounter.diagnoses Diagnosis
      where Diagnosis.code in "Advanced Illness"
  )
    and OutpatientEncounter.relevantPeriod starts 2 years or less on or before 
    end of "Measurement Period"

FrailtyLTI.Two Outpatient Encounters with Advanced Illness on Different Dates of Service

from
  "Outpatient Encounters with Advanced Illness" OutpatientEncounter1,
  "Outpatient Encounters with Advanced Illness" OutpatientEncounter2
  where OutpatientEncounter2.relevantPeriod ends 1 day or more after day of 
  end of OutpatientEncounter1.relevantPeriod
  return OutpatientEncounter1

Denominator
- - "Initial Population"

Denominator Exclusions

Hospice."Has Hospice"
  or FrailtyLTI."Advanced Illness and Frailty Exclusion Not Including Over Age 80"
  or ( exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate
      where ( Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 65 )
        and FrailtyLTI."Has Long Term Care Periods Longer Than 90 Consecutive Days"
        or PalliativeCare."Palliative Care in the Measurement Period"
  )

End Stage Renal Disease Encounter

["Encounter, Performed": "ESRD Monthly Outpatient Services"]

Hospice.Has Hospice

exists ( ["Encounter, Performed": "Encounter Inpatient"] DischargeHospice
    where ( DischargeHospice.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
        or DischargeHospice.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
    )
      and DischargeHospice.relevantPeriod ends during "Measurement Period"
)
  or exists ( ["Intervention, Order": "Hospice care ambulatory"] HospiceOrder
      where HospiceOrder.authorDatetime during "Measurement Period"
  )
  or exists ( ["Intervention, Performed": "Hospice care ambulatory"] HospicePerformed
      where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps "Measurement Period"
  )

Initial Population

exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) in Interval[18, 75 )
)
  and exists ( AdultOutpatientEncounters."Qualifying Encounters"
      union "Telehealth Services"
  )
  and exists ( ["Diagnosis": "Diabetes"] Diabetes
      where Diabetes.prevalencePeriod overlaps "Measurement Period"
  )

Nephropathy Diagnoses

( ["Diagnosis": "Hypertensive Chronic Kidney Disease"]
  union ["Diagnosis": "Kidney Failure"]
  union ["Diagnosis": "Glomerulonephritis and Nephrotic Syndrome"]
  union ["Diagnosis": "Diabetic Nephropathy"]
  union ["Diagnosis": "Proteinuria"] ) NephropathyDiagnoses
  where NephropathyDiagnoses.prevalencePeriod overlaps "Measurement Period"

Nephropathy Screenings

( ( "Renal Procedures"
    union "Renal Interventions"
    union "Protein Urea Lab Test" ) ScreeningNephropathy
    where Global."NormalizeInterval" ( ScreeningNephropathy.relevantDatetime, ScreeningNephropathy.relevantPeriod ) during "Measurement Period"
)
  union ( "End Stage Renal Disease Encounter" ESRDEncounter
      where ESRDEncounter.relevantPeriod during "Measurement Period"
  )

Numerator

exists ( "Active ACE or ARB Medications" )
  or exists ( "Nephropathy Diagnoses" )
  or exists ( "Nephropathy Screenings" )

PalliativeCare.Palliative Care in the Measurement Period

exists ( ["Assessment, Performed": "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"] PalliativeAssessment
    where Global."NormalizeInterval"(PalliativeAssessment.relevantDatetime, PalliativeAssessment.relevantPeriod) overlaps "Measurement Period"
)
  or exists ( ["Encounter, Performed": "Palliative Care Encounter"] PalliativeEncounter
      where PalliativeEncounter.relevantPeriod overlaps "Measurement Period"
  )
  or exists ( ["Intervention, Performed": "Palliative Care Intervention"] PalliativeIntervention
      where Global."NormalizeInterval"(PalliativeIntervention.relevantDatetime, PalliativeIntervention.relevantPeriod) overlaps "Measurement Period"
  )

Protein Urea Lab Test

["Laboratory Test, Performed": "Urine Protein Tests"] ProteinUreaResult
  where ProteinUreaResult.result is not null

Renal Interventions

["Intervention, Performed": "Other Services Related to Dialysis"]
  union ["Intervention, Performed": "Dialysis Education"]

Renal Procedures

( ["Procedure, Performed": "Kidney Transplant"]
    union ["Procedure, Performed": "Dialysis Services"]
)

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Telehealth Services

["Encounter, Performed": "Telephone Visits"] TelehealthEncounter
  where TelehealthEncounter.relevantPeriod during "Measurement Period"

Functions

Global.CalendarAgeInYearsAt(BirthDateTime DateTime, AsOf DateTime)
- - years between ToDate(BirthDateTime)and ToDate(AsOf)

Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

if pointInTime is not null then Interval[pointInTime, pointInTime]
  else if period is not null then period 
  else null as Interval<DateTime>

Global.ToDate(Value DateTime)

DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)

Terminology

code "Birth date" ("LOINC Code (21112-8)")
code "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)")
code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)")
code "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" ("LOINC Code (71007-9)")
valueset "ACE Inhibitor or ARB or ARNI" (2.16.840.1.113883.3.526.3.1139)
valueset "Acute Inpatient" (2.16.840.1.113883.3.464.1003.101.12.1083)
valueset "Advanced Illness" (2.16.840.1.113883.3.464.1003.110.12.1082)
valueset "Annual Wellness Visit" (2.16.840.1.113883.3.526.3.1240)
valueset "Care Services in Long-Term Residential Facility" (2.16.840.1.113883.3.464.1003.101.12.1014)
valueset "Dementia Medications" (2.16.840.1.113883.3.464.1003.196.12.1510)
valueset "Diabetes" (2.16.840.1.113883.3.464.1003.103.12.1001)
valueset "Diabetic Nephropathy" (2.16.840.1.113883.3.464.1003.109.12.1004)
valueset "Dialysis Education" (2.16.840.1.113883.3.464.1003.109.12.1016)
valueset "Dialysis Services" (2.16.840.1.113883.3.464.1003.109.12.1013)
valueset "Emergency Department Visit" (2.16.840.1.113883.3.464.1003.101.12.1010)
valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
valueset "ESRD Monthly Outpatient Services" (2.16.840.1.113883.3.464.1003.109.12.1014)
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "Frailty Device" (2.16.840.1.113883.3.464.1003.118.12.1300)
valueset "Frailty Diagnosis" (2.16.840.1.113883.3.464.1003.113.12.1074)
valueset "Frailty Encounter" (2.16.840.1.113883.3.464.1003.101.12.1088)
valueset "Frailty Symptom" (2.16.840.1.113883.3.464.1003.113.12.1075)
valueset "Glomerulonephritis and Nephrotic Syndrome" (2.16.840.1.113883.3.464.1003.109.12.1018)
valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016)
valueset "Hospice care ambulatory" (2.16.840.1.113762.1.4.1108.15)
valueset "Hypertensive Chronic Kidney Disease" (2.16.840.1.113883.3.464.1003.109.12.1017)
valueset "Kidney Failure" (2.16.840.1.113883.3.464.1003.109.12.1028)
valueset "Kidney Transplant" (2.16.840.1.113883.3.464.1003.109.12.1012)
valueset "Nonacute Inpatient" (2.16.840.1.113883.3.464.1003.101.12.1084)
valueset "Nursing Facility Visit" (2.16.840.1.113883.3.464.1003.101.12.1012)
valueset "Observation" (2.16.840.1.113883.3.464.1003.101.12.1086)
valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
valueset "Other Services Related to Dialysis" (2.16.840.1.113883.3.464.1003.109.12.1015)
valueset "Outpatient" (2.16.840.1.113883.3.464.1003.101.12.1087)
valueset "Palliative Care Encounter" (2.16.840.1.113883.3.464.1003.101.12.1090)
valueset "Palliative Care Intervention" (2.16.840.1.113883.3.464.1003.198.12.1135)
valueset "Payer" (2.16.840.1.114222.4.11.3591)
valueset "Preventive Care Services - Established Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1025)
valueset "Preventive Care Services-Initial Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1023)
valueset "Proteinuria" (2.16.840.1.113883.3.526.3.1003)
valueset "Race" (2.16.840.1.114222.4.11.836)
valueset "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)
valueset "Urine Protein Tests" (2.16.840.1.113883.3.464.1003.109.12.1024)

Data Criteria (QDM Data Elements)

"Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" using "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal) (LOINC Code 71007-9)"
"Device, Applied: Frailty Device" using "Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300)"
"Device, Order: Frailty Device" using "Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300)"
"Diagnosis: Diabetes" using "Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001)"
"Diagnosis: Diabetic Nephropathy" using "Diabetic Nephropathy (2.16.840.1.113883.3.464.1003.109.12.1004)"
"Diagnosis: Frailty Diagnosis" using "Frailty Diagnosis (2.16.840.1.113883.3.464.1003.113.12.1074)"
"Diagnosis: Glomerulonephritis and Nephrotic Syndrome" using "Glomerulonephritis and Nephrotic Syndrome (2.16.840.1.113883.3.464.1003.109.12.1018)"
"Diagnosis: Hypertensive Chronic Kidney Disease" using "Hypertensive Chronic Kidney Disease (2.16.840.1.113883.3.464.1003.109.12.1017)"
"Diagnosis: Kidney Failure" using "Kidney Failure (2.16.840.1.113883.3.464.1003.109.12.1028)"
"Diagnosis: Proteinuria" using "Proteinuria (2.16.840.1.113883.3.526.3.1003)"
"Encounter, Performed: Acute Inpatient" using "Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083)"
"Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240)"
"Encounter, Performed: Care Services in Long-Term Residential Facility" using "Care Services in Long-Term Residential Facility (2.16.840.1.113883.3.464.1003.101.12.1014)"
"Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit (2.16.840.1.113883.3.464.1003.101.12.1010)"
"Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
"Encounter, Performed: ESRD Monthly Outpatient Services" using "ESRD Monthly Outpatient Services (2.16.840.1.113883.3.464.1003.109.12.1014)"
"Encounter, Performed: Frailty Encounter" using "Frailty Encounter (2.16.840.1.113883.3.464.1003.101.12.1088)"
"Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016)"
"Encounter, Performed: Nonacute Inpatient" using "Nonacute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1084)"
"Encounter, Performed: Nursing Facility Visit" using "Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012)"
"Encounter, Performed: Observation" using "Observation (2.16.840.1.113883.3.464.1003.101.12.1086)"
"Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
"Encounter, Performed: Outpatient" using "Outpatient (2.16.840.1.113883.3.464.1003.101.12.1087)"
"Encounter, Performed: Palliative Care Encounter" using "Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090)"
"Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1025)"
"Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1023)"
"Encounter, Performed: Telephone Visits" using "Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080)"
"Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory (2.16.840.1.113762.1.4.1108.15)"
"Intervention, Performed: Dialysis Education" using "Dialysis Education (2.16.840.1.113883.3.464.1003.109.12.1016)"
"Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory (2.16.840.1.113762.1.4.1108.15)"
"Intervention, Performed: Other Services Related to Dialysis" using "Other Services Related to Dialysis (2.16.840.1.113883.3.464.1003.109.12.1015)"
"Intervention, Performed: Palliative Care Intervention" using "Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135)"
"Laboratory Test, Performed: Urine Protein Tests" using "Urine Protein Tests (2.16.840.1.113883.3.464.1003.109.12.1024)"
"Medication, Active: ACE Inhibitor or ARB or ARNI" using "ACE Inhibitor or ARB or ARNI (2.16.840.1.113883.3.526.3.1139)"
"Medication, Active: Dementia Medications" using "Dementia Medications (2.16.840.1.113883.3.464.1003.196.12.1510)"
"Patient Characteristic Birthdate: Birth date" using "Birth date (LOINC Code 21112-8)"
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
"Procedure, Performed: Dialysis Services" using "Dialysis Services (2.16.840.1.113883.3.464.1003.109.12.1013)"
"Procedure, Performed: Kidney Transplant" using "Kidney Transplant (2.16.840.1.113883.3.464.1003.109.12.1012)"
"Symptom: Frailty Symptom" using "Frailty Symptom (2.16.840.1.113883.3.464.1003.113.12.1075)"

Supplemental Data Elements

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Risk Adjustment Variables

None

Measure Set

None