Quality of care measurement and implementation both pose unique challenges. The Friday morning session at ASN Kidney Week, “Quality is Job One: Improving Care for CKD and ESRD Patients” tackled these two key issues.

Nephrology has seen a proliferation of quality metrics, primarily in its ESRD Quality Incentive Program (QIP). Daniel E. Weiner, MD, FASN, chair of ASN’s Quality Committee, shared his framework for assessing quality metrics, based on his experience developing these in conjunction with the Centers for Medicare and Medicaid Services (CMS). 

Guidelines → Metrics → Incentives

CMS has a standardized approach to develop quality metrics through its Measures Management System. Dr. Weiner points out that even with a low level of evidence, guidelines often become metrics, and metrics become incentives. There is no perfect quality metric. Each comes with a tradeoff between importance, validity and reliability, and usability:

Dr. Weiner used this framework to discuss three quality metrics in ESRD care:

1. Vascular Access Type,
2. ICH CAHPS (In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems) Survey, and
3. The Bloodstream Infection Measure

Importance of Quality Metrics

The importance of a quality metric depends on whether it falls within a key priority area and highlights a performance gap. Dr. Weiner discusses that all the above measures highlight key areas of performance gaps. For example, dialysis centers vary on their performance on the ICH CAHPS survey, indicating room for improvement. In terms of priority areas, vascular access is a priority for quality, ICH CAHPS for patient experience, and bloodstream infections for patient safety.

Validity and Reliability of Quality Metrics

The presentation examined validity and reliability as both are technically challenging when designing quality measures. The specifications for how the numerator and denominator are defined are carefully considered but have limitations. Each QIP measure is benchmarked to the 90th percentile of national performance.  This can pose challenges for validity. For example, the vascular access benchmark is extremely low at 3%, which doesn’t account for patients unable to get an access placed, patient preference, or exhaustion of vascular access options. Furthermore, risk adjustment of the metrics may be incomplete. For bloodstream infections, the benchmark is zero infections, which isn’t feasible for most dialysis units and indicates this metric is likely underreported.

Usability of Quality Metrics

Usability of metrics is critically important to the success of quality metrics and minimizing reporting burden. Metrics should be accessible and quantifiable. In this way, ICH CAHPS has its limitations, due to moderate response rates and the length of the survey leading to potential survey fatigue. Metrics should be attributable to the unit and allow for within unit and between unit comparisons.

In closing, Dr. Weiner calls us to recognize that dialysis care can improve, and we can use metrics to target significant gaps. He stresses to:

• Avoid clinically topped out metrics
• Use meaningful measures that directly affect outcomes
• Minimize the potential for unintended consequences
   

Ultimately, the goal for quality improvement programs is not just to mandate reporting, but to actually stimulate real quality improvement that can drive change for our patients.