Percentage of Prevalent Patients Waitlisted for Kidney Transplant (PPPW) and

Measure Specification

A measure focusing on 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 kidney transplant, 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]. The PPPW and aPPPW measures focus specifically on the prevalent dialysis population, examining waitlisting status or waitlisting in active status, monthly for each patient, respectively.

As this measure assesses monthly waitlisting status or waitlisting in active status of patients, it evaluates and encourages maintenance of patients on the waitlist which is important given the long duration most patients have to wait to eventually access a deceased donor transplant (national median of roughly 4 years) [6]. In particular, maintenance of active status requires ongoing attention by dialysis practitioners to optimizing the health of patients, to ensure sustained suitability for transplant waitlisting.

Maintenance of active status on the waitlist is additionally important given demonstrated disparities [7] and positive association with subsequent transplantation [8]. Overall, maintenance of patients on the waitlist is an important area to which dialysis practitioners can contribute through ensuring patients remain healthy, and complete any ongoing testing activities required to remain on the waitlist.

In contrast to this measure, other waitlisting measures, such as the First Year Standardized Waitlist Ratio, focus solely on new waitlistings and living donor kidney transplants to incentivize early action, rather than ongoing maintenance on the waitlist, as this measure does.

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 [9]. Participants include both patients with advanced chronic kidney disease prior to transplant, and recipients of transplants, and 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 [10]. 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, p<0.001). A national study using registry data (United States Renal Data System) from 2005-2007 examined the association between whether patients were informed about kidney transplantation (based on reporting on the Medical Evidence Form 2728) and subsequent access to kidney transplantation (waitlisting or receipt of a live donor transplant) [11].

Approximately 30% of patients were uninformed about kidney transplantation, and this was associated with half the rate of access to transplantation compared to patients who were informed. In a related survey study of 388 hemodialysis patients, whether provision of information about transplantation by nephrologists or dialysis staff occurred was directly confirmed with patients [12].

Patient report of provision of such information was associated with a three-fold increase in likelihood of waitlisting. Finally, a large survey study of 170 dialysis facilities in the Heartland Kidney Network (Iowa, Kansas, Missouri and Nebraska) was conducted to examine transplant education practices [13]. Facilities employing multiple (>3) 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.

This measure contains two submission criteria which assess for all patients on the waitlist and those who were in Active Status each month. There are 2 Submission Criteria for this measure: 1) Patients in the practitioner group’s denominator with observed months on the waitlist. AND 2) Patients observed in active status on any kidney or kidney-pancreas transplant waitlist.

This measure will be calculated with 2 performance rates: 1) Percentage of Prevalent Patients Waitlisted (PPPW). 2) Percentage of Prevalent Patients Waitlisted in Active Status (aPPPW) For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 2 is used for performance. For the purposes of MIPS implementation, this patient-periodic measure is submitted a minimum of once per patient per timeframe specified by the measure for the performance period.

The most advantageous quality data code (QDC) will be used if the measure is submitted more than once for the specified timeframe. 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.