Can CMO agenda influence dialysis providers in improving quality?

Three years ago, the Chief Medical Officers from 13 dialysis providers (listed below) met to share common issues associated with patient outcomes and the patient experience with kidney failure. They shared both successes and areas where improvement was needed. From those initial meetings arose a commitment to share clinical and facility level approaches to procedures, protocols, and policies, even data. Since that time there have been three national meetings attended by the CMOs and their operational teams, plus monthly phone calls to discuss issues. Enormous collaboration has resulted from this collaboration.

This initiative lacks formal structure; it is sort of a "non-group” group. It has no leadership; all CMOs functioning equally, regardless of the size of the parent dialysis provider. Tom Parker III, MD, Doug Johnson, MD, Allen Nissenson, MD, and Frank Maddox coordinate the many activities and Parker, CMO of Renal Ventures Management before handing over these responsibilities recently to George Aronoff, MD, has served as a spokesperson, and helped to coordinate a series of CMO position papers in NN&I (see nephrologynews.com/cmo).

He brought the CMOs together in Nashville this past May to discuss strategic plans for the upcoming year, and shared some of the details with NN&I.

NN&I: What have consistently been the “hot button” issues for the CMOs over the last three years in efforts to improve quality? Like David Letterman, does the group have a “Top 10” list?

Parker: Thank you for the opportunity to partially tell the story of what concerns the CMOs the most. Clearly, there is a "list," but I won't run the risk of assigning priorities to the initiatives. The obvious ones are:

Continuing to emphasize permanent access over catheters, for incident and prevalent patients

Infection control, predominantly through discouraging catheters, buttonhole needle insertion except in very special situations, and avoiding use of antibiotics without specific protocols. We also need to improve staff––and especially physician––hygiene in the dialysis facility.

Improving nutritional status, with encouragement of protein and energy intake and foregoing the prior emphasis on restrictions. If there is to be restriction, the emphasis should be on sodium.

Emphasis on volume control, through lessening interdialytic weight gain and moving toward objective assessment of euvolemia vs. subjective determination of "dry weight."

Concern for "sudden death" as the predominant cause of mortality in dialysis patients and what part of this is actionable by changing dialysate composition, temperature, time on dialysis, ultrafiltration rates, and quantity of volume removal.

Offering optional therapies other than in-center dialysis, with emphasis on transplantation, peritoneal dialysis, and other home-based options.

NN&I: It can be difficult to assess how CMOs influence practice in the clinics; medical directors tend to get the most attention. You had a “get in the trenches” approach as CMO at Renal Ventures Management, but the CMO role in the provider community hasn’t been clear. Has this initiative helped to change that perspective?

Parker: The CMOs in our group see their position as one of determining the focus and direction of quality initiatives and patient care for their individual providers. Each does this a different way within their companies. The benefit of the CMOs collaborating to change outcomes is that we learn from one another––what works and doesn't work. Likewise, as an example, it is much easier for me to implement change in Renal Ventures if I know that other providers are doing the same and it is becoming the standard of practice.

Physicians change based on evidence and predominant practices. We are assessing the evidence and creating predominant practices. These CMOs represent over 80% of the patients undergoing dialysis in the U.S. If we agree that each of our providers, whom we represent, are trying to implement these changes, then others will follow.

NN&I: Some of the articles in the NN&I series and in other journals have focused on establishing baseline positions on common issues – increasing the number of patients on home dialysis, getting physicians to improve their hand hygiene, proper use of antibiotics, etc. But you have had some controversial position papers, like eliminating the buttonhole as a cannulation technique. Can you point to others?

Parker: The buttonhole did create some controversy, but data from the individual providers who have been the most successful in fully implementing the change shows a dramatic decrease in access infections.

However, the most controversial initiative has been our collaboration with Allan Collins and his Chronic Disease Research Group. The U.S. Renal Data System is a hugely successful and essential data source for the renal community. I can't imagine where we would be without the insights provided us through that resource. When the contract for the USRDS Coordinating Center went to the University of Michigan Kidney Epidemiology and Cost Center and the Arbor Research Collaborative for Health, it allowed the CMOs to approach Dr. Collins to determine if we could access data other than that provided by the USRDS. We wanted data that could be more contemporaneous, and if it could be more provider- and physician-specific. The concept that we termed––PEER––emerged (their initial report was recently published in the American Journal of Kidney Diseases).

There really are two paths for PEER.

1). How PEER can help the CMOs collectively, along with the individual dialysis providers, assess quality outcomes that are not available through USRDS or their individual data resources. How close to real-time data can we get?

2). How can we help the Centers for Medicare & Medicaid Services, the ESRD Networks, and other organizations identify trends that, if actionable, can really make a difference in patients' lives. Some reports we will make public, others will remain proprietary with the providers. More information on PEER is at peerkidney.org.

NN&I: The CMO group has had several meetings with various agencies within the CMS, and has acted as a resource to advocacy groups like the Kidney Care Council and Kidney Care Partners. Does this CMO Initiative have enough clout, in your view, to influence policy at CMS on quality improvement in the ESRD Program? Have you had some successes in that area?

Parker: That’s difficult to measure. Certainly the leadership of CMS has sought the counsel of the CMOs, has listened, and speaking collectively as a group has had more of an impact than we could have as individual providers, large or small, for profit or not for profit. Along with KCP, KCC, and other groups like the American Society of Nephrology, the Renal Physicians Association, the American Association of Kidney Patients, the National Kidney Foundation, and others, our voice is being heard.

So many changes are occurring within CMS, and these are manifest in programs such as the Five-Star Rating System and others. There are more Technical Expert Panels being organized, more public forums, and more input from outside organizations. This is a collective effort and the CMOs are acting as just one more resource to affect change. It is our desire to assure that the change affirmatively determines patients’ well-being and outcomes.

NN&I: What is on the agenda for the CMO group this coming year?

Parker: Home therapies, more ways to use PEER, volume control, depression and pain assessment, and follow-through on earlier initiatives. We’ll keep you informed.