4. Patient Characteristics from CMS Medical Evidence Form

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Patient Characteristics from HCFA Medical Evidence Form USRDS 1999 Annual Data Report 3.5 Serum Albumin and Body Mass Index (BMI) for New ESRD Patients, 1995-98* Average Serum Albumin (g/dl) Average BMI (kg/m 2 ) 27 3.4 3.3 3.2 3.25 3.22 3.20 3.19 25.39 25.52 25.67 26.05 26 25 3.1 3.0 24 1995 1996 1997 1998 1995 1996 1997 1998 IV -11 *Reported on HCFA Medical Evidence Form; 1998 data are through June USRDS 1999 Figure IV-11 Average serum albumin (g/dl) and body mass index (BMI, kg/m 2 ) by year for new ESRD patients as reported on the HCFA Medical Evidence Form, 1995 through June of 1998. BMI is computed as weight/(height) 2 . Source: Reference Table L.21. In 1998, the mean serum albumin before first chronic dialysis was reported to be 3.2 g/dl (Figure IV-11). This is far below the normal range of 4.0-5.0 g/dl. It highlights the fact that, on average, new patients to dialysis are considered “malnourished”, which maybe related to many pre-ESRD factors and the timing of dialysis initiation. As serum albumin is an important predictor of mortality, both in the short term and for up to 5 years following dialysis initiation (Leavey), our attention should be focused on improving pre-ESRD care and on interventions that might improve nutritional status. Similarly, in 1998 the average BMI was reported to be 26 kg/m² (Figure IV-11). This measure has also been shown to be an independent predictor of mortality among dialysis patients (Leavey). Reporting of Comorbid Conditions Among New Dialysis Patients It is recognized that inadequate data recording and the omission of pertinent patient characteristics may affect the validity of the data collected. The potential for poor recording of patient characteristics is increased as the workload of many dialysis units increases and resources are stretched. Longenecker et al. have addressed the issue of validity with respect to data collected from the medical evidence form as compared to data collected from the Choices for Healthy Outcomes in Caring for ESRD study (CHOICE) (Longenecker). They found that the sensitivity of reporting for comorbid medical conditions was poor using data from the Medical Evidence Report Form, ranging between 17 percent to 78 percent. As such, the prevalence of comorbid medical conditions among new ESRD patients may be underestimated and reduce the validity of analyses utilizing these data. The comparison of the percentage of comorbid conditions reported in the Medical Evidence Report Form data with the USRDS (DMMS) data can also be used to address the question of the validity of the data collected. The percent agreement (Kappa statistic) was generally low. It was highest for cardiovascular conditions and lowest for noncardiovascular comorbid conditions. However, as there is no ‘gold standard’ that gives the “true” prevalence of comorbidity, one can only surmise that some conditions may be under-reported and others over-reported. The lack of agreement is of concern in that estimates of the true burden of disease is necessary for determining public health policies and allocating health resources. 66
USRDS 1999 Annual Data Report Patient Characteristics from HCFA Medical Evidence Form In general, the prevalence of reported comorbid conditions was substantially lower for the HCFA Medical Evidence Form data compared to the DMMS Wave 2 data. As mentioned previously, there is likely to be substantial variation in the methods and personnel used to complete the Medical Evidence Report Form whereas the DMMS data collection instrument is completed in a standardized manner by detailed medical chart abstraction. It is conceivable that in many instances the Medical Evidence Report Form is completed using recall rather than using medical records. There has been some discussion as to which measurement technique is likely to be more clinically relevant. On one hand, the detailed chart abstraction is likely to be more complete. However, one may speculate that the use of recall may be more useful as only the clinically more significant conditions are recorded. Of interest is the fact that the presence of various comorbid conditions in both data sources have been predictive of outcome in the past. This suggests that either data source can be used for epidemiological studies. However, there is also the possibility that the section on comorbid conditions is simply “passed over” for some patients. One may speculate that this may not be a random event and that these practices may vary by facility. To further explore this possibility, Figure IV-12 shows the distribution of facilities by average number of comorbid conditions reported per incident patient during 1995-1997, as recorded on the HCFA Medical Evidence Report Form. In 92 percent of facilities, the average number of comorbid conditions was one or more, with 35.4 percent of facilities having an average of 2 or more. On average, one would expect similar reporting of comorbidities by most facilities. However, as shown in Figure IV-13, this is not the case. In 33 percent of facilities, 20-30 percent of patients had zero comorbid conditions recorded; in 18.7 percent of facilities, 30 to 40 percent of patients have zero comorbid conditions reported; in 7.3 percent of facilities, 40 to 50 percent of patients had zero comorbid conditions recorded, and in a little over 6 percent of facilities over 50 percent of patients had no comorbid conditions reported. This suggests the possibility that there are facilities in which the section on comorbid conditions may simply not be completed for a large proportion of patients. As such, the value of this data source may be compromised. The overall objective to ultimately improve the outcome of patients with ESRD by epidemiological study of these data would be greatly enhanced by improved reporting of these comorbid conditions for all patients. There is a need for an increased awareness of the importance of this type of data collection in the renal community to achieve more accurate and complete reporting of comorbid conditions. Are Incident Patients in the United States Being Started on Dialysis Earlier Distribution of Facilities by Average Number of Comorbidities Reported per Patient, 1995-97* 60 50 Facilities (%) 55.6 N = 3,250 Facilities ** 40 30 31.5 20 10 0 0.2 8.8 Figure IV-12 3.5 0.3 0.1 0
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4. Patient Characteristics from CMS Medical Evidence Form

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