← the access Reviewed as of 15 July 2026
THE ACCESS · HOW IS CARE MEASURED AND JUDGED?

The Two Ladders

One adequacy number read three ways—the regulatory floor the cohort is scored against, the best-practice target the guidelines set, and the individualized goal one person’s plan of care sets. In peritoneal dialysis the two ladders disagree.

TEXT ALTERNATIVE ↓
WIDE DRAWING · SCROLL SIDEWAYS TO READ IT ALL · THE FULL CONTENT IS ALSO IN WORDS BELOW
The regulatory floor—the rung the cohort is scored against (QIP-scored, punitive; adult thresholds)
The best-practice target—the rung the guidelines set for the cohort (aspirational)
One patient’s goal—the rung the plan of care sets for a person (illustrative)
The dissolved rung—ISPD 2020 sets no single number; the person is the target
Reviewed as of 15 July 2026 Changelog

The drawing in words

  1. The drawing is two panels on one shared vertical scale—the adequacy number itself. Left, the HD ladder, read on spKt/V per session (3x/week), scale 1.0 to 1.6. Right, the PD ladder, read on weekly Kt/V urea (dialysis plus residual kidney function), scale 1.3 to 2.0.
  2. Each panel carries three rails, side by side: the regulatory floor (cohort grammar—percent of patients, QIP-scored, punitive), the best-practice target (cohort grammar—aspirational, evidence-graded), and this patient’s goal (person grammar—the plan of care). Below a floor the panel is hatched: below the floor is where a facility is cited. [1 · 2]
  3. HD, regulatory floor: spKt/V 1.2 (or URR 65%)—percent of adult patients at or above; in the live QIP measure set; payment reduction up to 2%. Source: MAT V629 plus V544; QIP PY2028 roster. The same sentence of 494.90(a)(1) carries the alternative for both floors—it is not a PD-only provision. [1 · 2 · 3]
  4. HD, best-practice minimum: 1.2—the guideline’s own floor. Source: KDOQI HD Adequacy 2015 Update. [4]
  5. HD, best-practice target: spKt/V 1.4—grade 1B; prescribe above the minimum to deliver it. Source: KDOQI HD Adequacy 2015 Update. [4]
  6. HD, this patient’s goal: 1.3—set in the plan of care, between floor and target, justified by measured residual kidney function. Illustrative. [1 · 4]
  7. PD, regulatory floor: weekly Kt/V 1.7 for adult patients. The regulation’s alternative is a CLINICAL STANDARD, not a chart entry, and one sentence carries it for BOTH floors: the dose must meet HD Kt/V 1.2 and PD weekly Kt/V 1.7, or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. Source: 42 CFR 494.90(a)(1) (Dose of dialysis); MAT V629 plus V544. Below 1.7 without an equivalent professionally-accepted standard: citation exposure. [1 · 2]
  8. PD, best-practice target: no single number. ISPD 2020 asks for high-quality, goal-directed PD—the target is the person: euvolemia, blood pressure, residual kidney function, symptom burden, trend. CMS still surveys the 1.7—the two ladders disagree, and the chart must carry the reconciliation. [5]
  9. PD, this patient’s goal: 1.5—below the regulatory floor, lawfully. NOT by documenting a rationale: 494.90(a)(1) permits an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis, and here that standard is the ISPD 2020 goal-directed frame, anchored on measured residual kidney function and clinical goals. Illustrative. [1 · 5]
  10. The patient goals on both panels (HD 1.3, PD 1.5) are declared illustrative examples inside verified mechanics—never real patients.

BRACKETED NUMBERS TRACE EACH LINE TO THE SOURCE LIST BELOW · EVERY SOURCE IS HELD IN THE REFERENCES LEDGER WITH ITS LOCATOR, ITS LAST-CHECKED DATE, AND HOW IT WAS VERIFIED