Comorbidity ascertainment from the ESRD Medical Evidence Report and Medicare claims around dialysis initiation: a comparison using US Renal Data System data

Am J Kidney Dis. 2015 Nov;66(5):802-12. doi: 10.1053/j.ajkd.2015.04.015. Epub 2015 May 23.


Background: The end-stage renal disease Medical Evidence Report serves as a source of comorbid condition data for risk adjustment of quality metrics. We sought to compare comorbid condition data in the Medical Evidence Report around dialysis therapy initiation with diagnosis codes in Medicare claims.

Study design: Observational cohort study using US Renal Data System data.

Setting & participants: Medicare-enrolled elderly (≥66 years) patients who initiated maintenance dialysis therapy July 1 to December 31, 2007, 2008, or 2009.

Index tests: 12 comorbid conditions ascertained from claims during the 6 months before dialysis therapy initiation, the Medical Evidence Report, and claims during the 3 months after dialysis therapy initiation.

Reference test: None.

Results: Comorbid condition prevalence according to claims before dialysis therapy initiation generally exceeded prevalence according to the Medical Evidence Report. The κ statistics for comorbid condition designations other than diabetes ranged from 0.06 to 0.43. Discordance of designations was associated with age, race, sex, and end-stage renal disease Network. During 23,930 patient-years of follow-up from 4 to 12 months after dialysis therapy initiation (8,930 deaths), designations from claims during the 3 months after initiation better discriminated risk of death than designations from the Medical Evidence Report (C statistics of 0.674 vs 0.616). Between the Medical Evidence Report and claims, standardized mortality ratios changed by >10% for more than half the dialysis facilities.

Limitations: Neither the Medical Evidence Report nor diagnosis codes in claims constitute a gold standard of comorbid condition data; results may not apply to nonelderly patients or patients without Medicare coverage.

Conclusions: Discordance of comorbid condition designations from the Medical Evidence Report and claims around dialysis therapy initiation was substantial and significantly associated with patient characteristics, including location. These patterns may engender bias in risk-adjusted quality metrics. In lieu of the Medical Evidence Report, claims during the 3 months after dialysis therapy initiation may constitute a useful source of comorbid condition data.

Keywords: CMS 2728; CMS quality metrics; Medical Evidence Report; Medicare claims; US Renal Data System (USRDS); comorbid conditions; comorbidity ascertainment; data discordance; diagnosis codes; dialysis information systems; dialysis initiation; end-stage renal disease (ESRD); misclassification; renal replacement therapy (RRT).

Publication types

  • Comparative Study
  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Alcoholism / epidemiology
  • Cardiovascular Diseases / epidemiology*
  • Comorbidity
  • Coronary Artery Disease / epidemiology
  • Data Collection
  • Databases, Factual
  • Diabetes Mellitus / epidemiology*
  • Female
  • Heart Failure / epidemiology
  • Humans
  • Kidney Failure, Chronic / epidemiology*
  • Kidney Failure, Chronic / therapy
  • Male
  • Medicare
  • Mobility Limitation*
  • Neoplasms / epidemiology*
  • Peripheral Vascular Diseases / epidemiology
  • Proportional Hazards Models
  • Pulmonary Disease, Chronic Obstructive / epidemiology*
  • Renal Dialysis
  • Retrospective Studies
  • Substance-Related Disorders / epidemiology*
  • Tobacco Use Disorder / epidemiology
  • United States / epidemiology