Table 3.

PCMH-KD intervention outcome measures

Measure	Instrument
Patient-Reported Outcomes
Primary care coordination	Primary Care Assessment Survey
Quality of life	Kidney Disease Quality of Life-36 (KDQOL-36)
Management of chronic disease	Self-Efficacy for Managing Chronic Disease
Knowledge of hemodialysis	Chronic Hemodialysis Knowledge Survey
Depression Screening	Patient Health Questionnaire-9
Medication compliance	Morisky Medication Adherence
Patient satisfaction with dialysis care	Consumer Assessment of Healthcare Providers and System: In-center Hemodialysis Survey
Fluid and dietary compliance	Renal Adherence Attitudes Questionnaire
	Renal Adherence Behavior Questionnaire
Comorbidities	Patient intake form
Dialysis history	Patient intake form
Clinical Outcomes
Primary disease prevention	Receipt of age-appropriate cancer screenings
	Receipt of recommended vaccinations
	Bone densitometry
	Periodontal disease
Secondary disease prevention	Hemoglobin A1c measurement
	Receipt of aspirin and/or beta-blockers
Permanent vascular access	Type of access: fistula, graft, or catheter
Dialysis adequacy	Kt/V
	Interdialytic weight gain (kg)
	Pre-and post-dialysis weight (kg)
	Urea reduction ratio
Nutrition status	Serum albumin
Anemia management	Serum hemoglobin
	Serum ferritin
	Serum transferrin saturation
Bone and mineral metabolism and electrolytes	Serum parathyroid hormone (PTH)
	Serum phosphorus
	Serum calcium
	Serum potassium
Other	Pre- and post-dialysis systolic and diastolic blood pressure
	Blood stream infections
	Treatment compliance: missed dialysis treatments or failure to complete entire dialysis treatment
	Current medications
	Status on transplant list (yes/no)
Health Care Use
Health care utilization	Number of inpatient hospital admissions
	Number of readmissions to hospital within 30 days of discharge
	Number of avoidable hospitalizations
	Number of emergency room visits
Staff Perceptions
Dialysis Team Cohesiveness	Healthcare Team Vitality Instrument