Do current quality measures truly reflect the quality of dialysis?

Abstract

The US End Stage Renal Disease (ESRD) Program, which came into existence in 1973, was initially envisioned to provide needed financial coverage for about 50 000 patients through Medicare. Over the past 45 years the evolution of the ESRD program has been quite different, and it now serves over one half million dialysis and transplant patients. The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 Section 153(c) requires the Centers for Medicare and Medicaid Services (CMS) to develop and implement quality measures for dialysis patients as part of the ESRD Quality Incentive Program (QIP) beginning in payment year (PY) 2012. The annual ESRD Prospective Payment System (PPS) rulemaking process allows CMS to create ESRD QIP rules that specify the measures, scoring methods, and payment reduction ranges applicable to the respective PY. CMS assesses each facility's performance and calculates a score for each measure, according to the method detailed for that PY. Scores for each measure are combined to create the Total Performance Score (TPS) for each facility. If a facility's TPS does not meet or exceed the performance standards established during the earlier comparison period, the facility will incur a payment reduction of up to 2% for the entire PY. The QIP program has evolved over the several years since its inception. There have been deletions and additions of various measures. CMS uses additional measures in its Dialysis Facility Compare (DFC) website which is available to the public and forms the basis of the 5-star rating system for dialysis facilities. The evidence underlying inclusion many of these measures in the QIP and DFC remains an area of debate. In this review, we discuss the evolution of these measures and their appropriateness. We recommend that some of the current QIP and DFC measures should not be used for public reporting and/or payment as unintended consequences may occur. Nonetheless, all the current QIP and DFC measures and others are suitable for internal quality review.

Delivery of a patient-friendly functioning report to improve patient-centeredness of dialysis care: a pilot study

“…The lowest PPPC subscores we observed in this pilot were for “finding common ground,” further suggesting this may be the primary communication barrier to patient-centered care in this population. Future studies in this population may be improved with engagement of geriatricians or geriatric interprofessional teams as an alternative to engagement of nephrologists, who have been trained in a disease-oriented approach to care, which is further reinforced by required quality reporting that does not prioritize patient-centeredness [1, 2, 38].…”

Evaluating national trends in outcomes after implementation of a star rating system: Results from dialysis facility compare

“…[13][14][15] Some in the dialysis community have questioned the value of including the dialysis adequacy and hypercalcemia measures in public reporting and the star ratings because they are already at high levels of achievement and not as meaningful as outcomes like mortality and hospitalization. 10,11,16,17 24 In contrast, one study reported that the Hospital Compare star ratings were associated with a better experience of care, lower risk-adjusted mortality, and lower readmission rates. 25 Clearly there is a fair amount of variability within and across star rating programs, something that has been reported across the Hospital, Nursing…”

“…Dialysis adequacy and hypercalcemia are generally considered to be both more directly attributed to, and actionable by, dialysis facilities. 10,11 It is possible that facilities' efforts to improve on these measures, combined with the star rating weighting scheme, had the unintended consequence of focusing provider efforts on intermediate outcomes, which can be improved over the shorter term but may ultimately be less important to patients than primary outcomes like mortality, hospitalizations, or vascular access. In hindsight, the DFC star ratings might have been more impactful on improving these primary outcomes if proportionally greater weight had been assigned to Domains 1 and 2.…”

Are Dialysis Facility Quality Incentive Program Scores Associated With Patient Survival?

“…Although metrics such as hemoglobin and Kt/V are simple to measure, it is becoming more evident patients do not care about laboratory values as much as they do about quality-of-life outcomes. 11 However, although criteria such as mortality, hospitalization, and quality of life are important to patients, using them as metrics for payment and public reporting is problematic because of attribution and appropriate case-mix adjustment issues.…”