eCQM Title

Kidney Health Evaluation

eCQM Identifier (Measure Authoring Tool)

951

eCQM Version Number

1.5.000

NQF Number

Not Applicable

GUID

53ae1027-d9cc-4152-8454-874ab1b95324

Measurement Period

January 1, 20XX through December 31, 20XX

Measure Steward

National Kidney Foundation

Measure Developer

PCPI(R) Foundation (PCPI[R])

Measure Developer

National Kidney Foundation

Endorsed By

None

Description

Percentage of patients aged 18-75 years with a diagnosis of diabetes who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within the measurement period

Copyright 2022 National Kidney Foundation. All Rights Reserved.

Disclaimer

Physician Performance Measures (Measures) and related data specifications developed by the National Kidney Foundation (NKF) are intended to facilitate quality improvement activities by health care professionals.

These Measures are intended to assist health care professionals in enhancing quality of care. These Measures are not clinical guidelines and do not establish a standard of medical care and have not been tested for all potential applications. NKF encourages testing and evaluation of its Measures.

Measures are subject to review and may be revised or rescinded at any time by NKF. The measures may not be altered without prior written approval from NKF. The measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes. Commercial use is defined as the sale, license, or distribution of the measures for commercial gain, or incorporation of the measures into a product or service that is sold, licensed, or distributed for commercial gain. Commercial uses of the measures require a license agreement between the user and NKF. Neither NKF nor its members shall be responsible for any use of the measures.

THESE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets.

CPT(R) contained in the Measure specifications is copyright 2004-2021 American Medical Association. LOINC(R) is copyright 2004-2021 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2021 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2021 World Health Organization. All Rights Reserved.

The PCPI’s and AMA’s significant past efforts and contributions to the development and updating of the measure are acknowledged.

Due to technical limitations, registered trademarks are indicated by (R) or [R].

Measure Scoring

Proportion

Measure Type

Process

Stratification

None

Risk Adjustment

None

Rate Aggregation

None

Rationale

Chronic Kidney Disease (CKD) is a major driver of morbidity, mortality and high healthcare costs in the United States. Currently, 37 million American adults have CKD and millions of others are at increased risk (NKF, 2019), with an estimated population prevalence growing to nearly 17% among Americans aged 30 years and older by the year 2030 (Saran, 2019; Hoerger, 2015). Total Medicare spending in 2016 on both CKD and ESRD was over $114 billion, comprising 23% of total Medicare fee-for-service spending overall with costs increasing exponentially with advancing CKD (Saran, 2019; Nichols, 2020). In the US from 2002-2016, the burden of CKD, defined as years of life lost, years living with disability, disability-adjusted life years, and deaths, outpaced changes in the burden of disease for other conditions (Bowe, 2018). Patients with CKD are readmitted to the hospital more frequently than those without diagnosed CKD (Saran, 2019). CKD is the 9th leading cause of death in the US and is the fastest growing non-communicable disease in terms of in burden largely due to death (Hoerger, 2015; Bowe, 2018). This public health issue is driven largely by the impact of diabetes—the most common comorbid risk factor for CKD (Saran, 2019; Bowe, 2018).  

The intent of this process measure is to improve rates of guideline-concordant kidney health evaluation in patients with diabetes to more consistently identify and potentially treat or delay progression of CKD in this high-risk population. Annual kidney health evaluation in patients with diabetes to determine risk of CKD using estimated glomerular filtration rate (eGFR) and urine albumin creatinine ratio (uACR) is recommended by clinical practice guidelines (ADA, 2022; NKF, 2007; NKF, 2012) and has been a focus of various local and national health care quality improvement initiatives, including Healthy People 2020 (United States Renal Data System, 2018). However, performance of these tests in patients with diabetes remains low, with rates that vary across Medicare (41.8%) and private insurers (49.0%) (Saran, 2019; Alfego, 2021; Stempneiwicz, 2021). Low rates of detection of CKD in a population of patients with diabetes have been demonstrated to be associated with low patient awareness of their own kidney health status (Szczech, 2014). Indeed, 90% of individuals with CKD are unaware of their condition due to under-recognition and under-diagnosis (Saran, 2019; Centers for Disease Control and Prevention, 2019). Currently, an individual’s lifetime probability of developing CKD is relatively high, reaching 54% for someone currently aged 30-49 years (Hoerger, 2015). Regular kidney health evaluations, utilizing both eGFR and uACR, provide an opportunity to improve identification and potential reversal of worsening kidney function, particularly in high risk populations, such as those with diabetes.

Clinical Recommendation Statement

The following evidence statements are quoted verbatim from the referenced clinical guidelines and other sources, where applicable:

At least once a year, assess urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and estimated glomerular filtration rate in patients with type 1 diabetes with duration of >= 5 years, in all patients with type 2 diabetes, and in all patients with comorbid hypertension. B (American Diabetes Association Professional Practice Committee, 2019)

Patients with diabetes should be screened annually for Diabetic Kidney Disease (DKD). Initial screening should commence:
  - 5 years after the diagnosis of type 1 diabetes; (A) or
  - From diagnosis of type 2 diabetes. (B)

Screening should include:
  - Measurements of urinary albumin-creatinine ratio (ACR) in a spot urine sample; (B)
  - Measurement of serum creatinine and estimation of GFR. (B) 
(National Kidney Foundation [NKF], 2007; NKF, 2012)

Improvement Notation

Higher score indicates better quality

Reference

Reference Type: CITATION

Reference Text: 'Alfego, D., Ennis, J., Gillespie, B., Lewis, M.J., Montgomery, E., Ferrè, S., … Letovsky, S. (2021). Chronic kidney disease testing among at-risk adults in the U.S. remains low: Real-world evidence from a National Laboratory database. Diabetes Care, 44(9), 2025-2032.
https://doi.org/10.2337/dc21-0723'

Reference

Reference Type: CITATION

Reference Text: 'American Diabetes Association Professional Practice Committee. (2022). Chronic kidney disease and risk management: Standards of medical care in diabetes—2022.
Diabetes Care, 45(Supplement_1), S175-S184. https://doi.org/10.2337/dc22-S011'

Reference

Reference Type: CITATION

Reference Text: 'Bowe, B., Xie, Y., Li, T., Mokdad, A. H., Xian, H., Yan, Y.,... Al-Aly, Z. (2018). Changes in the US burden of chronic kidney disease from 2002 to 2016. JAMA Network Open, 1(7).'

Reference

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention. (2019). Chronic kidney disease in the United States. Retrieved from: https://www.cdc.gov/kidneydisease/publications-resources/2019-national-facts.html.'

Reference

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention. Chronic Kidney Disease in the United States. (2022). Retrieved from: https://www.cdc.gov/kidneydisease/publications-resources/ckd-national-facts.html'

Reference

Reference Type: CITATION

Reference Text: 'Healthy People 2030. Retrieved from: https://health.gov/healthypeople/objectives-and-data/browse-objectives/chronic-kidney-disease'

Reference

Reference Type: CITATION

Reference Text: 'Hoerger, T. J., Simpson, S. A., Yarnoff, B. O., Pavkov, M. E., Burrows, N. R., Saydah, S. H., . . . Zhuo, X. (2015). The future burden of CKD in the United States: A simulation model for the CDC CKD Initiative. American Journal of Kidney Diseases, 65(3), 403-411. doi:10.1053/j.ajkd.2014.09.023'

Reference

Reference Type: CITATION

Reference Text: 'National Kidney Foundation. (2007). KDOQI Clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. Retrieved from: https://www.kidney.org/sites/default/files/docs/diabetes_ajkd_febsuppl_07.pdf'

Reference

Reference Type: CITATION

Reference Text: 'National Kidney Foundation. (2012). KDOQI Clinical practice guideline for diabetes and CKD: 2012 Update. Retrieved from: http://www.kidney.org/sites/default/files/docs/diabetes-ckd-update-2012.pdf'

Reference

Reference Type: CITATION

Reference Text: 'National Kidney Foundation. (2022). About chronic kidney disease. Retrieved from: https://www.kidney.org/atoz/content/about-chronic-kidney-disease'

Reference

Reference Type: CITATION

Reference Text: 'Nichols, G.A, Ustyugova, A., Déruaz-Luyet, A., O’Keeffe-Rosetti, M., & Brodovicz, K.G. (2020). Health care costs by type of expenditure across eGFR stages among patients with and without diabetes, cardiovascular disease, and heart failure. JASN, 31(7), 1594-1601. https://doi.org/10.1681/asn.2019121308'

Reference

Reference Type: CITATION

Reference Text: 'Saran R. B., Abbott K. C., …, Zhang, X. (2019). US renal data system 2018 annual data report: Epidemiology of kidney disease in the United States. American Journal of Kidney Diseases, 73(3), Svii-Sxxii. https://doi.org/10.1053/j.ajkd.2019.01.001'

Reference

Reference Type: CITATION

Reference Text: 'Stempneiwicz, N., Vassalotti, J.A., Cuddeback, J.K., Ciemins, E., Storfer-Isser, A., Sang, Y., … Coresh, J. (2021). Chronic kidney disease testing among primary care patients with type 2 diabetes across 24 U.S. health care organizations. Diabetes Care, 44(9), 2000-2009.
https://doi.org/10.2337/dc20-2715'

Reference

Reference Type: CITATION

Reference Text: 'Szczech, L. A., Stewart, R. C., Su, H., Deloskey, R. J., Astor, B. C., Fox, C. H., . . . Vassalotti, J. A. (2014). Primary care detection of chronic kidney disease in adults with type-2 diabetes: The ADD-CKD study (Awareness, detection and drug therapy in type 2 diabetes and chronic kidney disease). PLoS ONE, 9(11), e110535. https://doi.org/10.1371/journal.pone.0110535'

Definition

None

Guidance

This measure assesses performance of a comprehensive kidney evaluation in adults aged 18-75. This measure does not preclude or discourage the use of regular laboratory testing for CKD in patients outside of the age range (patients under 18 years and those over 75 years of age).  

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Transmission Format

TBD

Initial Population

All patients aged 18-75 years with a diagnosis of diabetes at the start of the measurement period with a visit during the measurement period

Denominator

Equals Initial Population

Denominator Exclusions

Patients with a diagnosis of End Stage Renal Disease (ESRD); Patients with a diagnosis of Chronic Kidney Disease (CKD) Stage 5; Patients who have an order for or are receiving hospice or palliative care

Numerator

Patients who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within 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

AgeInYearsAt(date from start of "Measurement Period")in Interval[18, 75]
  and "Has Active Diabetes Overlaps Measurement Period"
  and "Has Outpatient Visit During Measurement Period"

- Denominator
  - "Initial Population"

Denominator Exclusions

exists "Has CKD Stage 5 or ESRD Diagnosis Overlaps Measurement Period"
  or Hospice."Has Hospice Services"
  or PalliativeCare."Palliative Care in the Measurement Period"

Numerator

"Has Kidney Panel Performed During Measurement Period"

- Numerator Exclusions
  - None

- Denominator Exceptions
  - None

- Stratification
  - None

Definitions

Denominator
- - "Initial Population"

Denominator Exclusions

exists "Has CKD Stage 5 or ESRD Diagnosis Overlaps Measurement Period"
  or Hospice."Has Hospice Services"
  or PalliativeCare."Palliative Care in the Measurement Period"

Has Active Diabetes Overlaps Measurement Period

exists ( ["Diagnosis": "Diabetes"] Diabetes
    where Diabetes.prevalencePeriod overlaps "Measurement Period"
)

Has CKD Stage 5 or ESRD Diagnosis Overlaps Measurement Period

( ["Diagnosis": "Chronic Kidney Disease, Stage 5"]
  union ["Diagnosis": "End Stage Renal Disease"] ) CKDOrESRD
  where CKDOrESRD.prevalencePeriod overlaps "Measurement Period"

Has Kidney Panel Performed During Measurement Period

exists ( ["Laboratory Test, Performed": "Estimated Glomerular Filtration Rate"] eGFRTest
    where Global."NormalizeInterval" ( eGFRTest.relevantDatetime, eGFRTest.relevantPeriod ) during "Measurement Period"
      and eGFRTest.result is not null
)
  and exists ( ["Laboratory Test, Performed": "Urine Albumin Creatinine Ratio"] uACRTest
      where Global."NormalizeInterval" ( uACRTest.relevantDatetime, uACRTest.relevantPeriod ) during "Measurement Period"
        and uACRTest.result is not null
  )

Has Outpatient Visit During Measurement Period

exists ( ( ["Encounter, Performed": "Annual Wellness Visit"]
    union ["Encounter, Performed": "Home Healthcare Services"]
    union ["Encounter, Performed": "Office Visit"]
    union ["Encounter, Performed": "Outpatient Consultation"]
    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": "Telephone Visits"] ) ValidEncounter
    where ValidEncounter.relevantPeriod during "Measurement Period"
)

Hospice.Has Hospice Services

exists ( ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
    where ( InpatientEncounter.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
        or InpatientEncounter.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
    )
      and InpatientEncounter.relevantPeriod ends during day of "Measurement Period"
)
  or exists ( ["Encounter, Performed": "Hospice Encounter"] HospiceEncounter
      where HospiceEncounter.relevantPeriod overlaps "Measurement Period"
  )
  or exists ( ["Assessment, Performed": "Hospice care [Minimum Data Set]"] HospiceAssessment
      where HospiceAssessment.result ~ "Yes (qualifier value)"
        and Global."NormalizeInterval" ( HospiceAssessment.relevantDatetime, HospiceAssessment.relevantPeriod ) overlaps "Measurement Period"
  )
  or exists ( ["Intervention, Order": "Hospice Care Ambulatory"] HospiceOrder
      where HospiceOrder.authorDatetime during day of "Measurement Period"
  )
  or exists ( ["Intervention, Performed": "Hospice Care Ambulatory"] HospicePerformed
      where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps "Measurement Period"
  )

Initial Population

AgeInYearsAt(date from start of "Measurement Period")in Interval[18, 75]
  and "Has Active Diabetes Overlaps Measurement Period"
  and "Has Outpatient Visit During Measurement Period"

Numerator

"Has Kidney Panel Performed During Measurement Period"

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 (["Diagnosis": "Encounter for palliative care"] PalliativeDiagnosis
where PalliativeDiagnosis.prevalencePeriod 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"
  )

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"]

Functions

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>

Terminology

code "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)")
code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)")
code "Encounter for palliative care" ("ICD10CM Code (Z51.5)")
code "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" ("LOINC Code (71007-9)")
code "Hospice care [Minimum Data Set]" ("LOINC Code (45755-6)")
code "Yes (qualifier value)" ("SNOMEDCT Code (373066001)")
valueset "Annual Wellness Visit" (2.16.840.1.113883.3.526.3.1240)
valueset "Chronic Kidney Disease, Stage 5" (2.16.840.1.113883.3.526.3.1002)
valueset "Diabetes" (2.16.840.1.113883.3.464.1003.103.12.1001)
valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
valueset "End Stage Renal Disease" (2.16.840.1.113883.3.526.3.353)
valueset "Estimated Glomerular Filtration Rate" (2.16.840.1.113883.3.6929.3.1000)
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016)
valueset "Hospice Care Ambulatory" (2.16.840.1.113883.3.526.3.1584)
valueset "Hospice Encounter" (2.16.840.1.113883.3.464.1003.1003)
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 "Outpatient Consultation" (2.16.840.1.113883.3.464.1003.101.12.1008)
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 "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 Albumin Creatinine Ratio" (2.16.840.1.113883.3.6929.3.1007)

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)"
"Assessment, Performed: Hospice care [Minimum Data Set]" using "Hospice care [Minimum Data Set] (LOINC Code 45755-6)"
"Diagnosis: Chronic Kidney Disease, Stage 5" using "Chronic Kidney Disease, Stage 5 (2.16.840.1.113883.3.526.3.1002)"
"Diagnosis: Diabetes" using "Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001)"
"Diagnosis: Encounter for palliative care" using "Encounter for palliative care (ICD10CM Code Z51.5)"
"Diagnosis: End Stage Renal Disease" using "End Stage Renal Disease (2.16.840.1.113883.3.526.3.353)"
"Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240)"
"Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
"Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016)"
"Encounter, Performed: Hospice Encounter" using "Hospice Encounter (2.16.840.1.113883.3.464.1003.1003)"
"Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
"Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008)"
"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 (2.16.840.1.113883.3.526.3.1584)"
"Intervention, Performed: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
"Intervention, Performed: Palliative Care Intervention" using "Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135)"
"Laboratory Test, Performed: Estimated Glomerular Filtration Rate" using "Estimated Glomerular Filtration Rate (2.16.840.1.113883.3.6929.3.1000)"
"Laboratory Test, Performed: Urine Albumin Creatinine Ratio" using "Urine Albumin Creatinine Ratio (2.16.840.1.113883.3.6929.3.1007)"
"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)"

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