Quality measures that matter can help kidney community reimagine home dialysis
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The COVID-19 pandemic has changed how we approach health care in the United States in myriad ways, especially for vulnerable populations.
In highlighting the trust that patients place in their dialysis facilities to provide safe and effective care under these challenging circumstances, the pandemic provides a new context and a new opportunity to reevaluate longstanding approaches to measuring care quality and to encourage new methods and practices that aim to improve outcomes.
For the tens of millions of Americans living with kidney disease today, including approximately 800,000 people with kidney failure who depend on regular dialysis care or a kidney transplant, COVID-19 has been particularly concerning.
As the CDC has recognized, individuals with CKD, especially those requiring dialysis, are at high risk of poor outcomes with COVID-19. Healthy individuals who contract COVID-19 are also at risk of AKI from the virus.
This additional layer of risk adds urgency to finding ways to, where appropriate, bring more components of kidney care into the home. Not only is care in the home often preferred by the patient, it also offers kidney patients peace of mind, allowing them to maintain physical distance during these times of uncertainty while continuing to receive the care they need.
Transition to home care
Since the beginning of the pandemic, the kidney community has worked closely with policymakers at CMS, health officials and leaders to implement solutions that accelerate the transition to in-home care. These changes have expanded access to home-based services, such as telehealth and in-home laboratory testing, to make it easier for patients to choose home dialysis.
But improving patient access to care is just one piece of the puzzle. It is just as important to focus on the quality of care and to continue the community-wide shift to a patient-centered, quality-based approach to kidney care. This starts by rethinking the current ESRD Quality Incentive Program (QIP), a 10-year-old CMS initiative that uses a pay-for-performance approach to evaluate dialysis providers.
Individuals dependent on dialysis are medically complex, comprising a vulnerable patient population with multiple comorbid conditions at heightened risk for adverse events. These individuals are also more likely to be socioeconomically disadvantaged compared to the general population, with high levels of poverty and low levels of health literacy. However, the QIP more often penalizes the facilities caring for the patients that need additional resources the most.
The QIP has become cumbersome as additional clinical performance measures have been added. Providers must currently track 14 of these measures. A number of these do not meet the rigorous scientific criteria required by the National Quality Forum (NQF) for endorsement and are not necessary to provide patients and clinicians with reliable, valid information to make informed care decisions.
The use of “unendorsed” measures detracts from those who do meet NQF’s consensus-based criteria and are meaningful, statistically sound and community-supported. Leaders from across the broader kidney community recognize it is time to re-evaluate the current slate of measures and take a more patient-centered approach that focuses on a smaller set of “measures that matter.” Doing so will reinforce accountability for the specific actions dialysis facilities can take that truly improve patient outcomes.
Patient-reported outcomes
For example, kidney community advocates have, for years, raised concerns about the only patient-reported outcome measure in the QIP, the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey, which assesses patient experience. The daunting length of the current tool creates a real risk of survey fatigue, which is suspected to contribute to low response rates.
This issue has demonstrably compromised the validity of the survey and its use as a performance measure. Current response rates across the nation are less than 30%, with non-responders to the ICH-CAHPS more likely to be from historically underrepresented groups, dual Medicare/Medicaid eligible, and less educated patients, further highlighting disparities in kidney care assessment.
Similarly, recently published studies show the current bloodstream infection measure is not valid or reliable. It paradoxically gives high ratings to facilities that do not report bloodstream infections and lower ratings to those facilities monitoring and reporting infections as intended. This metric, which disincentivizes diligent tracking of infections, counters the tenets of safety and quality improvement. Only those facilities actively monitoring and evaluating bloodstream infections can take the necessary actions to reduce the infections.
We need to reconsider the QIP measures to ensure providers and CMS are accurately and equitably evaluating dialysis performance and using the QIP to deliver actionable improvements that honestly and meaningfully reflect patient experience. Furthermore, modifications to the program should focus on the measures that are most valid, robust, equitable and scientifically sound, ensuring the care processes and outcomes these measures assess are actionable and amenable to intervention.
New quality measures
The kidney care community is committed to improving care and the measures of quality in the QIP, beginning with identifying meaningful clinical domains for quality assessment. The Kidney Care Quality Alliance (KCQA), a nonprofit group of experts from across the kidney care spectrum, including patient and professional societies, kidney care providers, industry and academia are completing development of a paired set of home dialysis performance measures that assess care at the dialysis facility level. These measures are the product of a rigorous multistakeholder consensus process conducted this year and are consistent with the guiding principles of the KCQA, offering a patient-centric, equitable and actionable way to measure and advance the quality of home dialysis.
The goal of the proposed home dialysis measures is to grow successful, patient-centered home dialysis utilization by addressing both sides of the home dialysis equation: initiation and retention.
The home dialysis rate measure will assess prescription of home modalities, while the home dialysis retention measure will provide a counterbalancing effect to allow facilities and dialysis organizations to assess the success of their efforts to create a sustainable home program through proper investment in patient education, support and preparation for the transition home. The measure specifications are undergoing real-world empiric testing by leading kidney care providers in preparation for submission to the NQF for formal endorsement consideration.
KCQA is also developing dialysis facility-level transplant measures, and will be revisiting measures addressing anemia management, bloodstream infections and bone mineral metabolism in the future. We are committed to developing and refining measures that will improve care, highlighting that the QIP should include a parsimonious set of these measures targeting the greatest gaps in care delivery.
Change status quo
We know there is broad agreement among the kidney stakeholder community that the status quo of quality measurement must change – a sentiment that has been echoed by the independent Medicare Payment Advisory Committee to Congress since at least 2019 when it called for quality measurement to be “patient-oriented” and to use a “small set of population-based measures” to assess the quality of care.
KCQA continues its work to develop such measures – dialysis facility-level performance metrics that effectively meet the unique needs of dialysis patients, providers, the broader kidney care community and federal policymakers. These new proposed measures are no exception, and we will continue to build on the historical successes of the KCQA in developing meaningful kidney care measures to help define and refine the ESRD quality agenda.
COVID-19
COVID-19 has crystalized for us what matters most for patients on dialysis, their care partners and providers. It is not reporting mildly elevated serum calcium or even small molecule clearance; rather it is feeling safe and well cared for, staying out of the hospital and getting the most out of life. These new measures and a focus on fewer measures that matter most are just one component of a broader effort to improve the full spectrum of kidney care.
We are confident the kidney care community can achieve that vision by working collaboratively with CMS and policymakers to improve access to, and success with, home dialysis and transplant care for all Medicare beneficiaries with kidney failure.
- For more information:
- Mary Dittrich, MD, is the chief medical officer for U.S. Renal Care. She can be reached at mary.dittrich@usrenalcare.com.
- Daniel Weiner, MD, is an associate professor at Tufts University School of Medicine and past chair of the American Society of Nephrology Quality Committee. He can be reached at dweiner@tuftsmedicalcenter.org.
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