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CLINICAL RESEARCH www.jasn.org
Measuring Quality in Kidney Care: An Evaluation ofExisting Quality Metrics and Approach to FacilitatingImprovements in Care Delivery
Mallika L. Mendu,1 Sri Lekha Tummalapalli,2 Krista L. Lentine,3 Kevin F. Erickson ,4
Susie Q. Lew,5 Frank Liu,6,7 Edward Gould,8 Michael Somers,9 Pranav S. Garimella ,10
Terrence O’Neil,11 David L. White,12 Rachel Meyer,12 Scott D. Bieber,13 andDaniel E. Weiner14
Due to the number of contributing authors, the affiliations are listed at the end of this article.
ABSTRACTBackground Leveraging quality metrics can be a powerful approach to identify substantial performancegaps in kidney disease care that affect patient outcomes. However,metricsmust bemeaningful, evidence-based, attributable, and feasible to improve care delivery. As members of the American Society ofNephrology Quality Committee, we evaluated existing kidney quality metrics and provide a frameworkfor quality measurement to guide clinicians and policy makers.
Methods We compiled a comprehensive list of national kidney quality metrics from multiple establishedkidney and quality organizations. To assess themeasures’ validity, we conducted two rounds of structuredmetric evaluation, on the basis of the American College of Physicians criteria: importance, appropriatecare, clinical evidence base, clarity of measure specifications, and feasibility and applicability.
Results We included 60 quality metrics, including seven for CKD prevention, two for slowing CKD pro-gression, two for CKD management, one for advanced CKD and kidney replacement planning, 28 fordialysis management, 18 for broad measures, and two patient-reported outcome measures. We deter-mined that on the basis of defined criteria, 29 (49%) of themetrics have high validity, 23 (38%) havemediumvalidity, and eight (13%) have low validity.
Conclusions We rated less than half of kidney disease quality metrics as highly valid; the others fell shortbecause of unclear attribution, inadequate definitions and risk adjustment, or discordance with recentevidence. Nearly half of the metrics were related to dialysis management, compared with only onemetric related to kidney replacement planning and two related to patient-reported outcomes. We ad-vocate refining existingmeasures and developing newmetrics that better reflect the spectrum of kidneycare delivery.
JASN 31: 602–614, 2020. doi: https://doi.org/10.1681/ASN.2019090869
Over the past two decades, there has been increasednational emphasis on encouraging patient-centered,high-quality, and high-value health care delivery.1
In kidney care, the Medicare Improvements forPatients and Providers Act of 2008 mandated thefirst pay-for-performance system in Medicare,which was reinforced in subsequent laws, includingthe 2010 Affordable Care Act and the 2015 Medi-care Access and CHIP Reauthorization Act. Tradi-tionally, health care quality has been monitored by
Received September 2, 2019. Accepted November 25, 2019.
M.L.M. and S.L.T. contributed equally to this work.
Published online ahead of print. Publication date available atwww.jasn.org.
Correspondence: Dr. Mallika L. Mendu, Division of Renal Med-icine, Brigham and Women’s Hospital, 75 Francis Street, MRB-4,Boston, MA 02115. Email: mmendu@bwh.harvard.edu
Copyright © 2020 by the American Society of Nephrology
602 ISSN : 1046-6673/3103-602 JASN 31: 602–614, 2020
self-regulated credentialing, with oversight by credentialingorganizations and, in some instances, market forces.
Health policy experts have argued for a shift from self-regulation, which is marked by variation in care and financialincentives to increase the quantity of care, to accountabilityand integration, marked by incentives to provide better qual-ity rather than more care. To enable this transition to pay-for-performance, assessment and quantification of measures ofquality are critical.2 Yet, how to best define and measure qual-ity remains debated and is challenged by a proliferation ofquality measures that vary in relevance, validity, and align-ment with meaningful patient outcomes.2,3
CKD represents a significant public health problem, affect-ing 14% of adults in the United States, with some sociodemo-graphic groups suffering from particularly high diseaseburden.4,5 CKD and its associated comorbid conditions areassociated with high mortality and frequent complications.4,5
Kidney failure is associated with higher mortality than mostadvanced cancers, and incurs .$35 billion dollars in annualMedicare expenditures.4 Suboptimal outcomes for individualswith CKD result, in part, from gaps in care.4,6 Almost 50% ofpatients who receive dialysis are not seen by a nephrologistbefore initiation of kidney replacement therapy, and one thirdreceive little or no education regarding dialysis modalitychoice.5,7 In the United States in 2016, only 10% of incidentkidney failure patients initiated kidney replacement therapywith home dialysis and,3% with a preemptive kidney trans-plant.4 Among incident patients on hemodialysis, only 20%initiated dialysis with an arteriovenous fistula (AVF) or arte-riovenous graft, compared with 80% starting with a centralvenous catheter.4 These data demonstrate substantial perfor-mance gaps in CKD care. Leveraging quality metrics to im-prove care delivery for all individuals with kidney diseasecould be a potentially powerful approach to affect patient out-comes. However, metrics must be meaningful, clearly defined,evidence-based, appropriately attributed and risk-adjusted,and feasible to be utilized by nephrologists to truly improvethe care of patients with kidney disease.
The ESRD Quality Incentive Program (QIP), launched in2012 by the Centers for Medicare and Medicaid Services(CMS), evaluates dialysis facility performance, expandingover the past decade from three metrics to 13 metrics in2020.8 The ESRD QIP highlights many of the strengths andlimitations of quality metrics: benefits related to improvedperformance on clinical outcome metrics, such as vascularaccess type where a considerable performance gap existed;and risks related to “cherry-picking” and less ability to indi-vidualize care. Risks can be amplified when evaluating rela-tively small populations, as one or two patients can havea dramatic effect on overall dialysis facility performance.
In contrast with the relative homogeneity in structural as-pects of dialysis care delivery that facilitates development offacility-level metrics, nephrologists have diverse practices, rang-ing from office-based clinics for CKD and hypertension, to di-alysis clinics, to hospital consultation for AKI, acid-base
disorders, and electrolyte derangements, to the care of kidneytransplant candidates and recipients. This combination of epi-sodic and longitudinal care makes development of paymentmodels challenging, particularly when determining attribution.
This article, mirroringmethods from the American Collegeof Physicians (ACP) for evaluating measures that may be rele-vant to the Merit-based Incentive Payment System/QualityPayment Program, reports on the independent evaluation ofexisting quality metrics by themembers of the American Societyof Nephrology (ASN)Quality Committee. The aim is to identifywhether existing measures for physicians can effectively addressand guide quality improvement in the care of patients with kid-ney disease. Notably, many metrics are shaped by CMS, eitherdirectly, with CMS acting as a measure steward, or indirectly,with CMS selecting existing measures for inclusion in qualityprograms and then adapting them for use in these programs.
The ACP recently called for a “time out” with respect todeveloping and utilizing existing national health care qualitymetrics.9 The Performance Measurement Committee of theACP found only 37% of national value-based purchasing meas-ures to be valid, whereas 28% were of uncertain validity. Otherauthors have cautioned about the unintended consequences ofimplementing quality metrics, namely overtesting, overmedica-tion, inappropriate classification of patients for denominatorcapture, and distraction from patients’ needs.10 We apply ACPcriteria to evaluate the validity of national kidney disease qualitymetrics, and assess the scope and unintended consequences ofthe measures. Although many of the metrics are not in the pri-mary domain of the nephrologist, we provide a framework ofhow to approach quality measurement in kidney diseasemovingforward, to guide policy makers and clinicians about how todesign, implement, and use measures to guide practice to im-prove kidney patient outcomes.
METHODS
Evaluation of Existing Kidney Disease Quality MetricsWe compiled a comprehensive list of quality measures relatedto kidney disease frommultiple established kidney and quality
Significance Statement
Leveraging quality metrics can be a powerful approach to improvepatient outcomes. However, the validity of existing kidney-relatedquality metrics is unknown. To identify whether existing measurescan effectively address and guide quality improvement in care ofpatients with kidney disease, the American Society of Nephrology’sQuality Committee performed a systematic compilation and eval-uation of national kidney metrics. They identified 60 metrics, ratingonly 29 as highly valid and the other 31metrics as of medium to lowvalidity, on the basis of defined criteria. Almost half of themeasureswere related to dialysis management, compared with only onemetric related to kidney replacement planning and two related topatient-reported outcomes. The authors urge refinement of exist-ing quality metrics and development of new measures that betterreflect kidney care delivery.
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metric organizations: Renal Physician Association (RPA),11
National Quality Forum (NQF),12 Healthcare EffectivenessData and Information Set (HEDIS),13 Merit-based IncentivePayment System,14 and CMS QIP.15 Quality metrics were in-cluded if they met the following criteria: (1) had defined nu-merator, denominator, and exclusion criteria; (2) werephysician-directed measures relevant to the care of kidneydisease patients or were classified as a kidney disease metricby the organization; and (3) were published or endorsed by anorganization recognized nationally for quality metrics, as op-posed to single health system or organization-specific metrics.We did not include clinical practice guidelines without spec-ified numerator and denominator parameters. We organizedthese metrics on the basis of applicability across the spectrumof kidney disease care delivery: CKD prevention, slowing CKDprogression, CKD management, advanced CKD and kidneyreplacement planning, and dialysis management.We also clas-sified broad measures as applying across the spectrum ofkidney disease care and metrics that were patient reportedoutcome measures (PROMs).
Ratings were completed similar to the approach outlined bythe ACP Performance Measurement Committee, utilizing theRAND Corporation/University of California, Los Angeles(UCLA) method of evaluating a medical intervention. Asa part of their effort to review existing performance measures,the Performance Measurement Committee of the ACP devel-oped and applied five criteria to evaluate measures included inthe Quality Payment Program (Supplemental Table 1):
1. Importance: The metric will lead to measurable andmeaningful improvement in clinical outcome or there is anopportunity for improvement.
2. Appropriate care: The metric will stem overuse or under-use of a test or treatment.
3. Clinical evidence base: The metric is on the basis of high-quality and high-quantity evidence, and has consistent datarepresenting clinical knowledge.
4. Measure specifications: The metric has clarity (a clearlydefined numerator and denominator), validity, reliability,and appropriate risk adjustment.
5. Feasibility and applicability: The metric is under the in-fluence of the individual or entity being assessed, attribu-tion level is appropriate, data collection is feasible andburden acceptable, and results will help improve care.
ACP criteria as well as consideration of unintended conse-quences were applied to all measures to evaluate validity.9
Validity is defined by this methodology as “the measure iscorrectly assessing what it is designed to measure, adequatelydistinguishing good and poor quality.”9,16 Two rounds of met-ric evaluation were conducted by 11 members of the ASN
Quality Committee (authors M.L.M., S.L.T., K.L.L., K.E.,S.Q.L., F.L., E.G., M.S., P.S.G., T.O.N., and S.D.B.). In the firstround, members evaluated the measures independently inspring of 2019; the second round of ratings was conductedduring an in-person meeting in July 2019, using a formalgroup process, with a senior committee member (D.E.W.)serving as moderator. After a group discussion of each measure,members provided an individual score from 1 to 9 for each ACPdomain, and a separate high/medium/low categorical rating. Theoverall metric ratings were unchanged from round one to two,and there was strong correlation between domain criteria ratingsand overall ratings (see Supplemental Figure 1). Intraclass corre-lation coefficients (ICCs) showed a moderate correlation amongoverall ratings (ICC50.68) and ACP domain ratings (ICC range:0.59–0.82) (see Supplemental Figure 2 and SupplementalTable 2). Individual comments were collected from the firstround of ratings, and group comments were collected fromthe second round. After the individual metrics were rated forvalidity, a subset of the committee (M.L.M., S.L.T., D.E.W.,and S.D.B.) organized them into subcategories and globallyassessed the scope and attribution of the metrics. Please seeSupplemental Appendix 1 for additional methods.
RESULTS
Figure 1, Table 1, and Supplemental Tables 3a–g summarizesthe 60 metrics included in the following categories: CKD pre-vention (seven metrics), slowing CKD progression (two met-rics), CKD management (two metrics), advanced CKD andkidney replacement planning (one metric), dialysis manage-ment (28 metrics), broad measures (18 metrics), and PROMs(two metrics). With respect to validity, 49% of metrics weredetermined to have high validity, 38% were determined tohave medium validity, and 13% were determined to havelow validity, on the basis of defined criteria. Three commonthemes affecting validity emerged. First, there was unclear at-tribution of many metrics to nephrology (i.e., successful AVFthrombectomies, a procedure not typically performed by non-interventional nephrologists) or unclear delineation from pri-mary care (i.e., comprehensive management of diabetes).Eighteen metrics were determined to not be attributable tonephrologists, of which ten were related to primary care andeight were applicable to other specialties. The second themewas the need for improvedmetric definition, particularly relatedto exclusion criteria and risk adjustment. The third theme wasnonevidence-based metrics, not reflective of the latest evidenceor guidelines. Metrics are discussed in further detail below.
CKD PreventionThere were sevenmetrics in the CKDprevention section: threewere related to hypertension and four were related to diabe-tes. The NQF 0018 controlling high BP metric, defined aspatients aged 18–85 years who had a diagnosis of hyperten-sion and whose BP was controlled ,140/90 mm Hg during
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the measurement period, was rated as having high validity;although there was discussion about the need for home BPrecordings, lack of applicability to dialysis, and target goal inlight of SPRINT findings. The HEDIS controlling high BPmetric was rated as having medium validity, primarily be-cause of its recommendation of a BP target of ,150/90 mmHg in patients aged 60–85 years, which does not reflectmore recent American College of Cardiology/AmericanHeart Association guidelines. Four metrics were diabetes-centric, involving glycated hemoglobin control, LDL control,comprehensive diabetes care, and the need for “medical at-tention for nephropathy,” which refers to urine albuminmeasurement and use of angiotensin-converting enzyme in-hibitor or angiotensin receptor blocker therapy. Two of thediabetes metrics were considered to be primary care physi-cian–directed, rather than nephrologist-directed, and wererated as having medium validity. The HEDIS comprehensivediabetes care metric was thought to be the most comprehen-sive, but delineation of responsibilities was unclear and a spe-cific exclusion for patients with kidney failure is needed,given lack of evidence-based BP targets and potential unre-liability of glycated hemoglobin in the population.
Slowing CKD ProgressionOnly two metrics addressed slowing CKD progression. NQF1662, which counts adults with a diagnosis of nondialysisCKD and proteinuria who are prescribed angiotensin-converting enzyme inhibitor or angiotensin receptor blockertherapy within a 12-month period, was thought to have highvalidity, although there were safety concerns regarding hyper-kalemia. Similarly, RPA measure 122, which counts adultswith CKD stages 3–5 who are not receiving kidney replace-ment therapy and either have BP ,140/90 mm Hg orBP $140/90 mm Hg with a documented plan of care, was
considered to have high validity, although concerns wereraised about nondialysis patients with advanced CKD andappropriate BP targets.
CKD ManagementOnly two metrics were related to management of a patientwith CKD, not specifically to slow progression: (1) an ad-vanced directive completed in adults and (2) lipid profile mea-surement. The advanced directive measure received a highvalidity score, highlighting the importance of end-of-lifecare planning, but concerns were raised about documentationburden and applicability to patients aged 18–65 years withoutother chronic illnesses. The lipid profile measure receiveda medium validity score as concerns were raised regardingovertesting in patients already on lipid-lowering therapiesand overlap with primary care physician managementresponsibilities.
Advanced CKD and Kidney Replacement PlanningThe NQF 2594 optimal ESKD starts measure was the onlymetric specifically addressing advanced CKD and kidney re-placement planning. The measure captures the percentage ofpatients with a preemptive kidney transplant, home dialysisinitiation, or outpatient in-center hemodialysis via AVF orarteriovenous graft. The measure was rated as having highvalidity. Committee discussion centered on the importanceof having an evidence-based target given potential patientnonadherence, accelerated progression to kidney failure,and lack of timely nephrology referral. Most committeemem-bers felt that this metric was a step in the right direction,particularly considering the Advancing American KidneyHealth Initiative by Health and Human Services and theCenters for Medicare and Medicaid Innovation kidney caremodels.17 These mandatory and optional models emphasize
Category (# of Measures)
Hypertension, Diabetes
Hypertension/CKD
Advance Care Planning, Lipid Testing
Dialysis Access
Dialysis Access, Adequacy, Anemia, ESRD-related Complications, Transplant Referral,Advance Care Planning, Care Coordination
Preventive Care, Medication Reconciliationand Safety, Advance Care Planning, Falls,Complications/Misc.
PROMs
Subcategories Measure Validity Rating
2
2
1 10
10
17
8 4
7 4
6
0 02
5 0
0
High Medium Low
CKD Prevention (7)
Slowing CKD Progression (2)
CKD Management (2)
Dialysis Management (28)
Broad Measures (18)
PROMs (2)
Advanced CKD/KidneyReplacement (1)
Figure 1. Measure validity ratings for national kidney disease quality metrics. This figure reports a summary of national kidney diseasequality metrics, including the number of measures per category, measure subcategories, and overall measure validity ratings utilizingAmerican College of Physicians-specified criteria. 49% of metrics were determined to have high validity, 38% had medium validity, and13% had low validity.
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Table
1.Eva
luationof
existing
kidne
yqua
litymea
sures
MeasureCategory
(No.o
fMea
sures)
Mea
sure
Title
RPA/N
QF/MIPS/Q
IPACP1:
Importan
ce
ACP2:
Appropriaten
ess
ACP3:
Clin
ical
eviden
ce
ACP4:
Specifica
tions
ACP5:
Feasibility
Ove
rall
Measure
Validity
Rating
Rationa
le
CKD
preve
ntion(7)
Hyp
ertension
Con
trollin
gHighBP
NQF00
181
11
11
HIG
HBPgoa
lspoten
tially
lower
,13
0/80
mm
Hgon
thebasisof
theACC/A
HAguideline.
Prev
entiv
eCarean
d
Screen
ing:S
cree
ning
for
HighBPan
dFo
llow-Up
Doc
umen
ted
MIPS31
71
11
11
HIG
HWella
ccep
tedpartof
high-qua
litypatient
care,b
utmay
bealread
yun
iversally
practiced
.
Not
clea
rwha
tcon
stitu
tesareco
mmen
ded
follo
w-upplan,
somay
adddoc
umen
tatio
nburden
with
outmea
ning
fully
improving
clinical
care.
HED
ISCon
trollin
gHighBP
16
—6
1MED
Maske
dHTN
andwhite
coat
HTN
areno
taccou
nted
for.Non
rigorous
office
BPmea
suremen
t
may
notbevalid
orrelia
ble.
Doe
sno
tinc
orporateho
meBPor
ABPM
.Sittingve
rsus
stan
dingan
dmea
suremen
ttec
hnique
is
importan
tto
spec
ify.
Diabetes
Diabetes:H
emog
lobin
A1c
Poor
Con
trol
NQF00
59MIPS
001
11
16
—MED
Important
forkidne
you
tcomes,b
uttypicallytheprim
aryresp
onsibility
ofPC
Por
endocrinologist.
Con
sider
adjustmen
tfor
patient
factors.
Diabetes:L
DL-CCon
trol
(,10
0mg/dl)
NQF00
641
6—
1—
MED
New
erev
iden
cean
dguidelines
reco
mmen
dthat
man
agem
ents
houldbeindep
enden
tof
cholesterollev
els.
Patie
ntson
dialysisshou
ldbeex
clud
edfrom
den
ominator.
HED
IS-C
omprehe
nsive
Diabetes
Carea
NQF07
311
11
6—
MED
Shou
ldbedom
inan
tresp
onsibility
ofPC
Por
endocrinologist.
BPgoa
lsun
certainafterrece
ntACC/A
HAguideline.
Con
sider
exclusionford
ialysispatients,as
HbA1c
notrelia
ble
andBPgoa
lisun
clea
r.
Diabetes:M
edical
Atten
tion
forN
ephrop
athy
a
NQF00
62MIPS
119
11
16
6MED
American
Diabetes
Assoc
iatio
nguidelines
reco
mmen
dbotheG
FRan
dUACRtesting.
ACE-I/ARB
useshou
ldno
tco
untas
screen
ingforne
phrop
athy
.
SlowingCKD
progression(2)
Hyp
ertension
AdultKidne
yDisea
se:B
P
Man
agem
ent
MIPS12
21
11
11
HIG
HVeryim
portan
tmetric
asaprim
aryfactor
affectingCVD
even
tsan
dmortality.
Goa
lof,
140/90
mm
Hgno
treflec
tiveof
morerece
ntACC/A
HAguidelines,rec
ommen
ding
,13
0/80
mm
Hg.
Hyp
ertension/CKD
Ang
iotensin
Con
verting
Enzyme(ACE)
Inhibito
ror
Ang
iotensin
Rece
ptor
Blocker
(ARB)T
herapy
AKID
-21
11
66
HIG
HStrong
eviden
ce.D
oesno
tspec
ifyqua
ntity
ofproteinuria.M
aycausehy
perkalemia
and/or
crea
tinineelev
ation;
requiresmon
itorin
g.
CKD
man
agem
ent(2)
Advanc
ecare
plann
ing
Adva
nceDire
ctives
Com
pleted
RPAQIR18
11
11
1HIG
HIm
portant
parto
fhigh-qua
litycare.
Unc
lear
need
inyo
ungpatientswith
mild
CKD.W
ould
favo
rattrib
utingto
nephrolog
isto
nlyfor
CKD
stag
es4an
d5.
Lipid
testing
AdultKidne
yDisea
se:
LaboratoryTe
sting(Lipid
Profi
le)
NQF16
686
66
66
MED
Che
ckinglip
idpan
elsmay
notaffect
man
agem
entifstatin
sareindicated
irrespec
tiveof
LDL
leve
l(20
13KDIG
OLipid
Man
agem
entG
uidelinereco
mmen
dsstatin
usein
allp
ersons
with
CKD
age$50
years).T
estin
gno
tnec
essary
every12
mo.
Adva
nced
CKD
andkidne
yreplace
men
tplann
ing(1)
Dialysisacce
ssOptim
alES
KD
Starts
NQF25
941
11
11
HIG
HCurrent
catheter
rate
atHDstartisex
trem
elyhigh,
increa
sing
theris
kof
blood
stream
infections.
Thismetric
isall-e
ncompassing
towardim
proving
qua
lityof
initiationof
dialysiscare.
Nee
dsap
propria
teriskad
justmen
t.
Veryap
plicab
leto
newpaymen
tmod
els.
606 JASN JASN 31: 602–614, 2020
CLINICAL RESEARCH www.jasn.org
Table
1.Con
tinu
ed
MeasureCategory
(No.o
fMea
sures)
Mea
sure
Title
RPA/N
QF/MIPS/Q
IPACP1:
Importan
ce
ACP2:
Appropriaten
ess
ACP3:
Clin
ical
eviden
ce
ACP4:
Specifica
tions
ACP5:
Feasibility
Ove
rall
Measure
Validity
Rating
Rationa
le
Dialysisman
agem
ent(28
)
Dialysisacce
ssAdultKidne
yDisea
se:
Cathe
terU
sefor$90
D
MIPS33
01
11
11
HIG
HIm
portant
ascatheterscauseblood
stream
infections
andareasso
ciated
with
increa
sed
mortality,
andcu
rren
tlylargeperform
ance
gap
.
Den
ominator
appropria
tely
exclud
esforp
atientswho
malong
-term
vascular
acce
ssisno
t
appropria
te(e.g.,elderly,imminen
ttransplantation)
andpatientsthat
dec
lineAVG/A
VF.
Vascu
larAccessTy
pe(VAT)
Mea
sure
Topic–Cathe
ter
.90
DClin
ical
Mea
sure
NQF02
56QIP
11
11
1HIG
HDen
ominator
doe
sno
tinc
ludeex
clusions
forpatientswho
malong
-term
fistulaor
graftisno
t
appropria
te.
Metric
enco
urag
esproce
dures
which
may
notb
ein
linewith
patient
goa
ls.
Vascu
larAccess—
Func
tiona
l
Arteriove
nous
Fistula
(AVF)
orAVGraftor
Evalua
tionforP
lace
men
t
NQF02
511
11
11
HIG
HMostdetailedvascular
acce
ssmetric
that
acco
unts
ford
ifferen
tsce
nario
s.
Ann
uala
ssessm
entmay
notbene
cessaryforlong
-term
catheter
use.
AdultKidne
yDisea
se:
Cathe
terU
seat
Initiation
ofHem
odialysis
MIPS32
91
11
11
HIG
HAttrib
utab
leto
providersdeliveringcare
beforedialysisinitiation,
ifseen
byane
phrolog
ist.
Nee
dsap
propria
teriskad
justmen
t.
Arteriove
nous
FistulaRa
teAKID
-81
11
11
MED
Important
metric
andad
dresses
relevant
perform
ance
gap
.
Nee
dsad
equa
tead
justmen
tfor
patient
factors.
Shou
ldsupportcare
individua
lizationan
dshared
dec
ision-making.
Vascu
larAccessTy
pe(VAT)
Mea
sure
Topic–
Arteriove
nous
Fistula
(AVF)
Clin
ical
Mea
sure
NQF02
57QIP
11
16
1MED
Supported
byev
iden
cean
dthereisaperform
ance
gap
,but
itmay
notb
ethebesto
ptio
nfora
ll
patients.
Nee
dsto
adeq
uatelyacco
untforpatient-related
factors
andacce
ssto
vascular
surgery.
Shou
ldsupportrole
forp
atient
individua
lizationan
dshared
dec
ision-making.
Periton
ealD
ialysisCathe
ter
ExitSite
InfectionRa
te
RPAQIR17
11
11
6HIG
HMea
sure
ofPD
catheter
complicationisim
portant
forh
igh-qua
litycare,b
utisno
tattrib
utab
leto
thene
phrolog
ist.
Periton
ealD
ialysisCathe
ter
SuccessRa
teb
RPAQIR16
11
66
—LO
WNot
appropria
telyattributed
tone
phrologist.Defi
nitio
nof
successful
isno
tclear,soreportin
g
may
besubjective.
ArterialC
omplicationRa
te
Follo
wingArteriove
nous
AccessInterven
tionb
RPAQIR12
11
6—
—LO
WUnc
lear
howco
mplications
willbeiden
tified
anddefi
ned.N
otap
propria
telyattributed
to
nephrolog
ist,un
less
interven
tiona
lnep
hrolog
y.Interven
tiona
lists
may
dec
rease
interven
tionrate
ordec
reasereportin
gof
complications.
Arteriove
nous
Fistulae
Thrombec
tomySu
ccess
Rate
b
RPAQIR15
16
66
—LO
WNot
appropria
telyattributed
tone
phrologist,un
less
interven
tiona
lnep
hrolog
y.Th
rombec
tomy
successmay
berelatedto
underlyingpatient
factorsrather
than
qua
lityof
the
interven
tiona
list.May
resultin
moreab
andon
edfistulas.
Arteriove
nous
Graft
Thrombec
tomySu
ccess
Rate
b
RPAQIR14
16
66
—LO
WNot
appropria
telyattributed
tone
phrolog
ist,un
less
interven
tiona
lnep
hrolog
y.Cou
ldresultin
faster
referralsof
clottedgraftsbut
may
resultin
moreab
andon
edgrafts.
JASN 31: 602–614, 2020 Measuring Quality in Kidney Care 607
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Table
1.Con
tinu
ed
MeasureCategory
(No.o
fMea
sures)
Mea
sure
Title
RPA/N
QF/MIPS/Q
IPACP1:
Importan
ce
ACP2:
Appropriaten
ess
ACP3:
Clin
ical
eviden
ce
ACP4:
Specifica
tions
ACP5:
Feasibility
Ove
rall
Measure
Validity
Rating
Rationa
le
Adeq
uacy
AdultKidne
yDisea
se:
Hem
odialysisAdeq
uacy:
Solute
NQF03
231
11
11
HIG
HCertainselect
situations
whe
ncare
individua
lized
fora
given
patient
may
resultinKt/V,1.2.
No
inclusionof
residua
lkidne
yfunc
tion;
fore
xample,the
considerationof
increm
entald
ialysis.
Mea
sure
likelytopped
outan
dso
less
mea
ning
ful.
Kt/VDialysisAdeq
uacy
Com
prehe
nsiveClin
ical
Mea
sure
QIP
11
11
1HIG
HMoreco
mprehe
nsivemea
sure
than
othe
rad
equa
cymea
sures.Certain
select
situations
whe
n
care
individua
lized
fora
given
patient
may
resultin
Kt/Vlower
than
thesethresholds.May
disad
vantag
ePD
facilities.
AdultKidne
yDisea
se:
Periton
ealD
ialysis
Adeq
uacy:S
olute
NQF03
211
16
11
HIG
HGen
erallyacce
ptedas
stan
dardof
practicebut
noclinical
triale
viden
cebase.
Targetingawee
klyKt/Vof
1.7with
out
room
forindividua
lizationmay
lead
toco
nversion
to
hemodialysis.
Adeq
uacy
ofVolum
e
Man
agem
ent
AKID
-41
1—
—6
MED
Nostan
dardized
defi
nitio
nof
volumeassessmen
t.La
ckof
strong
supportingev
iden
ce.L
ikely
alread
yassessed
inpatientson
dialysis.
Pediatric
Kidne
yDisea
se:
Adeq
uacy
ofVolum
e
Man
agem
ent
MIPS32
71
1—
—1
MED
Given
alack
ofstrong
supportin
gev
iden
ce,m
ayposedoc
umen
tatio
nan
dmon
itorin
gburden
with
outsubstan
tialp
atient
ben
efit.
Ane
mia
ESKD
Patie
ntsRe
ceiving
Dialysis:Hem
oglobin
Leve
l,9g/dl
AKID
-61
11
11
HIG
HIm
portant
QOLmea
sure.
May
pen
alizedialysisfacilitieswith
patientswho
arefreq
uentlyad
mitted
andmissES
Adosing.
Ane
mia
Man
agem
ent
Reportin
gMea
sure
QIP
11
11
1HIG
HIm
portant
inform
ationto
track,but
notc
lear
that
thisinform
ationwillim
pac
torimprove
patient
care.
Doe
sno
tacco
untfor
ironad
ministration.
Stan
dardized
Tran
sfusion
Ratio
(STrR)C
linical
Mea
sure
QIP
11
16
6HIG
HTran
sfusionavoidan
ceim
portan
t.Sh
ould
mon
itorfor
anem
iaas
abalan
cemea
sure.C
onve
rsely
theremay
beince
ntiveto
overtrea
twith
ESAswhe
nno
tclinicallyindicated
.
Pediatric
Kidne
yDisea
se:
ESKD
Patie
ntsRe
ceiving
DialysisHem
oglobin
Leve
l
,10
g/dl
NQF16
67MIPS
328
11
11
1HIG
HIm
portant
forq
ualityof
life,
andgoo
dev
iden
ceforthishe
moglobin
thresholdinped
iatrics.May
notbemet
bypatientswho
arefreq
uentlyad
mitted
toho
spita
l.
ESKD-related
complications
Mineral
Metab
olism
Reportin
gMea
sure
NQF02
55QIP
11
11
1HIG
HRo
utinelyassessed
bydialysisfacilities,so
likelytopped
out.
Stan
dardized
Read
mission
Ratio
(SRR
)Clin
ical
Mea
sure
NQF24
96QIP
11
11
1HIG
HAccep
tedqua
litymetric
andince
ntivizes
toim
prove
care
coordination.
Read
mission
highin
ESKD
pop
ulationso
addresses
alargeperform
ance
gap
.
Read
mission
sto
theho
spita
linpatientswith
ESKD
areoftenun
relatedto
theindex
admission
andphy
sician
sor
facilitiesmay
have
limite
dco
ntrol.Re
quiresad
equa
teriskad
justmen
tfor
social
factors.
Avo
idan
ceof
Utilizationof
HighUltrafi
ltrationRa
te
($13
ml/kg
per
hour)
NQF27
011
11
11
HIG
HGoo
dob
servationa
ldataev
iden
cebaseform
etric
.Diffi
cultto
implemen
tinpracticebec
ause
it
isea
sier
toincrea
setheultrafi
ltrationrate
rather
than
extend
trea
tmen
ttim
e(lo
gistic
allyan
d
patient
preferenc
e).
InfectionMon
itorin
g:
Nationa
lHea
lthcare
Safety
Network
(NHSN
)
Blood
stream
Infectionin
Hem
odialysisPa
tients
Clin
ical
Mea
sure
NQF14
60QIP
11
16
6MED
Blood
stream
infectionrate
important
parto
fhem
odialysiscare
andmod
ifiab
leon
thebasisof
dialysisun
itpractices.
May
enco
urag
eun
derch
ecking
ofblood
cultu
res.Se
lf-reportedmetric
marke
dlylim
its
effectiven
ess.
Diffi
cultto
differen
tiate
dialysisve
rsus
nond
ialysis-relatedinfections.
608 JASN JASN 31: 602–614, 2020
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Table
1.Con
tinu
ed
MeasureCategory
(No.o
fMea
sures)
Mea
sure
Title
RPA/N
QF/MIPS/Q
IPACP1:
Importan
ce
ACP2:
Appropriaten
ess
ACP3:
Clin
ical
eviden
ce
ACP4:
Specifica
tions
ACP5:
Feasibility
Ove
rall
Measure
Validity
Rating
Rationa
le
Tran
splant
referral,
care
coordination,
advanc
ecare
plann
ing
Tran
splant
Referral
AKID
-13
11
16
1HIG
HIm
portant
mea
sure
forh
igh-qua
lityES
KD
care.S
omeriskof
increa
sing
inap
propria
tereferrals.
May
disad
vantag
eun
itsservingpop
ulations
with
moremed
ical
andsocial
riskfactors.
Requiresriskad
justmen
t.
AdultKidne
yDisea
se:
Referral
toHospice
MIPS40
31
16
61
MED
Hospicecare
may
notb
eap
propria
teforev
eryindividua
latthe
endof
life.
Lownu
mber
of
patientsforthismea
sure.
Rate
ofTimely
Doc
umen
tatio
n
Tran
smission
toDialysis
Unit/Re
ferringPh
ysician
RPAQIR13
11
61
—MED
Resp
onsibility
ofdoc
umen
tatio
ntran
smission
shou
ldno
tbesolelyon
thephy
sician
but
rather
onhe
alth
care
system
,EMRve
ndor,a
ndinform
atics.Diffi
cultto
mea
sure
andreport.
May
send
inco
mplete
doc
umen
tatio
nto
mee
t2-dtim
efram
e.
Adva
nceCarePlan
ning
(Ped
iatric
Kidne
yDisea
se)
PKID
-41
11
11
HIG
HIm
portant
forp
atientswith
organ
failu
re.D
ocum
entatio
nmay
notrefl
ectm
eaning
fuld
iscu
ssion.
Broad
mea
sures(18)
Prev
entiv
eCare
Pneu
mon
iaVaccina
tion
Status
forO
lder
Adults
NQF00
43MIPS
111
11
11
1HIG
HEv
iden
ce-based
.Sha
redresp
onsibility
with
PCP.
Pneu
mon
iavaccinationreco
mmen
dationwas
rece
ntly
updated
,soshou
ldreflec
tcu
rren
t
reco
mmen
dations.
Prev
entiv
eCarean
d
Screen
ing:Infl
uenza
Immun
ization
NQF00
41MIPS
110
11
11
1HIG
HIm
portant
mea
sure
with
goo
dev
iden
cebase.
Shared
resp
onsibility
with
PCP.
Prev
entiv
eCarean
d
Screen
ing:T
obac
coUse:
Screen
ingan
dCessatio
n
Interven
tiona
NQF00
281
11
11
HIG
HSm
okingisacritically
importan
tCKD
andCVD
riskfactor.
Nep
hrolog
ists
houldco
-ownmea
sure
along
with
PCP.
Unc
lear
that
mee
tingmea
sure
istheresultof
amea
ning
fulp
atient
engag
emen
torjust“box
chec
king
.”
One
-Tim
eSc
reen
ingfor
Hep
atitisCViru
s(HCV)for
Patie
ntsat
Risk
MIPS40
01
16
11
MED
Important
mea
sure
given
antiv
iraltreatmen
tsforH
CV.S
haredresp
onsibility
with
PCP.
Diabetes
Mellitus:D
iabetic
Foot
andAnk
leCare,
Perip
heralN
europathy
–
Neu
rologic
Evalua
tiona
NQF04
171
11
6—
MED
Highco
rrelationwith
falls;e
asyto
perform
anddoc
umen
t.Sh
ould
bedom
inan
tresponsibility
of
PCPor
endoc
rinolog
ist.
Diabetes
Mellitus:D
iabetic
Foot
andAnk
leCare,
Ulcer
Prev
entio
n–Ev
alua
tionof
Footwea
ra
NQF04
161
16
6—
MED
May
notb
ene
cessaryin
allp
atientsin
theab
senc
eof
neuropathy
.Not
appropria
teto
attribute
thismea
sure
toprovidersno
ttrained
intheev
alua
tionof
footw
ear.
Prev
entiv
eCarean
d
Screen
ing:B
odyMass
Index
(BMI)a
NQF04
211
16
6—
MED
Obesity
isincrea
sing
lyreco
gnizedas
riskfactor
forC
KD,a
ndisalso
amod
ifiab
leriskfactorfor
diabetes.
May
notap
ply
topatientson
dialysis.
Med
ication
reco
nciliation
andsafety
Med
icationRe
conc
iliation
Post-D
isch
arge
NQF00
97MIPS
046
11
11
1HIG
HIm
portant
forhigh-qua
litycare.
Diffi
cultto
verifyaccu
racy.
Doc
umen
tatio
nof
Current
Med
ications
inthe
Med
ical
Reco
rd
NQF04
19MIPS
130
11
61
6HIG
HPh
ysicians
doc
umen
tingmed
icationlistdoe
sno
tne
cessarily
tran
slateinto
accu
racy
of
med
icationlists
orpatientstaking
med
ications.
Cha
lleng
ingbec
ause
ofno
ninterop
erab
leEH
Ran
dpha
rmacysystem
s.
Use
ofHigh-Risk
Med
ications
intheElderlya
NQF00
226
66
6—
LOW
Diffi
cultforne
phrolog
isttoasce
rtainwhe
nan
dwho
ordered
themed
ication.
Med
icationlist
may
have
importan
tom
ission
san
dinap
propria
tead
dition
s.
Advanc
ecare
plann
ing
Adva
nceCarePlan
NQF03
26MIPS
047
11
11
1HIG
HRe
asona
ble
forpatientsag
e65
yran
dolder,b
utmay
notb
ereleva
ntto
care
inlowacuity
patients.
Shou
ldbedom
inan
tresp
onsibility
ofPC
Pin
earlier
stag
ekidne
ydisea
se.
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Table 1. Continued
Measure Category
(No. of Measures)Measure Title RPA/NQF/MIPS/QIP
ACP 1:
Importance
ACP 2:
Appropriateness
ACP 3:
Clinical
evidence
ACP 4:
Specifications
ACP 5:
Feasibility
Overall
Measure
Validity
Rating
Rationale
Falls Falls: Plan of Carea NQF 0101 1 1 1 1 — MED Important, but not attributable to nephrologist (PCP responsible).
May be documented bymedical assistants or other clinic staff leading to documentation burden
without improvement in care.
Falls: Risk Assessmenta NQF 0101 1 1 6 1 — MED Falls are associated with mortality and other complications.
Nephrologists lack knowledge to do falls assessments.
Falls: Screening for Future Fall
RiskaNQF 0101 1 1 6 1 — MED Not within nephrology practice; should be dominant responsibility of PCP.
Complications/
miscellaneous
Prevention of Catheter-
Related Bloodstream
Infections (CRBSI): Central
Venous Catheter (CVC)
Insertion Protocolb
NQF 0464 1 1 1 1 — MED Not usually relevant to nephrology (except temporary dialysis placement which is often not
performed by nephrologist).
Surgical Site Infection (SSI)b 1 1 1 6 — LOW Not appropriately attributed to nephrologist. Surgical centers and hospitals are already
required to report SSIs.
Radiology: Exposure Time
Reported for Procedures
using Fluoroscopyb
NQF 0510 1 1 6 6 — LOW Important to track cumulative ionizing radiation exposure. Not appropriately attributed to
nephrologist, unless interventional nephrology.
Hospitalization Rate
Following Procedures
Performed under
Procedure Sedation
Analgesiab
RPAQIR11 6 6 6 6 — LOW Not appropriately attributed to nephrologist. Unknown evidence base for established
acceptable rate in literature.
PROMs (2)
PROMs Patient Experience of Care:
In-Center Hemodialysis
Consumer Assessment of
Healthcare Providers and
Systems (ICH CAHPS)
Survey Clinical Measure
NQF 0258 QIP 1 6 6 6 6 MED Important to include patient-reported outcomes. Survey has $60 questions and twice-yearly
administration, whichmay lead to survey fatigue. Results may be biased due to low response
rate.
Functional Outcome
Assessment
NQF 2624 MIPS
182
1 6 6 6 6 MED Should be dominant responsibility of PCP. Should target older patients, such as those $65 yr,
and those who are more vulnerable.
The symbol “1” indicates a median rating of 7–9, “6” indicates a median rating of 4–6, and “—” indicates amedian rating of 1–3. Overall rating: HIGH for high, MED for medium, LOW for low. MIPS, Merit-basedIncentive Payment System; ACC/AHA, American College of Cardiology/American Heart Association; HTN, hypertension; ABPM, ambulatory blood pressure monitoring; PCP, primary care physician; HbA1C,glycated hemoglobin; UACR, urine albumin-to-creatinine ratio; ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CVD, cardiovascular disease; AKID, adult kidney disease;RPAQIR, Renal Physician Association Quality Improvement Registry; AVG, arteriovenous graft; PD, peritoneal dialysis; QOL, quality of life; ESA, erythropoiesis stimulating agent; EMR, electronic medical record;PKID, pediatric kidney disease; HCV, hepatitis C virus; EHR, electronic health record.aMetric is PCP-focused.bMetric should not be attributable to nephrologists.
610JA
SNJA
SN31:602
–614,2020
CLIN
ICALRESE
ARCH
www.jasn.o
rg
home dialysis, transplantation, and coordinated outpatientdialysis initiation, making the optimal ESKD starts metric par-ticularly relevant.
Dialysis ManagementNearly half of the measures were related to dialysis manage-ment, partly reflecting measures incorporated in the ESRDQIP that target dialysis facilities rather than physicians.Metrics focused on AVF and catheter utilization rates wererated high, although the need for robust exclusion criteriawere emphasized.Measures of hemodialysis adequacy, definedby solute clearance, and avoidance of high ultrafiltration rateswere deemed to have high validity despite being on the basis oflimited evidence. Adequacy was cited as a potentially “toppedout” measure, and there were concerns raised about the needto individualize care, particularly in peritoneal dialysis, resultingin occasional failure to meet solute clearance targets. Anemiameasures with the aim of reducing erythropoiesis stimulatingagent overuse were also rated high. The readmission measurewas rated as having high validity but attribution concerns wereraised; the measure could be improved upon by converting toa rate to benchmark over time, and should better account forpatients who are outliers.18
High-validity measures also included metrics deemedpatient-centered, like the transplant referral measure andpediatric advanced care planning, but the committee empha-sized the need for robust risk adjustment and exclusioncriteria. Metrics rated as having medium validity includederythropoiesis stimulating agent dosage reporting, blood-stream infection rate reporting, and timely documentationfrom the hospital or provider to dialysis unit, with reportingbias, administrative burden, and attribution raised as poten-tial issues. Measures that were rated as having low validity
related to vascular access success or complication rates afterinterventions. These measures were seen to be attributable tointerventional nephrologists or surgeons rather than thebroader nephrology field. Specific to the dialysis metrics,topped out status, need for adequate risk adjustment, andoverreliance on vascular access measures were highlightedas key concerns.
Broad MeasuresNumerous metrics spanned the spectrum of kidney diseasecare, with variable validity ratings. Measures related to med-ication reconciliation were rated as high, although documen-tation burden and workflow challenges were discussed.Similarly, vaccination measures were rated high, althoughthere was recognized overlap with primary care. Low-validity ratings were assigned to hospitalization rate after pro-cedures with sedation, surgical site infections, central venouscatheter infection prevention, and radiology exposure time,largely because of issues with unclear relevance to nephrologyand unclear attribution to a given specialty.
In addition to the CKD prevention metrics, a number ofmetrics that spanned the spectrum of CKDwere deemed to beprimary care physician–directed measures, specifically relatedto diabetic foot management, body mass index documenta-tion, falls assessment and plan of care, tobacco use screening,and high-risk medication ordering in the elderly. Almost allwere rated as having medium validity because of the applica-tion to all patients, not those specifically with CKD, and thefocus on general primary care. Tobacco use screening wasrated as having high validity because of the role of smokingin CKDprogression, and high-riskmedication ordering as lowvalidity because of the types of medications that are consid-ered to be high risk (and those that are not) in the metric.
Step 2: Delineation of metrics specific to nephrology,overlapping with primary care, and overlapping withother consultants.
Step 3: Expansion to key areas: prevention, slowingprogression, and planning for kidney failuretreatment, reflecting nephrology practice.
Step 4: Incorporation of patient reported outcomemeasures, including disability and employment, andshifting to metrics that are patient-centered.
Step 5: Capturing additional important clinicaloutcomes: time to kidney failure, utilization, andmortality.
Step 1: Ensuring all existing and proposed qualitymetrics have high validity, according to acceptedmeasure evaluation criteria.
Figure 2. Framework to refining quality metric development to foster care delivery improvements. Five-step approach outlining idealsteps to refine existing and create new measures that will support patient-centered, high-quality kidney care delivery.
JASN 31: 602–614, 2020 Measuring Quality in Kidney Care 611
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PROMsOnly twomeasures were considered to specifically be a PROM.The In-Center Hemodialysis Consumer Assessment ofHealthcare Providers and Systems (ICH CAHPS) measurewas rated as having medium validity because of applicabilityof the survey to clinician-provided care as opposed to dialysisfacilities, given the focus of most questions on facility-relatedfactors. Finally, the functional outcome assessment measurefor patients aged $18 years was rated as having medium val-idity because of the inclusion of all adults as opposed to thoseaged.65 years and the applicability to nephrologists, most ofwhom are unaware of functional outcome assessment tools.
Global Measure AssessmentMetrics were globally assessed for their scope in measuringquality across the spectrum of kidney disease. The committeenoted that almost half of the metrics (46%) were related todialysis management, whereas only onemetric (optimal ESKDstarts) related to advanced CKD and kidney replacement ther-apy planning, and two metrics reflected PROMs. Notably,none of the prevention metrics addressed screening for CKDwith GFR biomarkers such as serum creatinine or cystatin C.
DISCUSSION
The ASN Quality Committee’s review of existing kidneycare–related metrics determined that less than half of currentmetrics have high validity. Three frequent concerns were raised,even for measures with high validity: (1) appropriate nephrolo-gist attribution, (2) adequate risk adjustment and denominatorexclusions, and (3) nonevidence-based metrics. Lastly, althoughthere are amultitude of dialysis-relatedmetrics, there is a paucityof metrics related to slowing CKD progression, advanced CKDand kidney failure planning, and patient-reported outcomes.
There are significant limitations to current quality meas-ures used to assess kidney care quality. Lack ofmeasure validitymay result in potential unintended consequences andincreased provider burden, illustrating the need for incorpo-rating the strongest evidence when developing measures. At-tribution was a common concern, as many metrics potentiallyapplicable to nephrologists significantly overlap with primarycare, contributing to confusion about which provider bearsresponsibility for the care described in the metric. Notably, wefound thatmanymeasures related to kidney care should not beattributed to nephrologists, such as CKD preventionmeasuresin the realm of primary care, or vascular access–related meas-ures attributed to interventionalists. Phasing out measures onthe basis of the outdated evidence and clinically topped-outmeasures, such as those for adequacy, is crucial to ensuremeaningful measures that improve kidney care.
The scope of existing quality measures highlights opportu-nities for new measure development and further areas of re-search. First, there is an abundance of metrics that focus ondialysis care process metrics with varied validity. This is largely
driven by the current CMS reimbursement and incentivestructure, which focuses on facility-level dialysis care. How-ever, whether these dialysis-centric process measures directlycontribute to improvements in patient outcomes remains un-certain.9,19 Second, there is a paucity ofmetrics related to CKDprevention and slowing CKD progression, which may, in part,reflect limited evidence-based interventions to prevent or slowthe progression of CKD. New therapies such as sodium glu-cose cotransporter inhibitors may be candidates for new mea-sure development, once appropriate for the indication ofslowing CKD progression is established in guidelines andthrough additional clinical experience. Of note, there is onlyone measure related to advanced CKD and kidney replace-ment planning, despite the complex care and high costs inlate-stage CKD.Given the upcoming voluntary paymentmod-els within the Advancing American Kidney Health Initiativethat will include patients with CKD stages 4 and 5, additionalmeasures should be tested and developed for advancedCKD andkidney replacement planning.17 The absence of metrics reflect-ing care delivered at various stages in CKD care reflects a signif-icant missed opportunity to drive improvements in these areas.Lastly, a lack of metrics reflecting PROMs as well as limitedability to account for patient choice in many existing measuresrepresent a deficiency in measuring high-quality, patient-centered kidney care. Patient values can conflict with clinicalor laboratory metrics of performance, adding a layer of com-plexity to the assessment of clinician performance. Lack of qual-ity of life measures in the ESRD QIP has been previously noted,leading researchers to propose a patient-focused quality hierar-chy pyramid, with quality of life at the apex.20,21 ExistingPROMs, namely the ICH CAHPS Survey, have several limita-tions noted by the committee, specifically low response rate andsurvey fatigue.We urgemeasure developers to incorporate otherPROMs related to kidney disease, including PROMs for homedialysis, into new patient-centered quality measures.22
Other authors have commented on the need to refine ex-isting kidney disease quality measures.19,23,24 Proposals haveincluded a shared accountability model for patients withESKD across a defined geographic region19; incorporation ofmore patient-centric, goal-directed metrics23; and greater re-liance on defined important outcomes like mortality, hospi-talization, and employment.24,25 The common theme of theseproposals is the recognition that quality metrics have the po-tential to drive care improvements but, in the current state,have not consistently achieved this goal. In Figure 2, we outlinea five-step approach to quality metric development and utili-zation for kidney disease that will support care patient-centricdelivery improvements. Critically, this incorporatesmany ten-ets of the NQF’s measure endorsement process.
Step 1 involves ensuring that all existing and new quality met-rics are valid on the basis of established ACP criteria. Focusing onvalid metrics fosters a cohesive discussion with relevant stake-holders regarding the value of establishing measurement in keyareas, and avoids overlapping measures of variable validity. Step2 delineates metrics specific to nephrologists, involving both
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nephrology and primary care, and those involving other stake-holders. This is an important element of the process of metricdefinition—specifically, which providers have responsibility forperformance. The questions that need to be asked in this step are:(1) whether care should be defined as comanagement by ne-phrology and primary care, and (2) will care be more specificto one specialty versus another? Step 3 involves expansion ofmetrics in key areas such as prevention, slowing progression,and planning for kidney failure treatment. These critical aspectsof kidney disease care represent established care gaps that oftenare overlooked. Establishment of meaningful metrics in theseareas can facilitate care improvement. For example, a measurethat captures rates of patient-centered education and shareddecision-making related to conservativemanagement, kidney re-placement modality, and pre-emptive transplantation in patientstransitioning to kidney failure would be a significant advance-ment. Step 4 incorporates PROMs, representing a shift tometricsthat are patient-centered. Capturing patient symptoms, qualityof life, mental health, disability, employment, and values that aremost meaningful to patients is necessary in defining quality. Step5 involves capturing important clinical outcomes: time to kidneyfailure, utilization, and mortality. These outcomes must be ap-propriately risk-adjusted, which signifies a clear challenge, butdefining quality of care without these paramount outcomes ismeaningless.
In conclusion, we reviewed the existing 60 quality metricsrelated to nephrology care and identified substantial variationin metric validity. Less than half of current metrics were ratedwith high validity, largely because of unclear attribution, in-adequate definitions and risk adjustment, and discordancewith the latest evidence. We advocate for refinement of exist-ing measures and development of new, well-defined, well-validated “measures that matter,” characterized as reflectingthe spectrum of nephrology practice, capturing clinically rel-evant outcomes, and shifting focus to tools that will drivemeaningful improvements in patient-centered care.
ACKNOWLEDGMENTS
Drs. Mendu, Tummalapalli, and Weiner take responsibility for the in-
tegrity of the metric data presented and the accuracy of the analysis.
Drs. Mendu, Bieber, and Weiner were involved in the manuscript
concept and design. Review and ratings of the metrics were led by
Drs. Tummalapalli,Mendu, andWeiner, and conductedbyDrs.Mendu,
Tummalapalli, Lentine, Erickson, Lew, Liu, Gould, Garimella, O’Neil,
and Bieber. Drafting of the manuscript was carried out by Drs. Mendu,
Tummalapalli, Lentine, Erickson, Lew, Liu, Gould, Garimella, O’Neil,
Bieber, Mr. White, Ms. Meyer, and Dr. Weiner. Drafting of the tables
was carried out by Drs. Tummalapalli, Mendu, and Weiner. Critical
revision of the manuscript for important intellectual content was car-
ried out by Drs. Mendu, Tummalapalli, Lentine, Erickson, Lew, Liu,
Gould, Garimella, O’Neil, Bieber, and Weiner. Administrative or tech-
nical support was provided by Drs. Mendu, Weiner, Bieber, Mr. White,
and Ms. Meyer. This creation of this manuscript was supervised by
Drs. Mendu, Weiner, and Bieber. All authors have read and approve of
the final version of this manuscript.
DISCLOSURES
Dr. Bieber is a medical director for Northwest Kidney Centers and serves asfaculty for the Home Dialysis University. Dr. Erickson reports personal feesfrom Acumen LLC, other from American Society of Nephrology, personal feesfrom Dialysis Clinic, Inc., personal fees from Satellite Healthcare, outside thesubmitted work. Dr. Lew reports grants from Care First Foundation, personalfees fromReata, outside the submittedwork. Dr. O’Neil has a patent null pend-ing and is currently in the very early phases of submitting utility and designpatents on a device to reduce the risk of both venous line disconnection andmicrobial contamination of the bloodline-to-central-hemodialysis-catheter-hub connection points. The effort is entirely self-funded, is not proceedingunder the sponsorship or support of any other agency or business entity, andwas undertaken more than a year after his retirement to without-compensation emeritus teaching staff status from the James H. Quillen Vet-erans Affairs Medical Center (VAMC), in Johnson City Tennessee. Althoughsome of themetrics reviewed concerned dialysis safety, the nature and status ofthe device patents did not in any discernable way alter their assessment of thestatus of the metrics reviewed as one of the independent review panel.Dr. Mendu reports personal fees from Bayer Pharmaceuticals, outside thesubmitted work. Dr. Tummalapalli reports personal fees from Bayer Pharma-ceuticals, outside the submitted work.
FUNDING
The authors acknowledge funding for the ASN Quality Committee by theAmerican Society of Nephrology.
SUPPLEMENTAL MATERIAL
This article contains the following supplementalmaterial online at
http://jasn.asnjournals.org/lookup/suppl/doi:10.1681/ASN.2019090869/-/
DCSupplemental.
Supplemental Table 1. ACP Measure Review Criteria.
Supplemental Figure 1. Correlation between ACP domain ratings
and overall rating.
Supplemental Figure 2. Box plots showing median, interquartile
ranges (IQR), and minimum and maximum values of American
College of Physicians (ACP) domain ratings and overall rating across
metrics by reviewer (1-11).
Supplemental Table 2. Median and interquartile ranges (IQR) of
ACP domain ratings.
Supplemental Appendix 1. Supplemental methods.
Supplemental Table 3a. CKD prevention measures.
Supplemental Table 3b. Slowing CKD progression measures.
Supplemental Table 3c. CKD management measures.
Supplemental Table 3d. Advanced CKD and kidney replacement
planning measures.
Supplemental Table 3e. Dialysis management measures.
Supplemental Table 3f. Broad measures.
Supplemental Table 3g. Patient reported outcome measures
(PROMs).
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See related editorial, “Measuring Up,” on pages 454–455.
AFFILIATIONS
1Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; 2Division of Nephrology,University of California, San Francisco, San Francisco, California; 3Saint Louis University Center for Abdominal Transplantation, St. Louis,Missouri; 4Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas; 5Division of RenalDiseases and Hypertension, George Washington University, Washington, DC; 6The Rogosin Institute, New York, New York; 7Weill CornellMedical College, New York, New York; 8Division of Nephrology, Vanderbilt University Medical Center, Nashville, Tennessee; 9Division ofNephrology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts; 10Division of Nephrology-Hypertension, Universityof California, San Diego, San Diego, California; 11Nephrology Service and Dialysis Unit, Mountain Home Veteran Affairs Medical Center,Mountain Home, Tennessee; 12American Society of Nephrology, Washington, DC; 13Division of Nephrology, Department of Medicine,Harborview Medical Center, University of Washington, Seattle, Washington; and 14Division of Nephrology, Department of Medicine, TuftsMedical Center, Boston, Massachusetts
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