Ultrafiltration Rates and the Quality Incentive Program: Proposed Measure Definitions and Their Potential Dialysis Facility Implications

Abstract

Background and objectives 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.Design, setting, participants, & measurements 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.Results 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% 610.3% (July) to 22.8%610.6% (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%68.2% 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.Conclusions 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.

Effects of weight‐based ultrafiltration rate limits on intradialytic hypotension in hemodialysis

“…9 Results in this study provide unique observational data from a dialysis facility system that had the flexibility to adjust to treatment time changes, but it should be recognized that not all facilities have this flexibility. Most notable is the potential need for treatment time extensions for some patients on a given day based on UF requirements.…”

Ultrafiltration rate in conventional hemodialysis: Where are the limits and what are the consequences?

“…UFR is highest during the dialysis session following the two day hiatus. UFR also varies with the season, with lower UF rate reported in summer and higher rates in winter …”

Volume Balance and Intradialytic Ultrafiltration Rate in the Hemodialysis Patient

“…39, 52, 53 With a potential UFR threshold of ≤13 mL/hr/kg, many patients, who are not willing to extend their treatment times or change their daily fluid intakes, will potentially leave their HD treatments volume overloaded perpetuating a chronic volume overloaded state. The potential effects and consequences of a UFR limitation are unknown to us at this time as our UFR-related studies to date are observation in nature.…”

“…This question has recently come to national stage in the determination of dialysis care guidelines. 39, 40 The ultrafiltration rate (UFR), fluid volume removed per hour per patient DW (mL/hr/kg), has been studied in several observational studies to elucidate the optimal fluid removal rate during HD. Saran et al found that UFR of >10 mL/hr/kg were associated with higher all-cause mortality risk (HR 1.09, p=0.02) but not with cardiovascular (CV) related mortality 41 in the international DOPPs cohort.…”