ITAP TT1 MC - Chronic Renal Failure Nov 2015

ITAP TT1 MC - Chronic Renal Failure – Nov 2015

ITAP MANAGED CARE WORKING GROUP
TASK TEAM 1: CHRONIC DISEASE CONDITIONS (CDL’s)
– CHRONIC RENAL FAILURE –
Explanatory note to the Managed Care minimum reporting data specification (excel spreadsheet)

The aim of the project is to report on the value added by managed care organisations, who by means of capturing, measuring and reporting on clinical indicators that will demonstrate clinical outcome/s achieved. Hence this is by no means a representation of the full protocol, policy or guideline on chronic renal failuremanagement.

Additionally, these indicators will be included within the Annual statutory return to be completed by the Scheme.

1)Goal

The value of managing a disease is to determine goals that would enable the user to measure, record and report on an agreed health quality outcomes

(Diagnosis, treatment and care of all beneficiaries in line with evidence base medicine, cost effectiveness and affordability).

Prevent complications and or optimally manage the progression of disease.

2)Identification of beneficiaries that have Chronic Renal Failure / or registered on a managed care program

Please ensure the relevant consent and confidentially has been addressed when obtaining personal health information.

Identification of beneficiaries registered on the program may include

Registered on chronic / disease management programs
ICD-10 Codes
Anatomical Therapeutic Chemical Classification System (ATC Class)
National stock numbers (State stock code)

3)Minimum data specification: Process indicators, clinical outcomes and data

The level of ActiveManagement of chronic renal failurewill depend on the nature of the contract, the level of services covered and the fee structure for those services, e.g.screening, medication, procedures etc.

The minimum required fields for the effective collection of appropriate data to demonstrate the value of the managed care interventions for the below mentioned categories are detailed by way of process indicators (see attached spreadsheet).

Diagnosis

The diagnosis of Chronic Renal Failureis made by the specified registered provider.

Investigations
Pathology (Blood)
Full Blood Count (haematocrit, platelets, RBC etc.)
Creatinine
Albumin
Calcium
Phosphate
HB
Parathyroid Hormone
Iron Studies
Reticulocytes
Total Cholesterol

Pathology (Urine)

Glomerular filtration
Microalbuminuria
Protein

Radiology
Renal Ultrasound

-Glomerular Filtrationrate

-Management of Diabetes Mellitus and Hypertension progression in stages 3 and 4

Discipline Type

The service providersmust be registered with their relevant statutory bodies and as indicated by discipline coded list provided by BHF.

4)Treatment – Chronic Renal Failure

-B05D- PeritonealDialytic

-B05Z–Haemodialytic and Hemofiltrates

-B03XA01 - Erythropoietin

-V03AE - Drugs for treatment of hyperkalemia and hyperphosphatemia

-A11CC - Vitamin D and analogues

-L04A - Immunosuppressant’s

* Please note these recommendations do not replace the published algorithms, PMB entitlements etc. It is a means of measuring the value and quality of care provided.

* The above is merely the initial phase of the ITAP project and as such is not exhaustive.

5)Clinical Outcomes measures

Number of chronic renal diseaserelated hospital admissions
Number of all cause admissions
Number of casualty visits
Number of doctor visits
Number of

-Peritoneal or haemodialysis

Less than 3 sessions per week
More than 3 sessions per week

Stage of disease
All-cause mortality

* Information in regards to ICD-10 coding may be found on the following site

6)Reporting (MCO and Scheme)

*Definitions will be the same utilised within the Annual statutory returns – see Circular 10 of 2015.

All reports to be submitted to the Scheme for inclusion in the Annual Statutory Returns. Please complete the section relevant to the service rendered.

6.1By Managed Care Organisation: Management out of hospital

-Time period: Benefit year (Reporting period – Start and end)

-Per benefit option

-Per Scheme

-Member

-Beneficiary

-Service Date (Benefit Year)

-Gender – Male / Female

-Age (Age of the beneficiary is to be calculated as the Year of Reporting - Year of Birth)

6.1.1Program Demographics

Year: Bi-Annual / Actual Number of Beneficiaries registered for a Chronic Renal Failure on the Pharmacy Benefit and or Active disease management program (Longer than 6 months on program) / No of beneficiaries per stage of Chronic Renal Disease. / Number of New Registrations in the period / Number of Beneficiaries who left program *
Stage 1
eGFR > 90 / Stage 2
eGFR 60-90 / Stage 3
eGFR 30-59 / Stage 4
eGFR 15-29 / Stage 5
eGFR <15
Male / Female / Male / Female / Male / Female / Male / Female / Male / Female / Male / Female / Male / Female / Male / Female
Under 1
1 to 4
4 to 9
10 to 14
15 to 19
20 to 24
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85 and above
Total

Left the program – This may include various reason codes i.e. left the scheme, death, suspensions etc.

6.1.2Clinical Management

Year: Bi-Annual / No of beneficiaries on ACE Inhibitors / No of beneficiaries on Calcium Carbonate / No. of beneficiaries on Peritoneal or Haemodialysis Dialysis
Less than 3 sessions per week / No. of beneficiaries on Peritoneal or Haemodialysis Dialysis
More than 3 sessions per week / No. of beneficiaries that had a AV Fistula / No. of beneficiaries that had a renal transplant / Total Number of Beneficiaries identified with 2 or more co-morbidities
Male / Female / Male / Female / Male / Female / Male / Female / Male / Female / Male / Female
Under 1
1 to 4
4 to 9
10 to 14
15 to 19
20 to 24
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85 and above
Total

6.2Management in Hospital

-Time period: 1 January to 31 December (Service dates / financial year), define per quarter

-Per benefit option

-Per Scheme

-Hospital Admissions:

All cause admissions
Chronic Renal failure admissions

-Hospital Category

Day Admission
Long Stay
Readmission

-Gender

-Age

Admission definitions

Chronic Renal Failure related admission - please refer to attached list of ICD10 Codes.
Mortality / Exit codes – Where a hospital notifies the schemes / MCO / Administrator that a member is deceased. See attached
Emergency room – Definition is that member discharged from unit
Hospital admission
A day case is when admission day is same as discharge date
A long stay is when discharge date is after the admission day.
A re-admission is when a patient from hospital is readmitted within 90 days of previous discharge date

6.2.1Hospital Category: Day Case

Scheme / Total Number of Admissions (All Cause) / Total Number of Admissions (Chronic Renal Failure) Related / Admission Per Category / Mortality (Exit Codes = Expire) / Claimed Amount / Risk Paid Amount
Surgical / Medical / Paediatric / Emergency Room (Only)
Male / Female / Male / Female / Male / Female / Male / Female

6.2.2Hospital Category: Long Stay

6.2.3Hospital Category: Re-admission

7)References

Task Team 1 of the Managed Care ITAP working group;
Standard treatment guidelines and Essential medicine list
Circular 10 of 2015
Guidelines for Chronic Renal Dialysis – National Department of Health
Dr Errol Gottlich – Discovery Health