title: Ultrafiltration Rates and the Quality Incentive Program: Proposed Measure Definitions and Their Potential Dialysis Facility Implications.
abstract: Rapid ultrafiltration rates are associated with adverse outcomes among patients on hemodialysis. The Centers for Medicare and Medicaid Services is considering an ultrafiltration rate quality measure for the ESRD Quality Incentive Program. Two measure developers proposed ultrafiltration rate measures with different selection criteria and specifications. We aimed to compare the proposed ultrafiltration rate measures and quantify dialysis facility operational burden if treatment times were extended to lower ultrafiltration rates.
  
  
  
  Data were taken from the 2012 database of a large dialysis organization. Analyses of the Centers for Medicare and Medicaid Services measure considered 148,950 patients on hemodialysis, and analyses of the Kidney Care Quality Alliance measure considered 151,937 patients. We described monthly patient and facility ultrafiltration rates and examined differences in patient characteristics across ultrafiltration rate thresholds and differences in facilities across ultrafiltration rate measure scores. We computed the additional treatment time required to lower ultrafiltration rates <13 ml/h per kilogram.
  
  
  
  Ultrafiltration rates peaked in winter and nadired in summer. Patients with higher ultrafiltration rates were younger; more likely to be women, nonblack, Hispanic, and lighter in weight; and more likely to have histories of heart failure compared with patients with lower ultrafiltration rates. Facilities had, on average, 20.8%±10.3% (July) to 22.8%±10.6% (February) of patients with ultrafiltration rates >13 ml/h per kilogram by the Centers for Medicare and Medicaid Services monthly measure. Facilities had, on average, 15.8%±8.2% of patients with ultrafiltration rates ≥13 ml/h per kilogram by the Kidney Care Quality Alliance annual measure. Larger facilities (>100 patients) would require, on average, 33 additional treatment hours per week to lower all facility ultrafiltration rates <13 ml/h per kilogram when total treatment time is capped at 4 hours.
  
  
  
  Ultrafiltration rates vary seasonally and across clinical subgroups. Extension of treatment time as a strategy to lower ultrafiltration rates may pose facility operational challenges. Prospective studies of ultrafiltration rate threshold implementation are needed.
authors.affiliation: University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.|Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina; and.
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: Flythe
authors.affiliation: University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.|Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina.
authors.forename: Magdalene M
authors.initials: MM
authors.lastname: Assimon
authors.affiliation: University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
authors.forename: Julia B
authors.initials: JB
authors.lastname: Wenger
authors.affiliation: Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina; and.|Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina.
authors.forename: Lily
authors.initials: L
authors.lastname: Wang
mesh_terms: D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D000367:Age Factors; D000368:Aged; D000554:Ambulatory Care Facilities / Q000592:standards / Q000706:statistics & numerical data*; D001835:Body Weight; D014487:Centers for Medicare and Medicaid Services, U.S.; D017583:Hemodiafiltration / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data*; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D008875:Middle Aged; D011785:Quality Assurance, Health Care / Q000379:methods*; D019984:Quality Indicators, Health Care; D012621:Seasons; D012737:Sex Factors; D013997:Time Factors; D014481:United States
keywords: Epidemiology and outcomes; Humans; Kidney Failure, Chronic; Medicaid; Medicare; Prospective Studies; heart failure; hemodialysis; renal dialysis; ultrafiltration