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

• Published in: Journal of the American Society of Nephrology Vol. 31; no. 3; pp. 602 - 614
• Main Authors: Mendu, Mallika L, Tummalapalli, Sri Lekha, Lentine, Krista L, Erickson, Kevin F, Lew, Susie Q, Liu, Frank, Gould, Edward, Somers, Michael, Garimella, Pranav S, O'Neil, Terrence, White, David L, Meyer, Rachel, Bieber, Scott D, Weiner, Daniel E
• Format: Journal Article
• Language: English
• Published: United States American Society of Nephrology 01.03.2020
• Subjects: Benchmarking; Clinical Research; Delivery of Health Care; Female; Humans; Kidney Failure, Chronic - diagnosis; Kidney Failure, Chronic - therapy; Male; Patient Care - methods; Quality Improvement; Renal Dialysis - methods; Renal Insufficiency, Chronic - diagnosis; Renal Insufficiency, Chronic - therapy; United States; United States; chronic kidney disease; Quality Improvement; end-stage renal disease; Quality Metrics
• ISSN: 1046-6673; 1533-3450
• DOI: 10.1681/ASN.2019090869

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.