Dialysis Facility Compare, Star Ratings and Data Release
On October 28, 2016, the Centers for Medicare & Medicaid Services (CMS) added patient experience survey results and two new clinical quality measures as well as updated the way CMS calculates star ratings on the Dialysis Facility Compare website on Medicare.gov. The website also reflects improvements to make it easier for consumers to find and understand complex quality information. These changes are in response to stakeholder feedback and recommendations from a Technical Expert Panel and are designed to enhance how the information is presented on Dialysis Facility Compare and make the site easier to use.
Dialysis Facility Compare is the official CMS source for information about the quality of dialysis facilities and publishes data on thousands of Medicare-certified dialysis centers across the country. CMS is committed to making quality information easy to access and understand for consumers and is working to ensure that the Dialysis Facility Compare meets the needs of individuals with kidney disease and their caregivers, groups and individuals who advocate on behalf of kidney patients, health care providers, and others who may be involved in helping a patient have a better understanding of the care they receive.
CMS added the star ratings last year to its Compare websites with the goal of improving the usefulness of quality information for consumers. Star ratings are intended to enhance and supplement existing publicly reported quality information, which will continue to be available. Star ratings can help consumers quickly identify differences in quality when selecting a dialysis facility, as well as help existing patients understand how CMS measures quality for this program. In addition to summarizing performance, star ratings can help dialysis facilities identify areas for improvement. They are useful to consumers, consumer advocates, health care providers, and other stakeholders when updated regularly to present the most current information available. The star ratings were originally included on the Dialysis Facility Compare website on January 22, 2015, and were previously updated in October 2015. Currently, there are star ratings on Dialysis Facility Compare, Nursing Home Compare, Physician Compare, Home Health Compare, and Hospital Compare.
Patient Experience Survey Results
CMS is adding patient experience of care survey information from the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) to the Dialysis Facility Compare website. CMS, along with the Agency for Healthcare Research and Quality (AHRQ), developed the ICH-CAHPS Survey to provide a standardized survey instrument and data collection methodology for measuring patients' perspectives on the care they received at dialysis centers.
The ICH-CAHPS Survey contains 62 questions: 44 items assess important aspects of the dialysis experience. The remaining questions capture patient characteristics for analytical purposes.
Results from the patient experience survey are not part of the star ratings.
New Clinical Quality Measures
Dialysis Facility Compare is reporting two new clinical quality measures:
- National Healthcare Safety Network Standardized Bloodstream Infection Ratio
The standardized infection ratio (SIR) is a ratio of the number of bloodstream infections that are observed at a facility versus the number of bloodstream infections that are predicted for that facility, based on national baseline data.
- The Pediatric Peritoneal Dialysis (PD) Kt/V
Results of this measure equal the percent of eligible pediatric PD patients at the facility who had enough wastes removed from their blood during dialysis: Kt/V greater than or equal to 1.8.
Changes to Star Ratings Methodology
Following discussions with the community and a Technical Expert Panel held in 2015, the following changes were implemented to the star rating methodology, which are reflected in the star ratings released today on Dialysis Facility Compare:
- Measure Scoring
The original methodology (released January 2015) scored all measures (percentage measures and standardized measures) with 100 probit ranks based on “percentiles.” In the updated methodology, measures with potentially skewed distributions (percentage measures only) are instead scored with truncated z-scores, instead of probit scores.
- Setting a Baseline Year
The original methodology scored all facilities on a relative scale with the following cut-offs for assigning star ratings to facilities as follows: 10% receive 5-stars, 20% receive 4-stars, 40% receive 3-stars, 20% receive 2-stars, and 10% receive 1-star. The updated methodology establishes a baseline year to develop scoring functions, domains, and star rating cut-offs to be used in future years. For the baseline year only, star rating cut-offs are: 10% receive 5-stars, 20% receive 4-stars, 40% receive 3-stars, 20% receive 2-stars, and 10% receive 1-star (note: baseline ratings are not reported). The structure of the star rating is the same as the original methodology, except now a baseline year (e.g., 2014) is established to develop scoring and rating criteria. These criteria are applied to a current year of data (e.g., 2015) to produce final facility scores and star ratings. For the standardized measures only, these measures are first multiplied by an “adjustment factor” before scoring to represent facility quality comparable to standards fixed in a baseline year. Facilities are no longer strictly held to the set distribution.
In addition to updates made to the star rating methodology, several of the measures reported on Dialysis Facility Compare and/or in the star ratings were also updated as part of the required comprehensive measure reevaluation and National Quality Forum (NQF) review. For the Standardized Readmission Ratio (SRR) measure, updates were made in response to public comments and NQF committee review comments. These changes are listed below.
- Vascular Access (Catheter and Fistula)
Patients must have end-stage renal disease (ESRD) for more than 90 days to be included in the measure. The revision aligns with other measures—including the Kt/V and hypercalcemia measures—and takes into account that establishing permanent vascular access takes weeks to months. By excluding incident patients until after 90 days, attributing vascular access status to the appropriate dialysis facility improves.
CROWNWeb as the primary data source. The revision incorporates the requirement that the patient must be assigned to the dialysis facility for the entire month, which is determined through CROWNWeb. This requirement effectively removes from the measure calculation most patients who would be considered transient. The measure uses all available CROWNWeb and Medicare claims Kt/V data for patients reported by the dialysis facility. Medicare claims are used if CROWNWeb data is missing or reports out of range values.
Revised definition of “out of range” values. This revision removed lower limits, and raises upper limits from 2.5 to 5.0 for HD Kt/V and from 2.5 to 8.5 for PD Kt/V. The increased limits account for reasonable values while still excluding possible erroneous values.
Updated definition of frequent dialysis for pediatric patients. This revision was made to align with adult measure requirements of four or more sessions per week (previously five or more). Patients receiving frequent dialysis are excluded from the measure denominator.
Exclude readmissions within the first three days after index discharges from the numerator. This reflects the NQF-endorsed version of the measure. This revision excludes readmissions that may occur before the dialysis facility has a chance to see a patient after the index hospital discharge.
Patients with missing calcium values are now included in the denominator. The original measure calculation excluded patients with missing values, which created a potentially inappropriate incentive for dialysis facilities to not report calcium data.
Suggestions and comments on future measures to be considered for both Dialysis Facility Compare and the star ratings were requested on a National Provider call on October 5, 2016. Based on these recommendations, CMS will convene a Technical Expert Panel charged with evaluating the inclusion of potential future measures for the star ratings.
Questions or comments about the Dialysis Facility Compare star ratings can be submitted to the following email address: email@example.com, or questions may be directed to Elena Balovlenkov at Elena.Balovlenkov@cms.hhs.gov and Joel Andress at Joel.Andress@cms.hhs.gov.
More Information and Other Compare Websites
For more information on Dialysis Facility Compare, please visit: http://www.medicare.gov/dialysisfacilitycompare/#search.
For more information on the DIALYSIS FACILITY COMPARE star rating methodology, please visit: https://dialysisdata.org/sites/default/files/content/Methodology/UpdatedDIALYSIS FACILITY COMPAREStarRatingMethodology.pdf
CMS also has other Compare websites to help you in selecting providers across the continuum of care, including Home Health Compare, Hospital Compare, Nursing Home Compare, and Physician Compare. Visit these websites to learn more about CMS’s efforts to make health care quality information more transparent.