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      Measuring Quality in Kidney Care: An Evaluation of Existing Quality Metrics and Approach to Facilitating Improvements in Care Delivery

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          Abstract

          Leveraging quality metrics can be a powerful approach to improve patient outcomes. However, the validity of existing kidney-related quality metrics is unknown. To identify whether existing measures can effectively address and guide quality improvement in care of patients with kidney disease, the American Society of Nephrology’s Quality Committee performed a systematic compilation and evaluation of national kidney metrics. They identified 60 metrics, rating only 29 as highly valid and the other 31 metrics as of medium to low validity, on the basis of defined criteria. Almost half of the measures were related to dialysis management, compared with only one metric related to kidney replacement planning and two related to patient-reported outcomes. The authors urge refinement of existing quality metrics and development of new measures that better reflect kidney care delivery. Leveraging quality metrics can be a powerful approach to identify substantial performance gaps in kidney disease care that affect patient outcomes. However, metrics must be meaningful, evidence-based, attributable, and feasible to improve care delivery. As members of the American Society of Nephrology Quality Committee, we evaluated existing kidney quality metrics and provide a framework for quality measurement to guide clinicians and policy makers. We compiled a comprehensive list of national kidney quality metrics from multiple established kidney and quality organizations. To assess the measures’ validity, we conducted two rounds of structured metric evaluation, on the basis of the American College of Physicians criteria: importance, appropriate care, clinical evidence base, clarity of measure specifications, and feasibility and applicability. We included 60 quality metrics, including seven for CKD prevention, two for slowing CKD progression, two for CKD management, one for advanced CKD and kidney replacement planning, 28 for dialysis management, 18 for broad measures, and two patient-reported outcome measures. We determined that on the basis of defined criteria, 29 (49%) of the metrics have high validity, 23 (38%) have medium validity, and eight (13%) have low validity. We rated less than half of kidney disease quality metrics as highly valid; the others fell short because of unclear attribution, inadequate definitions and risk adjustment, or discordance with recent evidence. Nearly half of the metrics were related to dialysis management, compared with only one metric related to kidney replacement planning and two related to patient-reported outcomes. We advocate refining existing measures and developing new metrics that better reflect the spectrum of kidney care delivery.

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          Time Out — Charting a Path for Improving Performance Measurement

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            Improving outcomes for ESRD patients: shifting the quality paradigm.

            The availability of life-saving dialysis therapy has been one of the great successes of medicine in the past four decades. Over this time period, despite treatment of hundreds of thousands of patients, the overall quality of life for patients with ESRD has not substantially improved. A narrow focus by clinicians and regulators on basic indicators of care, like dialysis adequacy and anemia, has consumed time and resources but not resulted in significantly improved survival; also, frequent hospitalizations and dissatisfaction with the care experience continue to be seen. A new quality paradigm is needed to help guide clinicians, providers, and regulators to ensure that patients' lives are improved by the technically complex and costly therapy that they are receiving. This paradigm can be envisioned as a quality pyramid: the foundation is the basic indicators (outstanding performance on these indicators is necessary but not sufficient to drive the primary outcomes). Overall, these basics are being well managed currently, but there remains an excessive focus on them, largely because of publically reported data and regulatory requirements. With a strong foundation, it is now time to focus on the more complex intermediate clinical outcomes-fluid management, infection control, diabetes management, medication management, and end-of-life care among others. Successfully addressing these intermediate outcomes will drive improvements in the primary outcomes, better survival, fewer hospitalizations, better patient experience with the treatment, and ultimately, improved quality of life. By articulating this view of quality in the ESRD program (pushing up the quality pyramid), the discussion about quality is reframed, and also, clinicians can better target their facilities in the direction of regulatory oversight and requirements about quality. Clinicians owe it to their patients, as the ESRD program celebrates its 40th anniversary, to rekindle the aspirations of the creators of the program, whose primary goal was to improve the lives of the patients afflicted with this devastating condition.
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              Satisfaction with renal replacement therapy and education: the American Association of Kidney Patients survey.

              This study was undertaken by the American Association of Kidney Patients (AAKP) to better understand ESRD patients' satisfaction with their current renal replacement therapy (RRT) and the education they received before initiating therapy. In addition to an open invitation on the AAKP website, nearly 9000 ESRD patients received invitations to complete the survey, which consisted of 46 questions. Satisfaction was measured on a 1 (extremely dissatisfied) to 7 (extremely satisfied) scale. Survey respondents were younger, more highly educated, and more likely to be white as well as employed as compared with the U.S. dialysis population. A total of 977 patients responded. Overall patient satisfaction with current RRT treatment varied from a low of 4.5 for in-center hemodialysis (ICHD) to a high of 6.1 in transplant (TX) patients. Peritoneal dialysis (PD) and home hemodialysis (HHD) mean scores were 5.2 and 5.5, respectively. PD, HHD, and TX patients' satisfaction scores were significantly higher than those of ICHD patients (P < 0.05). Approximately 31% of respondents felt that the therapies were not equally and fairly presented as treatment options, and 32% responded that they were not educated regarding HHD. ESRD patients are not uniformly advised about all possible treatment methods and hence were only moderately satisfied with their pretreatment education. Once on RRT, those on a home therapy or with a kidney TX are more satisfied than those with ICHD.
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                Author and article information

                Journal
                Journal of the American Society of Nephrology
                JASN
                American Society of Nephrology (ASN)
                1046-6673
                1533-3450
                February 13 2020
                : ASN.2019090869
                Article
                10.1681/ASN.2019090869
                7062216
                32054692
                c7bc8f5d-f56e-4169-a2f7-b76d2a6810d3
                © 2020
                History

                Molecular medicine,Neurosciences
                Molecular medicine, Neurosciences

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