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Overview:
The goal of the Task is to detect the incidence, decrease the progression of chronic kidney disease (CKD),
and improve care among Medicare beneficiaries through provider adoption of timely and effective quality of
care interventions; participation in quality incentive initiatives; beneficiary education; and key linkages
and collaborations for system change at the state and local level. While this Task is for the purpose of
fulfilling the requirements of the QIO statute, it will benefit the goals of Healthy People 2010 in the
area of diabetes, access to health services, disparities, and CKD; the CMS arteriovenous fistula,
“FistulaFirst” Government Performance Results Act (GPRA) measure; PQRI; and the Value-Driven Health Care
Initiative. In addition to improving the quality of care for the elderly and frail-elderly, this Task aims
to reduce the rate of Medicare entitlement by disability through the delay and prevention of ESRD; thus,
resulting in higher quality care and significant savings to the Medicare Trust Fund.
Opportunity for Quality Improvement
Kidney disease is the ninth leading cause of death in the U.S. CKD affects 11% of the US population over
the age of 65, and those affected are at increased risk of cardiovascular disease (CVD) and kidney failure.
The cardiovascular mortality risk rate is 32 deaths/1000 person-years among those with CKD vs. 16/1000
person-years among those without it. In more than 90% of Medicare patients with CKD (1,336,320), the
disease is accompanied by diabetes (4.1%), hypertension (42.9%), or both diagnoses (43.9%), with 9.1%
diagnosed with CKD only. In comparison, while still high, 70-71% of CKD patients aged 50 and older
covered by group health plans carry a diagnosis of diabetes, hypertension, or both. The leading cause
of renal failure is diabetes with a primary diagnosis of diabetes representing 41.5% of the dialysis
patients in 2005. Additionally, ethnic minority populations are more likely to develop kidney failure,
particularly African-Americans (four times more likely than Whites), Hispanics (two times more likely
than Whites), and American Indians (three times more likely than Whites).
Cost Impace to Medicare
The cost to Medicare for managing CKD is high. Medicare beneficiaries with CKD (non- ESRD) account for
16.5% of Medicare costs in the year the disease is identified, and 11.1% in the next year. In 2004, CKD
costs per person per year (PPPY) reached $20,668, 5.3% more than in 2003, and a 41% increase over 1993.
Individuals with CKD or ESRD together consume 24% of Medicare expenditures. According to the United
States Renal Data System (USRDS), the savings to Medicare for each patient who does not progress to
dialysis is estimated to be $250,000 per patient ($65,000 annual cost of Medicare ESRD services times’
four-year life expectancy). Patients who carry a diagnosis of CKD, diabetes, and hypertension represent
the greatest disease burden to the Medicare program. Patients with any of these conditions, alone or in
combination with one another, account for 61.2% of the Medicare population, but they consume 80.8% of
total expenditures. While the costs are high, the potential for savings through effective medical
interventions are significant. For example, in hypertensive persons with diabetes, when all patients
were treated with angiotensin converting enzyme (ACE) inhibitors which have been shown to slow the
progression of disease by 50%, the cost effectiveness ratio is $7,500 per QALY (Quality-adjusted Life
Years) gained.
QIO Activities
In accomplishing this goal, the QIO shall:
| 1. |
Focus on provider implementation of clinical practices that have been tested and
proven to be successful in the prevention and management of CKD |
| 2. |
Target beneficiaries that are most likely to benefit from education on risk factors,
early identification, and treatment choices for CKD |
| 3. |
Disseminate tools and resources to providers and beneficiaries that are in existence
and available through Federal partners in the collaborative model |
| 4. |
Work through a collaborative model to affect system change that will have a lasting
impact on the prevention and management of CKD |
Similar in nature to the work in the 6.3 Prevention Theme in the area of cancer screening and immunization,
the QIO is encouraged to include a component that employs HIT in the implementation of clinical components
that align with the clinical focus areas of the CKD Task.
In developing its plan, the QIO may consider providing technical assistance to providers in Medicare quality
incentive programs that are directly aligned, and support achievement of the CKD clinical focus areas defined
in this SOW. Such quality incentive programs may include Medicare providers’ increased participation and CKD
quality of care outcomes in PQRI measures that are similar to the QIO clinical focus areas for CKD, and other
targeted CMS-sponsored quality initiatives that support the achievement of the CKD clinical focus areas and
are consistent with QIO statutory authority for quality improvement.
Quality Intervention Focus for CKD
The focus areas for quality improvement in CKD include:
| 1. |
Annual testing to detect the rate of kidney failure due to diabetes |
| 2. |
Slowing the progression of disease in hypertensive individuals with diabetes
through the use of ACE inhibitor and/or an angiotensin receptor blocking (ARB) agent |
| 3. |
Arteriovenous fistula (AV fistula) placement and maturation (as a first choice
for arteriovenous access where medically appropriate) for individuals who elect, as a part of
timely renal replacement counseling, hemodialysis as their treatment option for kidney failure |
Impact on Disparities
As a requirement of all contract awarded funds for Tasks related to CKD, in all measures, the QIO shall
anticipate and monitor the impact the quality interventions have on disparities in care (e.g., ethnic,
racial, socio-economic, and geographic), which includes a sufficiently large proportion of the Virgin
Islands’ Medicare population (i.e., 85% to 90%, depending upon the source) to include the entire
Territory. It is expected that the QIO will take rapid corrective action and implement activities to
correct and improve the quality of CKD care compared with non-QIO-intervened disparity populations overall.
Evaluation
In the area of CKD, a QIO is required to successfully pass the established targets in all clinical outcome
measures (e.g., testing, ACE/ARB, and AV fistula), to successfully pass the CKD Task. For the purpose of
determining QIO success (pass), or failure, at reaching established targets, because CKD is a relatively
new CMS program focus area for quality improvement, and since measures are still evolving through PQRI and
other sources, a “pass” in the area of CKD will be considered achievement of 80% or greater of the
established Virgin Islands Target Rate.
Resources
Medicare QIO Program: www.cms.hhs.gov/QualityImprovementOrgs/
MedQIC: www.medqic.org (click on “Chronic Kidney Disease”)
The Medicare QIO Program
Under the direction of the Centers for Medicare & Medicaid Services (CMS), the Quality Improvement Organization (QIO) Program
consists of a national network of 53 QIOs, responsible for each U.S. state, territory, and the District of Columbia. QIOs work
with healthcare providers, consumers and stakeholder groups to refine care delivery systems to make sure patients get the
right care at the right time, particularly patients from underserved populations. QIOs operate under three-year contracts
with CMS, known as Statements of Work (SOWs), the next of which will begin in August 2008 and continue through July 2011.
For more information: www.cms.hhs.gov/QualityImprovementOrgs/
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