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## Complete Summary

#### TITLE

Advanced chronic kidney disease (CKD): percent of patients with anemia
work-up.

#### SOURCE(S)

Renal Physicians Association. Appropriate patient preparation for renal
replacement therapy. Rockville (MD): Renal Physicians Association; 2002
Oct 1. 78 p.(Clinical Practice Guideline; no. 3).

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Process

The validity of measures depends on how they are built. By examining the
key building blocks of a measure, you can assess its validity for your
purpose. For more information, visit the [Measure
Validity](http://www.qualitymeasures.ahrq.gov/resources/measure_domains.aspx)
page.

#### SECONDARY MEASURE DOMAIN

Does not apply to this measure

### Brief Abstract

#### DESCRIPTION

This measure assesses the percent of patients with advanced chronic
kidney disease (CKD) and hemoglobin (Hb) less than 12 g/dL who have had
an anemia work-up.

#### RATIONALE

Anemia is common in patients with advanced chronic kidney disease (CKD)
and can lead to a variety of detrimental effects. In addition to the
direct effects of anemia on performance and ischemic symptoms, it has
also been suggested that mortality and major complications during
end-stage renal disease (ESRD) are associated with anemia that develops
early in the course of CKD. Correcting anemia before the initiation of
renal replacement therapy (RRT) may improve health outcomes.

Iron deficiency is the most common cause of anemia in advanced CKD and
can lead to erythropoietin resistance. Many secondary causes of anemia
are treatable.

#### PRIMARY CLINICAL COMPONENT

Advanced chronic kidney disease; anemia; hemoglobin; hematocrit; serum
iron; Total Iron Binding Capacity; percent transferrin saturation

#### DENOMINATOR DESCRIPTION

The number of adult patients with advanced chronic kidney disease (CKD)
for at least three months, not currently receiving renal replacement
therapy with a hemoglobin (Hb) less than 12 g/dL

#### NUMERATOR DESCRIPTION

The number of patients from the denominator with an anemia work-up (see
the related \"Numerator Inclusions/Exclusions\" field in the Complete
Summary)

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

-   A clinical practice guideline or other peer-reviewed synthesis of
    the clinical evidence

-   A formal consensus procedure involving experts in relevant clinical,
    methodological, and organizational sciences

-   A systematic review of the clinical literature

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Unspecified

### State of Use of the Measure

#### STATE OF USE

Pilot testing

#### CURRENT USE

Internal quality improvement

### Application of Measure in its Current Use

#### CARE SETTING

Ambulatory Care\
Physician Group Practices/Clinics

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Physicians

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Individual Clinicians

#### TARGET POPULATION AGE

Age greater than or equal to 18 years

#### TARGET POPULATION GENDER

Either male or female

#### STRATIFICATION BY VULNERABLE POPULATIONS

Unspecified

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

Two studies have identified anemia as being prevalent in patients with
advanced chronic kidney disease and it is also clear that the severity
of anemia increases considerably with worsening renal function.

#### EVIDENCE FOR INCIDENCE/PREVALENCE

1999 Annual report: ESRD clinical performance measures project (formerly
ESRD Core Indicators Project). Opportunities to improve care for adult
in-center hemodialysis and adult peritoneal dialysis patients. Baltimore
(MD): U.S. Department of Health and Human Services, Health Care
Financing Administration Office of Clinical Standards and Quality; 1999
Dec.

Obrador GT, Ruthazer R, Arora P, Kausz AT, Pereira BJ. Prevalence of and
factors associated with suboptimal care before initiation of dialysis in
the United States. J Am Soc Nephrol1999 Aug;10(8):1793-800.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10446948)

Pickett JL, Theberge DC, Brown WS, Schweitzer SU, Nissenson AR.
Normalizing hematocrit in dialysis patients improves brain function. Am
J Kidney Dis1999 Jun;33(6):1122-30.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10352201)

#### ASSOCIATION WITH VULNERABLE POPULATIONS

Unspecified

#### BURDEN OF ILLNESS

Anemia is associated with increased mortality, detrimental effects on
cardiac function, exercise capacity, quality of life, and cognitive
function.

#### EVIDENCE FOR BURDEN OF ILLNESS

Fink J, Blahut S, Reddy M, Light P. Use of erythropoietin before the
initiation of dialysis and its impact on mortality. Am J Kidney Dis2001
Feb;37(2):348-55.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11157377)

Kleinman KS, Schweitzer SU, Perdue ST, Bleifer KH, Abels RI. The use of
recombinant human erythropoietin in the correction of anemia in
predialysis patients and its effect on renal function: a double- blind,
placebo-controlled trial. Am J Kidney Dis1989 Dec;14(6):486-95. \[86
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2688405)

Lim VS, DeGowin RL, Zavala D, Kirchner PT, Abels R, Perry P, Fangman J.
Recombinant human erythropoietin treatment in pre-dialysis patients. A
double-blind placebo-controlled trial. Ann Intern Med1989 Jan
15;110(2):108-14. \[37 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2909202)

Madore F, Lowrie EG, Brugnara C, Lew NL, Lazarus JM, Bridges K, Owen WF.
Anemia in hemodialysis patients: variables affecting this outcome
predictor. J Am Soc Nephrol1997 Dec;8(12):1921-9. \[49 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9402095)

Portoles J, Torralbo A, Martin P, Rodrigo J, Herrero JA, Barrientos A.
Cardiovascular effects of recombinant human erythropoietin in
predialysis patients. Am J Kidney Dis1997 Apr;29(4):541-8.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9100042)

Revicki DA, Brown RE, Feeny DH, Henry D, Teehan BP, Rudnick MR, Benz RL.
Health-related quality of life associated with recombinant human
erythropoietin therapy for predialysis chronic renal disease patients.
Am J Kidney Dis1995 Apr;25(4):548-54. \[42 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7702049)

#### UTILIZATION

Unspecified

#### COSTS

Unspecified

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### Data Collection for the Measure

#### CASE FINDING

Users of care only

#### DESCRIPTION OF CASE FINDING

Adult patients 18 years and older with advanced chronic kidney disease
(CKD) and hemoglobin (Hb) less than 12g/dL

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Adult patients age 18 years and older with chronic kidney disease stage
4 or 5 (glomerular filtration rate \[GFR\] less than or equal to 30
mL/min/1.73 m^2^) for at least three months, not currently receiving
renal replacement therapy and hemoglobin (Hb) less than 12 g/dL

**Exclusions**\
Unspecified

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are equally eligible to appear in the
numerator

#### DENOMINATOR (INDEX) EVENT 

Clinical Condition

#### DENOMINATOR TIME WINDOW

Time window precedes index event

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
The number of patients from the denominator with an anemia work-up^\*^

^\*^Operationally defined as at least one test in each of the following
categories:

-   Tests to detect anemia

    -   Hemoglobin (HgB)

    -   Hematocrit (HcT)

-   Tests to detect iron deficiency

    -   Serum iron

    -   Total Iron Binding Capacity (TIBC),

    -   Percent transferrin saturation (TSAT \[serum iron X 100 divided
        by TIBC\])

-   Test for occult blood in stool

**Exclusions**\
Unspecified

#### MEASURE RESULTS UNDER CONTROL OF HEALTH CARE PROFESSIONALS, ORGANIZATIONS AND/OR POLICYMAKERS

The measure results are somewhat or substantially under the control of
the health care professionals, organizations and/or policymakers to whom
the measure applies.

#### NUMERATOR TIME WINDOW

Episode of care

#### DATA SOURCE

Administrative data\
Laboratory data\
Medical record

#### LEVEL OF DETERMINATION OF QUALITY

Individual Case

#### PRE-EXISTING INSTRUMENT USED

Unspecified

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

Better quality is associated with a higher score

#### ALLOWANCE FOR PATIENT FACTORS

Unspecified

#### STANDARD OF COMPARISON

Internal time comparison

### Evaluation of Measure Properties

#### EXTENT OF MEASURE TESTING

Unspecified

### Identifying Information

#### ORIGINAL TITLE

Number of patients with anemia work-up / number of patients with
advanced CKD and Hb greater than 12 g/dL.

#### MEASURE COLLECTION

[Renal Physicians Association Clinical Performance Measures on
Appropriate Patient Preparation for Renal Replacement
Therapy](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=23&doc=532)

#### MEASURE SET NAME

[Renal Physicians Association Clinical Performance Measures for Anemia
Recommendations](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=23&doc=533)

#### DEVELOPER

Renal Physicians Association

#### FUNDING SOURCE(S)

Ortho Biotech Products, LP

#### COMPOSITION OF THE GROUP THAT DEVELOPED THE MEASURE

W. Kline Bolton, MD, Working Group Chair, University of Virginia School
of Medicine, Charlottesville, VA; William F. Owen, Jr., MD, President,
RPA, Duke University School of Medicine Durham, NC; Baxter Healthcare
Corp., McGaw Park, IL; Dale Singer, MHA, Executive Director, RPA.

*Content Experts*: Jack Coburn, MD, UCLA School of Medicine, West Los
Angeles V.A. Healthcare Center, West Los Angeles, CA; William Haley, MD,
Mayo Clinic, Jacksonville, FL; Annamaria Kausz, MD, New England Medical
Center, Boston, MA; Adeera Levin, MD, St. Paul\'s Hospital, Vancouver,
BC; William Mitch, MD, University of Texas Medical Branch, Galveston,
TX; Patricia Painter, PhD, University of California, San Francisco, CA;
Michael Rocco, MD, MSCE, Wake Forest University School of Medicine,
Winston-Salem, NC.

*Association Representatives*: Carolyn Atkins, RN, BS, CCTC, National
Kidney Foundation, Medical City Dallas Hospital, Dallas, TX; Shelley
Clark, RN, National Renal Administrators Association, FMC North Roanoke
Dialysis, Roanoke, VA; Paul Eggers, PhD, National Institute of Diabetes
and Digestive and Kidney Diseases (NIDDK), Bethesda, MD; Lori Fedje, RD,
LD, NKF Council on Renal Nutrition, Pacific Northwest Renal Services,
Portland, OR; Richard Goldman, MD, Renal Physicians Association, Renal
Medicine Associates, Emeritus Albuquerque, NM; Joel Greer, PhD, Centers
for Medicare and Medicaid Services, Baltimore, MD; Richard Lafayette,
MD, American Society of Nephrology, Stanford University School of
Medicine, Stanford, CA; Eugene Z. Oddone, MD, American College of
Physicians - American Society of Internal Medicine, Durham VA Medical
Center, Durham, NC; Victoria Norwood, MD, American Society of Pediatric
Nephrology, University of Virginia, Charlottesville, VA; Paul M.
Palevsky, MD, Forum of ESRD Networks, University of Pittsburgh School of
Medicine, VA Pittsburgh Health Care System, Pittsburgh, PA; Sandy
Peckens, MSW, NKF Council of Nephrology Social Workers, Merrimack Valley
Nephrology, Methuen, MA; Venkateswara Rao, MD, American Society of
Transplantation, Hennepin County Medical Center, Minneapolis, MN;
Charlotte Thomas Hawkins, PhD, RN, CNN, American Nephrology Nurses
Association, Rutgers, The State University of New Jersey, Burlington,
NJ; Joseph White, American Association of Kidney Patients.

*Methodologists*: David B. Matchar, MD, FACP, Director, Duke Center for
Clinical Health Policy Research and Co-Director, Duke Evidence-based
Practice Center, Durham, NC; Douglas C. McCrory, MD, MHS, Co-Director
Duke Evidence-based Practice Center, Durham, NC; Joseph A. Coladonato,
MD, Duke Institute of Renal Outcomes Research & Health Policy, Durham,
NC; Preston S. Klassen, MD, MHS, Duke Institute of Renal Outcomes
Research & Health Policy, Durham, NC; Meenal B. Patwardhan, MD, MHSA,
Duke Center for Clinical Health Policy Research and Duke Evidence-based
Practice Center, Durham, NC; Donal N. Reddan, MD, MHS, Duke Institute of
Renal Outcomes Research & Health Policy, Durham, NC; Olivier T.
Rutschmann, MD, MPH, Duke Center for Clinical Health Policy Research,
Durham, NC; William S. Yancy, Jr., MD, MHS, Duke University Medical
Center, Durham, NC.

*Medical Editor*: Rebecca N. Gray, DPhil, Duke Evidence-based Practice
Center, Durham, NC.

*Project Manager and Editor*: Emily G. Shurr, MA, Duke Evidence-based
Practice Center, Durham, NC.

#### FINANCIAL DISCLOSURES/OTHER POTENTIAL CONFLICTS OF INTEREST

There were none disclosed.

#### ADAPTATION

Measure was not adapted from another source.

#### RELEASE DATE

2002 Oct

#### MEASURE STATUS

This is the current release of the measure.

#### SOURCE(S)

Renal Physicians Association. Appropriate patient preparation for renal
replacement therapy. Rockville (MD): Renal Physicians Association; 2002
Oct 1. 78 p.(Clinical Practice Guideline; no. 3).

#### MEASURE AVAILABILITY

The individual measure, \"Number of patients with anemia work-up /
number of patients with advanced CKD and Hb greater than 12 g/dL,\" is
published in \"Renal Physicians Association Clinical Practice Guideline
#3: Appropriate Patient Preparation for Renal Replacement Therapy.\"

For more information, contact RPA at 1700 Rockville Pike, Suite 220,
Rockville, MD 20852; phone: 301-468-3515; fax: 301-468-3511; Web site:
[www.renalmd.org](http://www.renalmd.org/); e-mail: <rpa@renalmd.org>.

#### NQMC STATUS

This NQMC summary was completed by ECRI on May 2, 2003. The information
was verified by the Renal Physicians Association on May 27, 2003.

#### COPYRIGHT STATEMENT

This NQMC summary is based on the original measure, which is subject to
the measure developer\'s copyright restrictions.

For more information, contact RPA at 1700 Rockville Pike, Suite 220,
Rockville, MD 20852; phone: 301-468-3515; fax: 301-468-3511; Web site:
[www.renalmd.org](http://www.renalmd.org/); e-mail: <rpa@renalmd.org>.

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© 2008 National Quality Measures Clearinghouse

Date Modified: 11/3/2008