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Kidney Disease Research Updates
Spring 2012

Kidney Interagency Coordinating Committee Meets to Discuss Quality Improvement in Care for Dialysis Patients


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The National Kidney Disease Education Program (NKDEP), a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), hosted a meeting of the Kidney Interagency Coordinating Committee (KICC) in September 2011 on the campus of the National Institutes of Health in Bethesda, MD.

Andrew S. Narva, M.D., F.A.C.P., director of the NKDEP, opened with a review of KICC’s history and its goals. KICC was founded in 1983 to help agencies in the Federal Government coordinate their efforts on kidney disease.

Dr. Narva introduced two guest speakers from the Centers for Medicare and Medicaid Services (CMS), as the focus of the day’s meeting would be discussing the role of federal agencies in improving quality of care.

The speakers, Kimberly Smith, M.D., M.S., and Shari Ling, M.D., represented CMS’s Office of Clinical Standards and Quality (OCSQ).

CMS Goals

Dr. Smith spoke first, saying that the CMS is trying to shift from a system of payment for quantity of health care services to a system of payment for quality of health care services and better outcomes.

She presented the CMS goals, including

  • Better care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe.
  • Healthy people: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.
  • Affordable care: Reduce the cost of quality health care for individuals, families, employers, and Government.
Dr. Smith clarified that “healthy people” refers to the prevention of disease and that “affordable care” was not to be interpreted as rationing.

Dr. Smith reported that a recent initiative of the OCSQ is the ESRD Quality Incentive Program (QIP), the first in a series of CMS programs that mark a significant change in how Medicare reimburses providers and facilities for patient care. CMS developed the ESRD QIP to be the nation’s first pay-for-performance, also known as “value-based purchasing,” program as mandated by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Along with the ESRD QIP, MIPPA also created a new payment system to replace a payment system in effect since 1983. The “composite rate” under the old system included some drugs, laboratory tests, and supplies. Over time, the expenditures for separately billable drugs, for example, erythropoeisisstimulating agents and vitamin D analogues, have increased substantially. They now constitute 40 percent of total Medicare spending for outpatient dialysis.

Dr. Smith emphasized that the CMS is eager to collaborate with other agencies to deal with issues of quality improvement in the delivery of dialysis services.

Measuring the Quality of Dialysis Services

Dr. Ling gave a presentation on the challenges of measuring the quality of dialysis services.

She asked, “Why measure quality? One answer is to drive improvement. Having the quality of your performance measured acts as an incentive for health care providers. Measurement provides information about whether goals are being met.”

Dr. Ling discussed three types of measurement: process, outcomes, and composite.

According to Dr. Ling, the two most commonly used are process and outcome measures. Process measures look at whether the appropriate processes are used to deliver the care. These types of measures are often favored by the health care community because they are within the control of the organization or clinician. Process measures are not usually risk adjusted. Instead they rely on the use of exclusions and the stratification of results by patient characteristics. Outcomes measure the end result and can be influenced by many factors, including patient factors. For this reason, they require risk adjustment.

Composite measures are usually created to look at how well a more comprehensive set of related processes of care are delivered and provide more insight into the quality of care delivered for a particular health condition. Combining measures can make it easier for users to quickly interpret the information.

A critical aspect of measure development is identifying appropriate data sources. Currently, claims data are being used to assess most measures, which does not allow for proper measurement. Implementation of CROWNWeb, the CMS electronic health record system, will improve measurement.

The measurement development process provides ample opportunity for involvement across federal agencies. CMS is already collaborating with the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention (CDC), and the Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation.


Drs. Smith and Ling proposed a series of questions to members of the committee:
  • How do you create quality measures for ESRD treatments?
  • Which data sources should be considered to evaluate the feasibility of a quality measurement?
  • How do you implement an incentive program that encourages quality improvement?
The members of the committee raised additional questions.
  • How do you translate measurements into better outcomes?
  • What data sources can be used to measure improvement at the population level?
Robert A. Star, M.D., director of NIDDK’s Division of Kidney, Urologic, and Hematologic Diseases, asserted that care for chronic kidney disease (CKD) patients before dialysis is critical to quality improvement. The measures for fistula preparation, education, and predialysis medical care are needed. He also raised the question, “How do we address the high mortality rate of patients in the first 6 months of dialysis?”

Drs. Smith and Ling repeated their invitation for other agencies represented at the KICC meeting to become involved in the quality improvement and measurement development process.

Agency Updates

Near the end of the meeting, committee members had an opportunity to report on their agencies’ activities. Christine Chang, M.D., M.P.H., informed the committee that the Agency for Healthcare Research and Quality will release a report on screening and monitoring for CKD. A portion of this report was used by a task force to develop screening recommendations, which will be released in 2012. The agency may allow for a public comment period on these recommendations. An upcoming report on biomarkers for management of anemia in pre-dialysis and dialysis patients will soon be coming out for public comment.

Desmond Williams, M.D., Ph.D., reported that the CDC has received funding for its CKD surveillance website for the next 5 years.

Dr. Narva closed the meeting, thanking attendees for their participation.


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NIH Publication No. 12–4531
June 2012

Page last updated June 26, 2012


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