The dataset includes the number of eligible patients by clinical measure. It covers the sample of patients with Hemoglobin > 12 as well as the records about hemodialysis patient-months with single-pool Kt/V (spKt/V) >= 1.2 ; (where Kt/V represents a number used to quantify hemodialysis and peritoneal dialysis treatment adequacy). The dataset also analyzes the peritoneal patient-months with Kt/V >= 1.7 Kt/V (dialytic + residual) during the four-month study period.
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Description
The Centers for Medicare & Medicaid Services (CMS) administers the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) to promote high-quality services in outpatient dialysis facilities treating patients with ESRD. As the first of its kind in Medicare, this program changes the way CMS pays for the treatment of patients with ESRD by linking a portion of payment directly to facilities’ performance on quality of care measures. These types of programs are known as “pay-for-performance” or “value-based purchasing” (VBP) programs.
The ESRD QIP will reduce payments to ESRD facilities that do not meet or exceed certain performance standards. The maximum payment reduction CMS can apply to any facility is two percent. This reduction will apply to all payments for services performed by the facility receiving the reduction during the applicable payment year (PY).
Payment reductions result when a facility’s overall score on applicable measures does not meet established standards. CMS publicly reports facility ESRD QIP scores; these scores are available online on Dialysis Facility Compare. In addition, each facility is required to display a Performance Score Certificate that lists its Total Performance Score, as well as its performance on each of the quality measures identified for that year.
The foundation, principles, and mechanisms guiding the ESRD QIP will remain the same over time, but the program’s specific quality measures, standards, weights, and formulas will change from year to year.
About this Dataset
Data Info
Date Created
2012-10-23
Last Modified
2020-01-21
Version
2020-01-21
Update Frequency
Quarterly
Temporal Coverage
2017-2019
Spatial Coverage
United States
Source
John Snow Labs; Centers for Medicare and Medicaid Services;
Source License URL
Source License Requirements
N/A
Source Citation
N/A
Keywords
Dialysis, Dialysis Facility Compare, Renal Disease Clinical Measures, Quality Measures, Linking Quality to Payment, Quality Net ESRD, ICH CAHPS
Other Titles
Quality Dialysis, Quality Improvement Program, CMS Quality Improvement Program
Data Fields
Name
Description
Type
Constraints
Facility_Name
The name of the Dialysis center or Facility.
string
-
CMS_Certification_Number_CCN
Center for Medicare & Medicaid Services (CMS) certification number (CCN). Identification number of the facility within the CMS dataset. The CCN for providers and suppliers is a 6 digit number. The first 2 digits identify the State in which the provider is located. The last 4 digits identify the type of facility.
integer
level : Nominal
Alternate_CCN
Identification number of the facility within the CMS dataset. The CCN for providers and suppliers is a 6 digit number. The first 2 digits identify the State in which the provider is located. The last 4 digits identify the type of facility.
integer
level : Nominal
Address1
The address of the dialysis center or facility.
string
-
Address2
The second address of the dialysis center or facility.
string
-
City
The city name in the location address of the facility being identified.
string
-
State_Abbreviation
The two-letter abbreviations of the state in the mailing address of the ambulatory center. This includes information on hospitals in different U.S. states.
string
-
Zip_Code
The postal Zip code in the mailing address of the hospital.
integer
level : Nominal
Network
Indicates the Network.
integer
level : Nominal
VAT_Catheter_Measure_Score
Identifies the score of Vascular Access Type (VAT) Catheter Measure. This measure indicates percentage of patient-months for patients on hemodialysis during the last hemodialysis treatment of month with a catheter continuously for 90 days or longer prior to the last hemodialysis session.
integer
level : Ratio
VAT_Catheter_Reason_For_No_Score
Indicates the reason for no score of Vascular Access Type (VAT) Catheter Measure.
string
-
VAT_Catheter_Achievement_Measure_Rate
Identifies the Vascular Access Type (VAT) Achievement Rate in percentage of Catheter Measure.
The number of Patients included in Vascular Access Type (VAT) Catheter Measure score achievement period.
string
-
VAT_Catheter_Achievement_Period_Numerator
The numerator of Vascular Access Type (VAT) in Catheter Measure score achievement period.
integer
level : Ratio
VAT_Catheter_Achievement_Period_Denominator
The denominator of Vascular Access Type (VAT) in Catheter Measure score achievement period.
integer
level : Ratio
VAT_Catheter_Improvement_Measure_Rate
Identifies the Vascular Access Type (VAT) improvement rate in percentage of Catheter Measure.
number
level : Ratio
VAT_Catheter_Improvement_Period_Numerator
The numerator of Vascular Access Type (VAT) included in Catheter Measure score improvement period.
integer
level : Ratio
VAT_Catheter_Improvement_Period_Denominator
The denominator of Vascular Access Type (VAT) included in Catheter Measure score improvement period.
integer
level : Ratio
VAT_Catheter_Measure_Score_Applied
Identifies the Vascular Access Type (VAT) Score Applied for Catheter Measure.
string
-
VAT_Fistula_Measure_Score
Identifies the score of Vascular Access Type (VAT) Fistula Measure. This measure indicates the percentage of patient-months on hemodialysis during the last hemodialysis treatment of the month using an autogenous AV fistula with two needles.
integer
level : Ratio
VAT_Fistula_Reason_For_No_Score
Indicates the reason for no score of Vascular Access Type (VAT) Fistula Measure.
string
-
VAT_Fistula_Achievement_Measure_Rate
Identifies the Vascular Access Type (VAT) achievement rate in percentage of Fistula Measure.
The number of patients included in the Vascular Access Type (VAT) Fistula Measure score achievement period.
string
-
VAT_Fistula_Achievement_Period_Numerator
The numerator of Vascular Access Type (VAT) in Fistula Measure score achievement period.
integer
level : Ratio
VAT_Fistula_Achievement_Period_Denominator
The denominator of Vascular Access Type (VAT) in Fistula Measure score achievement period.
integer
level : Ratio
VAT_Fistula_Improvement_Measure_Rate
Identifies the Vascular Access Type (VAT) improvement rate in percentage of Fistula Measure.
number
level : Ratio
VAT_Fistula_Improvement_Period_Numerator
The numerator of Vascular Access Type (VAT) in Fistula Measure score improvement period.
integer
level : Ratio
VAT_Fistula_Improvement_Period_Denominator
The denominator of Vascular Access Type (VAT) in Fistula Measure score improvement period.
integer
level : Ratio
VAT_Fistula_Measure_Score_Applied
Identifies Vascular Access Type (VAT) Score Applied for Fistula Measure.
string
-
VAT_Combined_Measure_Score
Identifies the combined score of Vascular Access Type (VAT) Measures.
integer
level : Ratio
National_Avg_VAT_Combined_Measure_Score
Identifies the National Average combined score of Vascular Access Type (VAT) Measures.
integer
level : Ratio
Vascular_Access_Combined_Reason_For_No_Score
Indicates the reason for no score of combined Vascular Access Measure.
string
-
KtV_Adult_Hemodialysis_Measure_Score
Identifies the score of Kt/V Adult Hemodialysis Measure. This measure indicates the percent of hemodialysis patient-months with spKt/V greater than or equal to 1.2.
integer
level : Ratio
KtV_Adult_Hemodialysis_Achievement_Measure_Rate
Identifies the achievement rate in percentage of Kt/V Adult Hemodialysis Measure.
The denominator of achievement rate in percentage of Kt/V Adult Hemodialysis period.
integer
level : Ratio
KtV_Adult_Hemodialysis_Improvement_Measure_Rate
Identifies the improvement rate in percentage of Kt/V Adult Hemodialysis Measure.
number
level : Ratio
KtV_Adult_Hemo_Improvement_Period_Numerator
The numerator of achievement rate in Kt/V Adult Hemodialysis Improvement period.
integer
level : Ratio
KtV_Adult_Hemo_Improvement_Period_Denominator
The denominator of achievement rate in Kt/V Adult Hemodialysis Improvement period.
integer
level : Ratio
KtV_Adult_Hemodialysis_Measure_Score_Applied
Identifies the Score Applied for Kt/V Adult Hemodialysis Measure.
string
-
KtV_Adult_Peritoneal_Dialysis_Measure_Score
Identifies the score of Kt/V Adult Peritoneal Measure. This measure indicates the percent of peritoneal dialysis patient-months with Kt/V greater than or equal to 1.7 Kt/V (dialytic + residual) during the four month study period.
Identifies the Score Applied for Kt/V Adult Peritoneal Measure.
string
-
KtV_Pediatric_Hemodialysis_Measure_Score
Identifies the score of Kt/V Pediatric Hemodialysis Measure. This measure indicates the percent of pediatric in-center hemodialysis patient-months with spKt/V greater than or equal to 1.2.
integer
level : Ratio
KtV_Ped_Hemodialysis_Achievement_Measure_Rate
Identifies the achievement rate in percentage of Kt/V Adult Pediatric Hemodialysis Measure.
The number of Patients included in Kt/V Adult Pediatric Hemodialysis Measure score achievement period.
string
-
KtV_Ped_Hemodialysis_Achievement_Period_Numerator
The numerator of Kt/V Pediatric Hemodialysis achievement period.
integer
level : Ratio
KtV_Ped_Hemodialysis_Achieve_Period_Denominator
The denominator of Kt/V Pediatric Hemodialysis achievement period.
integer
level : Ratio
KtV_Pediatric_Hemodialysis_Improve_Measure_Rate
Identifies the improvement rate in percentage of Kt/V Adult Pediatric Hemodialysis Measure.
number
level : Ratio
KtV_Ped_Hemodialysis_Improve_Period_Numerator
The numerator of Kt/V Pediatric Hemodialysis improvement period.
integer
level : Ratio
KtV_Ped_Hemodialysis_Improve_Period_Denominator
The denominator of Kt/V Pediatric Hemodialysis improvement period.
integer
level : Ratio
KtV_Pediatric_Hemodialysis_Measure_Score_Applied
Identifies the achievement Score Applied for Kt/V Adult Pediatric Hemodialysis Measure.
string
-
KtV_Pediatric_Peritoneal_Dialysis_Measure_Score
Identifies the score of Kt/V Pediatric Peritoneal Dialysis Measure. This measure indicates the percent of pediatric in-center peritoneal dialysis patient-months with spKt/V greater than or equal to 1.2.
The number of patients included in Hypercalcemia Measure score achievement period.
string
-
Hypercalcemia_Achievement_Period_Numerator
The numerator of Hypercalcemia achievement period.
integer
level : Ratio
Hypercalcemia_Achievement_Period_Denominator
The denominator of Hypercalcemia achievement period.
integer
level : Ratio
Hypercalcemia_Improvement_Measure_Rate
Identifies the improvement rate in percentage of Hypercalcemia Measure.
number
level : Ratio
Hypercalcemia_Improvement_Period_Numerator
The numerator of Hypercalcemia improvement period.
integer
level : Ratio
Hypercalcemia_Improvement_Period_Denominator
The denominator of Hypercalcemia improvement period.
integer
level : Ratio
Hypercalcemia_Measure_Score_Applied
Identifies the Score Applied for Hypercalcemia Measure.
string
-
NHSN_Measure_Score
Identifies the score of National Healthcare Safety Network (NHSN) Measure. This measure indicates the number of months for which facility reports NHSN Dialysis Event data to the Centers for Disease Control and Prevention (CDC).
integer
level : Ratio
NHSN_Achievement_Measure_Ratio
Identifies the achievement rate in percentage of National Healthcare Safety Network (NHSN) Measure.
Indicates the number of NHSN Patients included in National Healthcare Safety Network (NHSN) Measure Score achievement period.
string
-
NHSN_Observed_Achievement_Period_Numerator
Indicates the numerator of National Healthcare Safety Network (NHSN) observed achievement period.
integer
level : Ratio
NHSN_Predicted_Achievement_Period_Denominator
Indicates the denominator of National Healthcare Safety Network (NHSN) predicted achievement period.
number
level : Ratio
NHSN_Improvement_Measure_Ratio
Identifies the improvement rate in percentage of National Healthcare Safety Network (NHSN) Measure.
number
level : Ratio
NHSN_Observed_Improvement_Period_Numerator
Indicates the numerator of National Healthcare Safety Network (NHSN) observed improvement period.
integer
level : Ratio
NHSN_Predicted_Improvement_Period_Denominator
Indicates the denominator of National Healthcare Safety Network (NHSN) predicted improvement period.
number
level : Ratio
NHSN_Measure_Score_Applied
Identifies the Score Applied for National Healthcare Safety Network (NHSN) Measure.
string
-
NHSN_Influenza_Measure_Score
Identifies the score of National Healthcare Safety Network (NHSN) Measure for influenza. This measure indicates the number of months for which facility reports NHSN Dialysis Event data to the Centers for Disease Control and Prevention (CDC).
integer
level : Ratio
NHSN_Influenza_Reason_For_No_Score
Indicates the reason for no score of National Healthcare Safety Network (NHSN) Influenza Measure.
integer
level : Ratio
NHSN_BSI_Measure_Score
Identifies the score for National Healthcare Safety Network (NHSN) Bloodstream Infection (BSI) Measure.
integer
level : Ratio
NHSN_BSI_Reason_For_No_Score
Indicates the reason for no score of National Healthcare Safety Network (NHSN) Bloodstream Infection (BSI) Measure.
string
-
NHSN_BSI_Achievement_Measure_Ratio
Identifies the achievement rate in percentage of National Healthcare Safety Network (NHSN) Bloodstream Infection (BSI) Measure.
Identifies the number of completed surveys for In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Measure achievement period.
Identifies the number of completed surveys for In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Measure improvement period.
string
-
ICH_CAHPS_Measure_Score_Applied
Identifies the Applied Score of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Measure.
string
-
ICH_CAHPS_Admin_Score
Identifies the score of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS). This measure is attestation that facility administered survey in accordance with specifications.
integer
level : Ratio
ICH_CAHPS_Count_of_Completed_Surveys
Identifies the number of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) completed surveys.
string
-
ICH_CAHPS_Neph_Comm_and_Caring_Achievement_Rate
Identifies the number of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) nephrologists communication and caring achievement rate.
number
level : Ratio
ICH_CAHPS_Neph_Comm_And_Caring_Improvement_Rate
Identifies the number of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) nephrologists communication and caring improvement rate.
Identifies the Applied Score of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) nephrologists communication and caring measure.
Identifies the number of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) Quality of dialysis care and operations achievement rate.
Identifies the number of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) Quality of dialysis care and operations improvement rate.
Identifies the Applied Score of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) Quality of dialysis care and operations measure.
Identifies the number of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) providing information to patients achievement rate.
Identifies the number of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) providing information to patients improvement rate.
Identifies the Applied Score of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) providing information to patients measure.
string
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ICH_CAHPS_Overall_Rating_of_Neph_Achievement_Rate
Identifies the number of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) overall rating of nephrologists achievement rate.
number
level : Ratio
ICH_CAHPS_Overall_Rating_of_Neph_Improvement_Rate
Identifies the number of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) overall rating of nephrologists improvement rate.
Identifies the Applied Score of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) overall rating of nephrologists measure.
Identifies the number of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) overall rating of dialysis staff achievement rate.
Identifies the number of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) overall rating of dialysis staff improvement rate.
Identifies the Applied Score of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) overall rating of dialysis staff measure.
Identifies the score of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) overall rating of dialysis facility achievement rate.
Identifies the score of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) overall rating of dialysis facility improvement rate.
Identifies the Applied Score of In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems Measure (ICH CAHPS) overall rating of dialysis facility measure.
string
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Mineral_Metabolism_Measure_Score
Identifies the score of Mineral Metabolism Measure. This measure indicates the number of months for which facility reports serum calcium and phosphorus for each Medicare patient.
integer
level : Ratio
Mineral_Metabolism_Reason_For_No_Score
Identifies the reason for no score of Mineral Metabolism Measure.
Refers to the number of Patients included in mineral metabolism measure score achievement period.
string
-
Anemia_Management_Measure_Score
Identifies the score of Anemia Management Measure. This measure indicates the number of months for which facility reports ESA dosage (as applicable) and hemoglobin/hematocrit for each Medicare patient.
integer
level : Ratio
Anemia_Management_Reason_For_No_Score
Identifies the reason for no score of Anemia Management Measure.
Identifies the score of clinical Depression Screening and Follow-up (DSF) measure. This measure indicates the percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool and if positive, a follow-up plan is documented on the date of the positive screen.
Indicates the reason for no score of clinical Depression Screening and Follow-up (DSF) measure.
string
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Pain_Assessment_And_Followup_Measure_Score
Identifies the score of Pain Assessment and Follow-up (PAF) measure. This measure indicates the Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool on each visit and documentation of a follow-up plan when pain is present.
integer
level : Ratio
Patients_In_PAF_Measure_Score_Achievement_Period
Refers to the number of Patients included in Pain Assessment and Follow-up (PAF) measure score achievement period.
string
-
Pain_Assessment_And_Followup_Reason_For_No_Score
Indicates the reason for no score of Pain Assessment and Follow-up (PAF) measure.
string
-
SRR_Measure_Score
Measure Score of Standardized Readmission Ratio (SRR). The SRR is a ratio of the number of readmissions among eligible patients at the facility during the reporting period to the number of readmissions that would be expected among eligible patients at the facility during the reporting period, given the patient mix at the facility.
integer
level : Ratio
SRR_Reason_For_No_Score
Indicates the reason for no score of Standardized Readmission Ratio (SRR) measure.
integer
level : Ratio
SRR_Achievement_Measure_Ratio
Identifies the achievement rate in percentage of SRR Measure.
It is a SRR measure achievement period that indicates a hospital discharge eligible to be followed by a readmission.
string
-
SRR_Achievement_Period_Numerator
Indicates the numerator of SRR achievement period.
integer
level : Ratio
SRR_Achievement_Period_Denominator
Indicates the denominator of SRR achievement period.
number
level : Ratio
SRR_Improvement_Measure_Ratio
Identifies the improvement rate in percentage of SRR Measure.
number
level : Ratio
SRR_Improvement_Period_Numerator
Indicates the numerator of SRR improvement period.
integer
level : Ratio
SRR_Improvement_Period_Denominator
Indicates the denominator of SRR improvement period.
number
level : Ratio
SRR_Measure_Score_Applied
Identifies the Performance Score Applied for SRR Measure.
string
-
Standardized_Transfusion_Ratio_Measure_Score
Indicates the score for Standardized transfusions ratio measure. StrR is Standardized transfusion Ratio. It is a ratio of the number of transfusion events among eligible patients at the facility during the reporting period to the number of transfusion events that would be expected among eligible patients at the facility during the reporting period, given the patient mix at the facility.
Indicates the achievement rate for Standardized transfusions ratio measure. It is a ratio of the number of transfusion events among eligible patients at the facility during the reporting period to the number of transfusion events that would be expected among eligible patients at the facility during the reporting period, given the patient mix at the facility.