Dialysis Unplugged: "No Dialysis Patient Left Behind"

Editor – How does one improve the quality of care in dialysis? There is probably no-one in the nephrology arena more knowledgeable on this subject than Dr. Jay Wish, who has had a career-long involvement in advocating for quality care in dialysis. Jay is Professor of Medicine at Case Western Reserve University and Medical Director of the Dialysis Program at University Hospitals Case Medical Center in Cleveland, OH.  He is past-president of the Forum of ESRD Networks and has served on several technical expert panels for CMS regarding quality oversight of the ESRD Program, including chairman of the ESRD Clinical Performance Measure-Quality Improvement Committee from its inception in 1998 to 2006. In 1997, Dr. Wish also served on the workgroup for the National Kidney Foundation for developing original evidence-based clinical practice guidelines.  In recent times, Jay served on the steering committee to develop ESRD clinical performance measures for the National Quality Forum under a contract from CMS. He is currently the nephrology consultant to the Fistula First Breakthrough Initiative. Dr. Wish is also a member of the Board of Directors of the American Association of Kidney Patients and was recipient of the 2005 Visionary Award.  He is Vice Chairman of the Editorial Advisory Board of Nephrology News & Issues and has had many articles, abstracts, reviews, and book chapters published, especially in the areas of ESRD quality oversight/improvement, accountability and anemia management.

COMMENTARY – Dr. Jay Wish

The concept of quality should be quite familiar to nephrologists, especially the vast majority of whom serve as medical directors of dialysis facilities.  The most recent Conditions for Coverage for dialysis facilities emphasize the role of the medical director as the chief quality officer of the facility, with responsibilities ranging from infection control to water quality and staff education.  Perhaps the most important role of the medical director is as leader of the quality assessment and performance improvement (QAPI) program. 

The QAPI is designed to achieve measurable improvements in health outcomes and reduction in medical errors by using measures that are tracked over time. 

QAPI activities are prioritized based on the prevalence and severity of problems and their impact on clinical outcomes and patient safety.  Medicare specifies QAPI measures in the Measures Assessment Tool (MAT) which include dialysis adequacy, anemia management, nutrition, medical errors, infection control, reuse and patient quality of life/satisfaction.  The MAT is not intended to be all-inclusive, and the QAPI team should select additional measures that have been identified as opportunities for improvement.  Measures used for internal quality improvement (QI) do not require as robust an evidence basis as do those used for public reporting and payment for performance.  Accordingly, many of the measures in the MAT were not endorsed by the National Quality Forum (NQF) for public accountability, but nonetheless are useful to identify problems at the provider level.  Process measures such as vaccination, administration of patient-focused surveys and vascular access surveillance, for instance, do not require case mix adjustment, although they may pose more challenges in data collection than do intermediate outcome measures such as hemoglobin (Hgb) and URR.  

The ultimate goal of QI is to improve outcomes, and the assumption is that improved processes can be a surrogate for improved outcomes in the QI process.  Intermediate outcomes such as lab values are easy collect, may be actionable, and the assumption is that improvement in intermediate outcomes is associated with improvement in “hard” outcomes such as morbidity/hospitalization, mortality and perhaps quality of life.  Those “hard” outcomes are the ones that matter from a healthcare policy standpoint because they affect per capita costs, population health and experience of care, which have become Medicare’s “Triple Aim” for system improvement.  The challenge with using harder outcomes for accountability is that they must be case-mix adjusted to level the playing field and their actionability is not clear-cut.

In its proposed rule for the 2014 Quality Incentive Payment (QIP) for dialysis facilities, Medicare has outlined 5 measures that involve processes and outcomes (90% of score) and 3 measures that involve attestation of processes of care (10% of score).  The first group of measures includes Hgb, Kt/V, vascular access, infections, and standardized hospitalization ratio (SHR).  These were chosen because they can be collected in real-time using technology to be introduced in 2012 (CROWNWeb), because they were endorsed by the NQF as being sufficiently evidenced based, and because they are seen as actionable by the provider.  

There is a concern that the proliferation of QIP measures from 2 in 2013 to 8 in 2014 will disproportionately preoccupy the QAPI activities at the facility level so that other important quality issues are not given adequate attention.  The analogy can be made to the “No Child Left Behind” program that preoccupied public school educators with the student passage rate on standardized achievement tests at the expense of a better-rounded curriculum.   On the other hand, the inclusion of SHR as a QIP measure for 2014 can be seen as an opportunity for facilities to address, through their QAPI program, issues that require coordination of care as opposed to those, like our old friends Hgb and URR, that involve the facility in a vacuum. The recent FDA label changes for ESAs, which place the dosing floor as the minimum required to avoid transfusion, challenges the dialysis facility to account for blood transfusions as part of its anemia QAPI program.  This will require communication with sites where the patient may have received transfusions, such as hospitals and infusion centers.  

One of the most common causes of hospital readmission (>20% in 30 days among dialysis patients) is poor medication reconciliation between sites of care, including the dialysis facility.  This will challenge the QAPI team to develop better medication reconciliation processes to decrease errors and SHR.

One of the hallmark concepts of QI is that standardization of process leads to decreased variability of outcomes.  Models for standardization can come from one author’s experience in a peer-reviewed article, from the national headquarters of a large dialysis organization, or from a facility down the street that is willing to share.  However, QI is local, and all “off the shelf” protocols must be piloted tested at the facility level using a structured QAPI process.  Once improved protocols, care-paths and/or algorithms are validated as part of the QAPI program, it must be understood that these will apply to 80-85% of patients, but for the other 15-20% of patients it will be a square peg in a round hole.  That is when the judgment and experience of the nephrologist is essential to individualize the process to account for the patient’s unique barriers to response.

In conclusion, a new era of public accountability for all healthcare providers, not just dialysis facilities, will make it essential for nephrologists to master the concepts of QI and to promote QAPI activities that examine areas that may be unfamiliar territory such as coordination of care across providers and patient experience of care.  Preoccupation with public accountability must not divert attention from other important opportunities for improvement.  An alignment of incentives is clearly the goal of this new paradigm and, if successful, is a win x 4p for patients, providers, physicians and payers.