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    URSA-CKD-100: Advance Care Planning for Stage 4+ CKD Patients
    • 28 Jun 2025
    • 4 Minutes to read
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    URSA-CKD-100: Advance Care Planning for Stage 4+ CKD Patients

    • Updated on 28 Jun 2025
    • 4 Minutes to read
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    Article summary

    Measure Description

    Among ESRD or elderly CKD stage 4 or 5 patients, the percentage with evidence of advance care planning in the last 12 months

    Metadata

    • Measure Type: Rate Measure
    • Temporal Structure: Entity
    • Component Class: Long-Form
    • Denominator Case Field: Patient ID
    • Target Direction: Up

    Denominator Description

    Patients with end-stage renal disease or patients aged 65 or older with stage 4 or 5 chronic kidney disease; with current active membership in a targeted health plan and at least 6 months of continuous prior membership with the same payor

    Numerator Description

    Instances of documentation, in the last 12 months, of an advance care planning discussion, or of a past history of advance care planning, including DNR status

    Published Fields

    • Data Model Keys

      • Patient ID
      • Primary Plan ID
      • Primary Payor ID
      • Primary Plan Attributee Provider ID
      • Empirical Attributee Individual Nephrology Provider ID
      • Empirical Attributee Nephrology Group Provider ID
      • Empirical Attributee Primary Care Individual Provider ID
      • Empirical Attributee Primary Care Provider Group Provider ID
      • Document ID
      • Claim ID

    • Patient Fields

      • Is Patient Alive
      • Patient Age Integer
      • Patient Age Category Tier 1
      • Patient Age Category Tier 2
      • Patient Sex Category
      • Count Hospital Inpatient Admissions in Last 12 Months
      • Count ED Visits Without Inpatient Admissions in Last 12 Months

    • Date Fields

      • Start of Measurement Period
      • Period Start Date
      • Period End Date
      • Current Continuous Primary Payor Membership Episode Start Date
      • Current Continuous Primary Payor Membership Episode End Date
      • Current Dialysis Episode Start Date
      • Current Dialysis Episode End Date
      • Last Continuous Primary Payor Membership Episode End Date
      • Last Continuous Primary Payor Membership Episode Start Date
      • Current Continuous Medical Claim Data Coverage Episode End Date
      • Current Continuous Medical Claim Data Coverage Episode Start Date
      • Current CKD Stage Start Date
      • Current CKD Stage End Date
      • Patient Date of Birth
      • Segment Start Date -- The start date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
      • Segment End Date -- The end date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
      • Snapshot Date -- The date, evaluated at 00:00:00 AM, giving the moment the state of the world will be set to for the purposes of an analysis. The snapshot date does not represent the freshness of the data, or the date in real time at which an analysis was executed.

    • Provider Fields

      • Plan Attributee Provider Description
      • Count Nephrology Provider Visits in Last 12 Months
      • Empirical Attributee Individual Nephrology Provider Description
      • Empirical Attributee Nephrology Group Provider Description
      • Count Primary Care Visits for CKD in Last 12 Months
      • Primary Care Engagement Category
      • Count Primary Care Visits in Last 36 Months
      • Empirical Attributee Primary Care Provider Group Description
      • Empirical Attributee Individual Primary Care Provider Description
      • Count Nephrology Provider Visits in Last 6 Months
      • Count Visits with Attributee Individual Primary Care Provider in Last 36 Months
      • Count Visits with Attributee Primary Care Provider Group in Last 36 Months
      • Empirical Attributee Individual Nephrology Provider Practice Zip Code
      • Practice Address ZIP Code 5-Digit

    • Location Fields

      • Patient State Abbreviation
      • Patient ZIP Code 5-Digit
      • Patient County Description
      • UW HIP ADI Quintile Category
      • UW HIP ADI Decile Category
      • CDC SVI Overall Quintile Category
      • CDC SVI Socioeconomic Quintile Category
      • CDC SVI Household / Disability Quintile Category
      • CDC SVI Minority / Language Quintile Category
      • CDC SVI Housing / Transportation Quintile Category

    • Insurance Fields

      • Is Any Current Plan Membership
      • Primary Plan Description
      • Is CMS ESRD Status
      • Primary Plan Financial Class Description

    • Clinical Services Fields

      • Is Hospice in Last 12 Months
      • Is Last Dialysis Modality Hemodialysis
      • Is Last Dialysis Modality Peritoneal Dialysis
      • CMS Place of Service Code
      • CMS Place of Service Description

    • Diagnosis Fields

      • Count CCW Conditions
      • Is CCW System Behavioral Health
      • Is CCW System Cardiovascular
      • Is CCW System Genitourinary
      • Is CCW System Musculoskeletal
      • Is CCW System Pulmonary
      • Is CCW Acquired Hypothyroidism
      • Is CCW Acute Myocardial Infarction
      • Is CCW Alzheimers Disease
      • Is CCW Anemia
      • Is CCW Anxiety Disorders
      • Is CCW Asthma
      • Is CCW Atrial Fibrillation
      • Is CCW Benign Prostatic Hyperplasia
      • Is CCW Bipolar Disorder
      • Is CCW Breast Cancer
      • Is CCW Cataract
      • Is CCW CKD
      • Is CCW COPD and Bronchiectasis
      • Is CCW Colorectal Cancer
      • Is CCW Depression
      • Is CCW Depressive Disorders
      • Is CCW Diabetes
      • Is CCW Endometrial Cancer
      • Is CCW Glaucoma
      • Is CCW Heart Failure
      • Is CCW Ischemic Heart Disease
      • Is CCW Hip or Pelvic Fracture
      • Is CCW Hyperlipidemia
      • Is CCW Hypertension
      • Is CCW Lung Cancer
      • Is CCW Osteoporosis
      • Is CCW Prostate Cancer
      • Is CCW Rheumatoid Arthritis or Osteoarthritis
      • Is CCW Stroke or Transient Ischemic Attack
      • Is CCW Schizophrenia or Other Psychotic Disorders
      • CCW Count Category
      • Is CCW Alzheimers Disease and Related Disorders or Senile Dementia
      • Is CCW Obesity
      • Is CCW PVD
      • CCW Systems Category
      • Count CCW Systems
      • Is CCW System Congenital
      • Is CCW System Endocrine/Metabolic
      • Is CCW System Hematologic
      • Is CCW System Neurological
      • Is CCW System Oncologic
      • Is CCW System Ophthalmologic
      • Is CCW System Other

    • Numerator Fields

      • Document Effective Date
      • Is ACP Discussion Code
      • Is History of ACP Discussion Code
      • Is DNR Status Code
      • ICD-9-CM Diagnosis Code
      • ICD-10-CM Code
      • HCPCS Code

    • Metadata Fields

      • Is Medical Claim Data Coverage
      • Random Integer 1 to 1000

    • Measure Fields

      • Denominator
      • Numerator

    • Patient Observation Fields

      • Last GFR Result Date
      • Last Race-Adjusted GFR Result Numeric
      • Is Last Race-Adjusted GFR in CKD Stage 1 Range
      • Is Last Race-Adjusted GFR in CKD Stage 2 Range
      • Is Last Race-Adjusted GFR in CKD Stage 3 Range
      • Is Last Race-Adjusted GFR in CKD Stage 3a Range
      • Is Last Race-Adjusted GFR in CKD Stage 3b Range
      • Is Last Race-Adjusted GFR in CKD Stage 4 Range
      • Is Last Race-Adjusted GFR in CKD Stage 5 Range

    • Module Fields

      • CKD Stage Category
      • Is CKD Stage 1
      • Is CKD Stage 2
      • Is CKD Stage 3
      • Is CKD Stage 4
      • Is CKD Stage 5
      • Is ESRD
      • Is CKD Stage Unknown
      • Is CKD Stage 3 or Higher
      • Is CKD Stage 4 or Higher
      • Is Chronic Dialysis Patient
      • Is History of Kidney Transplantation
      • CKD Physician Management Category

    • [No Field Group]

      • Ursa Serial ID
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