Whereas quality metrics can be a powerful tool in helping identify substantial performance gaps in kidney disease care affecting patient outcomes, these metrics must be meaningful, evidence-based, attributable, and feasible if they are to aid in improving care delivery. With a myriad of quality measures related to nephrology care and CMS using many measures to guide incentive programs, the American Society of Nephrology Quality Committee sought to perform a systematic compilation and evaluation of national kidney quality metrics, explains Mallika L. Mendu, MD, MBA.

“The Trump administration recently proposed the Advancing American Kidney Health initiative with seeks to improve kidney care delivery to be more patient-centered and outcome-centered,” adds Dr. Mendu. “The need for measuring kidney care delivery quality is more important than ever in this context.”

Structured Evaluation

With the goal of evaluating existing kidney quality metrics and providing a framework for quality measurement to guide clinicians and policy makers, the committee complied a comprehensive list of national metrics from multiple established kidney and quality organizations. Two rounds of structured metric evaluation were conducted to assess validity, based on American College of Physicians criteria: importance, appropriate care, clinical evidence base, clarity of measure specifications, and feasibility and applicability.

Dr. Mendu and colleagues assessed a total of 60 quality. Among them, 28 were for dialysis management, 18 for broad measures, seven for CKD prevention, two for slowing CKD progression, two for CKD management, two focused on patient-reported outcomes, and one for advanced CKD and kidney replacement planning. “We rated less than half of the metrics as highly valid,” explains Dr. Mendu. Indeed, 29 (49%) had high validity, 23 (38%) had medium validity, and eight (13%) had low validity (Table).

Those that were not rated as highly valid “fell shot because of unclear attribution, inadequate definitions and risk adjustment, or discordance with recent evidence,” says Dr. Mendu. “With nearly half of the metrics 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, and present a framework as to how to achieve better measures (Figure). The steps we outline represent how to ensure highly valid metrics that are reflective of patient-centered outcomes and relevant to nephrology care.”

Driving True Care Improvements

As nephrologists are considering how best to deliver high-quality care to advance patient-centered outcomes, understanding how to define quality is particularly important, according to Dr. Mendu. “Improved quality metrics that capture how care is delivered have the ability to drive true care improvements,” she adds. “For example, the optimal starts metric, which measures how many patients start dialysis as an outpatient, on home dialysis, or receive a transplant before they need dialysis, we rated highly valid, and this type of measure can facilitate patient-centered transitions to dialysis.

“Over the past 2 decades, nationally, we have moved toward ‘high-quality’ and ‘high-value’ healthcare delivery as a goal, and the Affordable Care Act included provisions to help shift care delivery in this direction. However, how we define quality of care is important, particularly for kidney disease care. This is an important time given the national attention to kidney care delivery and efforts of the current administration to improve kidney care. As such, it is even more important to make sure that we are measuring high-quality kidney disease care accurately and appropriately.”