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Clin Exp Nephrol. 2017 Apr;21(2):247-256. doi: 10.1007/s10157-016-1274-8. Epub 2016 May 4.

Development of quality indicators for care of chronic kidney disease in the primary care setting using electronic health data: a RAND-modified Delphi method.

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Department of Healthcare Epidemiology, Kyoto University, Yoshida-konoe, Sakyo-ku, Kyoto, Japan.
Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, Hikarigaoka 1, Fukushima, Japan.
Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, Japan.
Department of Nephrology, Graduate School of Medicine, Kyoto University, Shogoin-kawaramachi 54, Sakyou-ku, Kyoto, Japan.
Hatta Medical Clinic, Shugakuin Yakushido 4, Sakyo-ku, Kyoto, Japan.
Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan.
Kidney Unit, National Fukuoka Higashi Medical Center, Chidori 1-1-1, Koga, Fukuoka, Japan.
Department of Nephrology and Rheumatology, Japan Labour Health and Welfare Organization Chubu Rosai Hospital, 1-10-5 Komei, Minato-ku, Nagoya, Japan.
Internal Medicine, Suzu General Hospital, 1-1 Nonoe-Yu, Suzu, Ishikawa, Japan.
Shichijo Clinic, 29 Sujaku-kitanokuchi-cho, Shimogyo-ku, Kyoto, Japan.
Japan Community Health Care Organization (JCHO), Tokyo Takanawa Hospital, Takanawa 3-10-11, Minato-ku, Tokyo, Japan.
Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.



The prevalence of chronic kidney disease (CKD) has recently increased, and maintaining high quality of CKD care is a major factor in preventing end-stage renal disease. Here, we developed novel quality indicators for CKD care based on existing electronic health data.


We used a modified RAND appropriateness method to develop quality indicators for the care of non-dialysis CKD patients, by combining expert opinion and scientific evidence. A multidisciplinary expert panel comprising six nephrologists, two primary care physicians, one diabetes specialist, and one rheumatologist assessed the appropriateness of potential indicators extracted from evidence-based clinical guidelines, in accordance with predetermined criteria. We developed novel quality indicators through a four-step process: selection of potential indicators, first questionnaire round, face-to-face meeting, and second questionnaire round.


Ten expert panel members evaluated 19 potential indicators in the first questionnaire round, of which 7 were modified, 12 deleted, and 4 newly added during subsequent face-to-face meetings, giving a final total of 11 indicators. Median rate of these 11 indicators in the final set was at least 7, and percentages of agreement exceeded 80 % for all but one indicator. All indicators in the final set can be measured using only existing electronic health data, without medical record review, and 9 of 11 are process indicators.


We developed 11 quality indicators to assess quality of care for non-dialysis CKD patients. Strengths of the developed indicators are their applicability in a primary care setting, availability in daily practice, and emphasis on modifiable processes.


Administrative claims data; Chronic kidney disease; Quality indicators; Quality of care; RAND

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