Most Quality Metrics for Kidney Care in the US Fall Short

Nancy A. Melville

February 17, 2020

Nearly half of national metrics used to assess the care of kidney disease in the US are of middle to low quality in terms of meeting criteria for having meaningful effectiveness, new research shows.

"We advocate refining existing measures and developing new metrics that better reflect the spectrum of kidney care delivery," concludes the study, conducted by the American Society of Nephrology (ASN) Quality Committee.

"As a nephrologist, I see patients with chronic kidney disease and end-stage renal disease," said lead author Mallika Mendu, MD, MBA, in a press release, "and when we discuss dialysis, they ask me, 'Is that all there is? Why aren't there innovative treatments for kidney disease like there are for other diseases?' "

"One of the reasons is that success is contingent on getting the details right," added Mendu, a practicing nephrologist and medical director for Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts. "When we measure quality of care to determine if a treatment is working for a patient, we need to be certain we're measuring the right thing."

The ASN Quality committee underscores that "the lack of [quality] measure validity may result in potential unintended consequences and increased provider burden, illustrating the need for incorporating the strongest evidence when developing measures."

The new study was conducted in the wake of the launch last year of the Advancing American Kidney Health initiative by the US Department of Health and Human Services. As detailed by Medscape, the initiative strives to improve care for the 14% of adults in the US with chronic kidney disease (CKD). These patients have poor outcomes: for those who progress to kidney failure, 50% of those who go on to dialysis will die within 3 years.

A critical factor in improving care is determining whether existing national benchmarks are indeed valid and meaningful, noted Mendu.

"We think about quality and safety metrics on a daily basis, but we need to understand which metrics truly reflect and drive the care improvements that matter to our patients."

Confusion About Which Provider Should Be Responsible for Which Metric

For the study, published last week in the Journal of the American Society of Nephrology, Mendu and the ASN committee evaluated 60 nationally used kidney disease quality metrics.

Specifically, the metrics included 7 addressing CKD prevention, 2 for slowing CKD progression, 2 for CKD management and 1 each for advanced CKD and kidney replacement planning. Additionally, there were 28 metrics for dialysis management, 18 for broad measures, and 2 for patient-reported outcome measures.

The metrics were assessed on the basis of five criteria established by the American College of Physicians (ACP): importance, appropriate care, clinical evidence base, clarity of measure specifications, and feasibility and applicability.

The committee determined that 29 (49%) of the metrics had validity that was considered high, while 23 (38%) had just medium validity, and 8 (13%) had low validity.

Among the leading concerns about the metrics — even for those considered as having high validity — was a failure to appropriately attribute nephrologist involvement; some measures, for instance, overlapped with primary care, hence causing confusion regarding which provider should take responsibility for the measure.

"Notably, we found that many measures related to kidney care should not be

attributed to nephrologists, such as CKD prevention measures in the realm of primary care, or vascular access–related measures attributed to interventionalists," the committee writes.

Other key concerns included metrics that were in fact not found to be evidence-based, and concerns about adequate risk adjustment and denominator exclusions.

Metrics Abundant in Some Areas but Lacking in Others

And while an abundance of measures focus on the issue of dialysis care process, the validity of those measures varies widely, and there is uncertainty regarding the efficacy of those measures in directly contributing to patient outcome improvements, the authors note.

Conversely, measures related to CKD prevention and slowing of disease progression are lacking, which may reflect the fact that evidence-based interventions to prevent or slow the progression of CKD are limited.

Notably, the report identified only one metric relating to advanced CKD and kidney replacement planning, despite the complexity of care and high costs involved in late-stage CKD.

"Given the upcoming voluntary payment models within the Advancing American Kidney Health Initiative that will include patients with CKD stages 4 and 5, additional measures should be tested and developed for advanced CKD and kidney replacement planning," the authors urge.

A significant lack of patient-reported outcome measures (PROMs), as well as limited ability to account for patient choice in many existing measures, was also observed; existing PROMs, the committee noted, have limitations such as low response rates and survey fatigue (respondents becoming bored or uninterested in the survey).

Better Clarification of Metrics Specific to Nephrologists Needed

The committee proposes a five-step approach to improve the shortcomings in patient-centric care for kidney disease, beginning with the recommendation that all new metrics should be valid according to ACP criteria and that metrics should better clarify those that are specific to nephrologists.

In addition, metrics should be expanded to address the key areas of prevention, slowing progression, and planning for kidney failure treatment in order for PROMs to be better represented.

Finally, improvements in metrics are needed in the capturing of important clinical outcomes such as time to kidney failure, utilization, and mortality.

"These outcomes must be appropriately risk-adjusted, which signifies a clear challenge, but defining quality of care without these paramount outcomes is meaningless," the authors note.

National healthcare quality metrics in the US, in general, have faced scrutiny, with some experts cautioning about unintended consequences, ranging from overtesting and overmedicating to distraction from patient needs.

The ACP, in an article in the New England Journal of Medicine, in 2018 called for a "time out" with respect to developing and utilizing existing national healthcare quality metrics, as reported by Medscape Medical News.

Mendu hopes the findings from the new study help drive an improvement in the care of patients with kidney disease.

"When done well, metrics can foster improvements in care," she noted. "We think the findings from our study will help to inform policy, regulation, and legislation moving forward."

"We believe that this study is timely in light of the Advancing American Kidney Health initiative, which has the potential to advance kidney care if success is defined and measured accurately," she concludes.

The authors acknowledge funding for the ASN Quality Committee by the American Society of Nephrology. Mendu reports personal fees from Bayer Pharmaceuticals outside the submitted work. The remaining authors' disclosures are listed with the published study.

J Am Soc Nephrol. Published February 13, 2020. Abstract

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