Laying a Foundation for Improving Quality Measures for Kidney Care

Existing kidney care measures

In 2019, the ASN Quality Committee members began the task of investigating the measures being used to evaluate nephrologists’ performance. They compiled a comprehensive list of 60 quality measures related to kidney disease from multiple established sources, cataloged them according to the aspect of kidney care measured, and used the criteria defined by the ACP to evaluate each measure’s validity. What did they learn?

Only 29—fewer than half—of the 60 measures studied were highly valid in the committee’s view, and they found other problems as well. Eighteen of the measures were determined to be not attributable to nephrologists. Some were poorly defined, particularly when it came to exclusion criteria and risk adjustment. Others were out of step with the latest evidence or guidelines, and far too many measures—28 in all—focused on dialysis. In contrast, only 2 focused on slowing the progression of kidney disease, the ultimate purpose of kidney care (2).

These findings, which appeared in the December 2019 issue of the Journal of the American Society of Nephrology (JASN), lay a much-needed foundation for improving quality measurement in nephrology, and ultimately, for improving care. “We hope our study will give backing to what a lot of nephrologists are probably feeling, which is, why do I need, for example, another measure on vascular access success, which I don’t have a lot of control over?” said Mendu, the study’s lead author. She would like to see the focus shift to measures where nephrologists do have control and where gains can drive improvement in clinical outcomes.

One such measure is the National Quality Forum’s Optimal ESKD Starts, which is the only measure among the 60 reviewed that is associated with advanced kidney disease and kidney replacement planning. The committee found this measure to be highly valid and underscored its importance, calling it “all-encompassing toward improving quality of initiation of dialysis care.” The authors considered the measure especially relevant in light of the Advancing American Kidney Health (AAKH) initiative announced by the U.S. Department of Health and Human Services (HHS) in 2019.

AAKH is intended to spur greater use of home dialysis and transplantation. Mendu said educating patients about home dialysis and evaluating whether their living situations can support it is a lot more work for clinicians than referring patients to a dialysis center. Nevertheless, “It’s the right thing to do,” she said, and universal adoption of a well-crafted measurement such as Optimal ESKD Starts has the potential to “fundamentally shift practice.”

In an editorial in the same issue of JASN, Paul M. Palevsky, MD, FASN, laid out the many challenges inherent in measuring quality (3). “Quality is subjective,” he said, but quality measurement needs a firmer grounding. The University of Pittsburgh professor of nephrology and chief of the renal section at the VA Pittsburgh Healthcare System has contributed to several quality measurement initiatives—as past chair of the Renal Physicians Association Quality, Safety and Accountability Committee, and as a co-chair of the American Medical Association-convened Physician Consortium for Performance Improvement renal measures work group.

“We have performance measures, which are typically based on clinical practice guidelines, but many of those guidelines are not based on rigorous evidence,” he said. What’s more, quality measures often focus on what’s easy to measure rather than what’s most important, Palevsky added, and in healthcare, the involvement of multiple conditions and multiple providers in a patient’s health can make it difficult to attribute improvement to the intervention of one particular physician.

An opportune time to advocate for change

With the administration currently working out the details of its kidney care initiatives, Mendu believes the time is right for nephrologists to encourage the development of more well-designed measures and the retirement of those with limited validity. “If the administration is focused on improving care, but we have the wrong measures,” she said, “then it doesn't matter how much federal funding there is or how many innovative care models we have.”

David White, ASN regulatory and quality officer, agrees. He said last year the Centers for Medicare & Medicaid Services (CMS) eliminated four nephrology measures from its Merit-based Incentive Payment System (MIPS), which ties participating clinicians’ reimbursement to their ability to provide high-quality, cost-efficient care. In order to receive incentive payments, clinicians must score well on eligible MIPS measures. “We are working with CMS to highlight more useful metrics,” White said, “and to assist the agency in developing a MIPS Value Pathway for nephrology.”

MIPS Value Pathways are CMS’s answer to clinician complaints that the MIPS program is overly complex and burdensome. CMS hopes this new framework will better identify measures that are relevant to clinicians’ scope of practice, meaningful to patient care, and in alignment across performance categories in each specialty (4). The agency has also convened a technical expert panel (TEP), which includes ASN members, to consider the development of a measure to track clinicians’ success in slowing the progression of kidney disease and delaying kidney failure.

Capturing and improving the patient experience

Another key finding of the ASN Quality Committee study was a paucity of measures for the patient experience of care. The committee found only two and rated both as having medium validity. Both Mendu and Palevsky would like to see more measures that reflect what matters to people with kidney disease: avoiding hospitalization, minimizing their symptoms, being healthy enough to work and function in their daily lives, and ultimately, the length of their survival (3).

They also want to see more measures that touch the lives of kidney care patients before their disease becomes severe. “Most measures focus on the small percentage of patients who are on dialysis,” Palevsky said. “They are the most expensive group of patients with kidney disease and the ones at greatest risk of complications, but there are millions of others with early stage kidney disease, and we really don’t have many useful measures on the quality of care they are receiving.”

Mendu agreed. “If our goal is to decrease the number of our patients who are on dialysis, we have to make sure that we have measures that are helping slow that progression to dialysis.”

Both are eager to see the nephrology community rally behind current efforts to develop better quality measures and take the lead in writing and validating measures to make sure they are truly meaningful. This won’t be easy. Having had a hand in developing some of the current measures, Palevsky is humbled by the challenge of developing measures that can capture genuinely high-quality care. “We need to do better, but we are humans,” he reflected. “We try things and we figure out what works and what doesn’t work, and then we move forward again. It’s an iterative process, and of course, medicine changes, and the right thing to do in 2020 may not be the right thing to do in 2025.”

Mendu also acknowledged that quality measurement is challenging, but when done correctly, she believes it is an effective tool for driving practice improvement. She said she hopes nephrologists, policymakers, and patients will all become invested in creating better measures, so the nephrology community will have objective ways to recognize and reward quality in the future.