Measuring Quality in Kidney Care: An Evaluation of Existing Quality Metrics and Approach to Facilitating Improvements in Care Delivery
Mallika L. Mendu, Sri Lekha Tummalapalli, Krista L. Lentine, Kevin F. Erickson, Susie Q. Lew, Frank Liu, Edward Gould, Michael J.G. Somers, Pranav S. Garimella, Terrence Jay O'Neil, David L. White, Rachel Meyer, Scott D. Bieber, Daniel E. Weiner
Abstract
Significance Statement 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. Background 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. Methods 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. Results 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. Conclusions 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.