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.

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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

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

www.jasn.org CLINICAL RESEARCH

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

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

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.

JASN 31: 602–614, 2020 Measuring Quality in Kidney Care 609

www.jasn.org CLINICAL RESEARCH

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

www.jasn.org CLINICAL RESEARCH

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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