Prevalent Standardized Kidney Transplant Waitlist Ratio (PSWR)

Measure Specification

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 prevalent patients on dialysis, examining for the occurrence of new waitlisting or living donor transplant events.

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]. Given that many patients may not be ready for transplant candidacy immediately following initiation of dialysis, this measure encourages ongoing attention to transplant candidacy throughout the period following dialysis initiation.

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 [10]. 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 [11]. 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) [12].

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 [13].

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 [14]. 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 together ensure capture of the full patient population and assessment of timely and continued listing to the kidney or kidney-pancreas transplant waitlist or receipt of a living donor transplant. There are 2 Submission Criteria for this measure: 1) Patients on dialysis who had documentation of waitlist status at the end of the performance period.

AND 2) Prevalent Standardized Waitlist Ratio (PSWR). 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. The measure will be calculated with 2 performance rates: 1) Percentage of patients on dialysis who had documentation of waitlist status at the end of the performance period.

2) Ratio of the observed number of waitlist events to the number of expected waitlist events for each calendar year. 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. For the purposes of MIPS implementation, this patient-process measure is submitted as a ratio based upon reporting for each patient during the performance period.

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 for 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. CMS determined that it’s not technologically feasible to calculate the 1st performance rate using the existing submission JavaScript Object Notation (JSON) structure. As a result, only the 2nd submission criteria will be accepted when submitting the measure for the performance period.

While not required for submission, MIPS eligible clinicians, groups, or third-party intermediaries must continue to collect and calculate the 1st submission criteria as the data is utilized to determine if the threshold requirement for the 2nd submission criteria is met and the measure can be reported. The noted exclusions represent conditions for which transplant waitlist candidacy is highly unlikely, and which can be identified readily with available data.

Patients who were attributed to dialysis practitioner groups with fewer than 11 patients or 2 expected events are not excluded from the measure. If a provider cannot be matched to a TIN, patients will be grouped into a separate ‘null’ TIN and still included in the models but are not summarized to any valid individual TINs. All patients who meet the denominator inclusion criteria are included and used to model a given dialysis practitioner group’s expected waitlist rate.

If a dialysis practitioner group has fewer than 11 patients or 2 expected events, then the dialysis practitioner group is excluded from reporting outcomes. 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.