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Higher patient mortality rates at dialysis facilities with lower ESRD Quality Incentive Program scores
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Researchers of a published study found dialysis facilities with lower ESRD Quality Incentive Program performance scores had higher rates of patient mortality.
“In its most recent payment reform in 2011, CMS proposed an expanded bundle payment program,” Fozia Ajmal, MD, PhD, of the Arnold School of Public Health at the University of South Carolina, and colleagues wrote. “The reform proposed a fixed payment per dialysis treatment. Given that fixed payments could potentially result in lower quality of services, CMS implemented a Quality Incentive Program (QIP) as part of the bundle payment reform ... Because the QIP was implemented without a prior pilot study, the impact of the program on health outcomes is still unknown.”
Conducting a retrospective cohort study, researchers examined the association between quality of care received at United States dialysis facilities and outcomes (survival vs. mortality) for 84,493 patients. Quality of care was assessed based on QIP scores (scale of 0 to 100), including both clinical (eg, hemoglobin level, central venous catheter use and presence of an arteriovenous fistula) and reporting (anemia management, mineral metabolism, bloodstream infections and patient experiences) measures. Patients were followed for an average of 5 months. During this time, 11.8% died.
Noting that most facilities were affiliated with large chains and were for profit, researchers found those with QIP scores less than 45 (HR = 1.39) or 45 to less than 60 (HR – 1.21) had higher patient mortality rates than facilities with scores more than 90. Patients who were unemployed, retired, underweight, affected by two or more comorbid conditions or had a central venous catheter access were more likely to die, while patients who were black, Hispanic or who had obesity/overweight had lower risk for mortality.
“This study reports the association between QIP scores and patient survival in freestanding dialysis facilities using a nationally representative data set,” the researchers wrote. “Our analysis accounted for multilevel patient, facility and county factors. If confirmed, our findings have national nephrology practice and policy implications.”
In an accompanying editorial, authors Nupur Gupta, MD, and Jay Wish, MD, wrote the research by Ajmal and colleagues “is one of the first studies to road test the association of Medicare dialysis QIP measures with hard outcomes such as mortality.” Despite the limitations of the data, the research “is a stepping stone for future studies providing a more detailed categorization of individual components of the QIP score and their associations with patient survival, ideally with prospective collection of patient characteristics to minimize confounding.”
Gupta and Wish suggested the intent and the value of the QIP, now 8 years old, should be reassessed. “In general, it is necessary to reopen the discussion among stakeholders regarding the direction of the ESRD QIP,” they wrote. “The QIP measures have been criticized because they are primarily easy-to-obtain laboratory-based indicators that are not most important to patients and have a minimal effect on quality of life. Future research targeting the development of quality metrics should be based on patient-and caregiver-identified outcomes, rather than outcomes identified by payers and regulators, who have
different agendas … the most vulnerable patients will be hurt if providers attempt to manipulate their QIP score and payment because value-based purchasing motivates them to adopt certain behaviors by using inappropriately vetted or inadequately case-mix–adjusted metrics.” – by Melissa J. Webb and Mark E. Neumann
Disclosures: Wish reports advisory board/consultant activities for AstraZeneca, Akebia, Otuska, Vifor, Rockwell Medical and Zydus and serving in the speakers bureau for Akebia. Ajmal and Gupta report no relevant financial disclosures.
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