The ESRD Quality Incentive Program-Can We Bridge the Chasm?

Patient-Centered Quality Measures for Dialysis Care: A Report of a Kidney Disease Outcomes Quality Initiative (KDOQI) Scientific Workshop Sponsored by the National Kidney Foundation

Providing high-quality patient-centered care is the central mission of dialysis facilities. Assessing quality and patient-centeredness of dialysis care is necessary for continuous dialysis facility improvement. Based predominantly on readily measured items, current quality measures in dialysis care emphasize biochemical and utilization outcomes, with very few patient-reported items. Additionally, current metrics often do not account for patient preferences and may compromise patient-centered care by limiting the ability of providers to individualize care targets, such as dialysis adequacy, based on patient priorities rather than a fixed numerical target. Developing, implementing, and maintaining a quality program using readily quantifiable data while also allowing for individualization of care targets that emphasize the goals of patients and their care partners provided the motivation for a September 2022 Kidney Disease Outcomes Quality Initiative (KDOQI) Workshop on Patient-Centered Quality Measures for Dialysis Care. Workshop participants focused on 4 questions: (1) What are the outcomes that are most important to patients and their care partners? (2) How can social determinants of health be accounted for in quality measures? (3) How can individualized care be effectively addressed in population-level quality programs? (4) What are the optimal means for collecting valid and robust patient-reported outcome data? Workshop participants identified numerous gaps within the current quality system and favored a conceptually broader, but not larger, quality system that stresses highly meaningful and adaptive measures that incorporate patient-centered principles, individual life goals, and social risk factors. Workshop participants also identified a need for new, low-burden tools to assess patient goals and priorities.

Pay-for-performance programs effectiveness in healthcare: the case of the end-stage renal disease quality incentive program

This paper focuses on Medicare's End-Stage Renal Disease Quality Incentive Program (QIP). QIP aims to promote high-quality services in outpatient dialysis facilities by tying their payments to their performance on pre-specified quality measures. In this paper, employing principal-agent theory, we examine the effectiveness of QIP by exploring the changes in various clinical/operational measures when they become a part of the program as a performance measure. We study five QIP quality measures; two are operational: hospitalization and readmission. And three others are clinical: blood transfusion, hypercalcemia, and dialysis adequacy. Overall, we observe a significant improvement in all QIP quality measures after being included in the program, except for readmission. We recommend adjusting the weight and redesigning the readmission measure for Medicare to incentivize providers to reduce readmission. We also discuss establishing care coordination and employing data-driven clinical decision support systems as opportunities for dialysis facilities to improve the care delivery process.

Policy and Payment Decisions on Peritoneal Dialysis in the United States: A Review

End-stage kidney disease (ESKD) accounts for a sizable proportion of Medicare spending. Peritoneal dialysis remains an underutilized treatment modality for ESKD despite its quality of life and cost-saving benefits. Medicare policy on reimbursements and patient eligibility for dialysis coverage has been amended numerous times since its inception in 1972. Over the last two decades, Medicare policy on ESKD reimbursements has evolved from a primarily fee-for-service model to a prospective payment system, and within the past few years, it has begun including more experimental payment structures. While prior work has explored the evolution of Medicare's ESKD policy as a whole, we specifically outline the impact of Medicare policy changes on peritoneal dialysis reimbursement rates, uptake by physicians and dialysis facilities, and accessibility to patients. This narrative review offers historical insights, an overview of modern ESKD policy, actionable strategies, and policy opportunities to increase the accessibility of this treatment modality.

System-Level Strategies to Improve Home Dialysis: Policy Levers and Quality Initiatives

Advocacy and policy change are powerful levers to improve quality of care and better support patients on home dialysis. While the kidney community increasingly recognizes the value of home dialysis as an option for patients who prioritize independence and flexibility, only a minority of patients dialyze at home in the United States. Complex system-level factors have restricted further growth in home dialysis modalities, including limited infrastructure, insufficient staff for patient education and training, patient-specific barriers, and suboptimal physician expertise. In this article, we outline trends in home dialysis use, review our evolving understanding of what constitutes high-quality care for the home dialysis population (as well as how this can be measured), and discuss policy and advocacy efforts that continue to shape the care of US patients and compare them with experiences in other countries. We conclude by discussing future directions for quality and advocacy efforts.

Home dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Home dialysis modalities (home hemodialysis [HD] and peritoneal dialysis [PD]) are associated with greater patient autonomy and treatment satisfaction compared with in-center modalities, yet the level of home-dialysis use worldwide is low. Reasons for limited utilization are context-dependent, informed by local resources, dialysis costs, access to healthcare, health system policies, provider bias or preferences, cultural beliefs, individual lifestyle concerns, potential care-partner time, and financial burdens. In May 2021, KDIGO (Kidney Disease: Improving Global Outcomes) convened a controversies conference on home dialysis, focusing on how modality choice and distribution are determined and strategies to expand home-dialysis use. Participants recognized that expanding use of home dialysis within a given health system requires alignment of policy, fiscal resources, organizational structure, provider incentives, and accountability. Clinical outcomes across all dialysis modalities are largely similar, but for specific clinical measures, one modality may have advantages over another. Therefore, choice among available modalities is preference-sensitive, with consideration of quality of life, life goals, clinical characteristics, family or care-partner support, and living environment. Ideally, individuals, their care-partners, and their healthcare teams will employ shared decision-making in assessing initial and subsequent kidney failure treatment options. To meet this goal, iterative, high-quality education and support for healthcare professionals, patients, and care-partners are priorities. Everyone who faces dialysis should have access to home therapy. Facilitating universal access to home dialysis and expanding utilization requires alignment of policy considerations and resources at the dialysis-center level, with clear leadership from informed and motivated clinical teams.

Mortality Risk of Patients Treated in Dialysis Facilities with Payment Reductions under ESRD Quality Incentive Program

BACKGROUND

The Centers for Medicare & Medicaid Services End-Stage Renal Disease Quality Incentive Program (ESRD QIP) measures quality of care delivered by dialysis facilities and imposes Medicare payment reductions for quality lapses. We assessed the association between payment reductions and patient mortality, a quality indicator not included in the ESRD QIP measure set.

METHODS

Association between mortality and ESRD QIP facility payment reduction based on the year of performance was expressed as the unadjusted rate and patient case-mix-adjusted hazard ratio. We also measured association between mortality and 1-year changes in payment reductions. Retrospective patient cohorts were defined by their treating dialysis facility on the first day of each year (2010-2018).

RESULTS

Facility performance resulted in payment reductions for 5%-42% of dialysis facilities over the 9 study years. Patients experienced progressively higher mortality at each payment reduction level. Across all years, unadjusted mortality was 17.3, 18.1, 18.9, 20.3, and 23.9 deaths per 100 patient-years for patients in facilities that received 0%, 0.5%, 1%, 1.5%, and 2% payment reductions, respectively. The adjusted hazard ratio showed a similar stepwise pattern by the level of payment reduction: 1.0 (reference), 1.08 (95% confidence interval [CI], 1.07 to 1.09), 1.15 (95% CI, 1.13 to 1.16), 1.19 (95% CI, 1.16 to 1.21), and 1.34 (95% CI, 1.29 to 1.39). Strength of the association increased from 2010 to 2016. Patients treated in facilities that improved over 1 year generally experienced lower mortality; patients in facilities that performed worse on ESRD QIP measures generally experienced higher mortality.

CONCLUSIONS

Patient mortality was associated with ESRD QIP facility payment reductions in dose-response and temporal patterns.

Hemodialysis facility star rating affects mortality in chronic hemodialysis patients: a longitudinal observational cohort study

BACKGROUND

Many countries have their own hemodialysis (HD) quality assurance programs and star rating systems for HD facilities. However, the effects of HD quality assurance programs on patient mortality are not well understood. Therefore, in the present study, the effects of the Korean HD facility star rating on patient mortality in maintenance HD patients were evaluated.

METHODS

This longitudinal, observational cohort study included 35,271 patients receiving HD treatment from 741 facilities. The fivestar ratings of HD facilities were determined based on HD quality assessment data from 2015, which includes 12 quality measures in structural, procedural, and outcome domains. The patients were grouped into high (three to five stars) and low (one or two stars) groups based on HD facility star rating. Cox proportional hazards model was used to evaluate the effects of star rating on patient mortality during the mean follow-up duration of 3 years.

RESULTS

The patient ratio between high and low HD facility star rating groups was 82.0% vs. 18.0%. The patients in the low star rating group showed lower single-pool Kt/V and higher calcium and phosphorus levels compared with subjects in the high star rating group. After adjusting for sociodemographic and clinical parameters, the HD facility star rating independently increased the mortality risk (hazard ratio, 1.11; 95% confidence interval, 1.04-1.18; p = 0.002).

CONCLUSION

The HD facilities with low star rating showed higher patient mortality.

Global Policy Barriers and Enablers to Exercise and Physical Activity in Kidney Care

OBJECTIVE

Impairment in physical function and physical performance leads to decreased independence and health-related quality of life in people living with chronic kidney disease and end-stage kidney disease. Physical activity and exercise in kidney care are not priorities in policy development. We aimed to identify global policy-related enablers, barriers, and strategies to increase exercise participation and physical activity behavior for people living with kidney disease.

DESIGN AND METHODS

Guided by the Behavior Change Wheel theoretical framework, 50 global renal exercise experts developed policy barriers and enablers to exercise program implementation and physical activity promotion in kidney care. The consensus process consisted of developing themes from renal experts from North America, South America, Continental Europe, United Kingdom, Asia, and Oceania. Strategies to address enablers and barriers were identified by the group, and consensus was achieved.

RESULTS

We found that policies addressing funding, service provision, legislation, regulations, guidelines, the environment, communication, and marketing are required to support people with kidney disease to be physically active, participate in exercise, and improve health-related quality of life. We provide a global perspective and highlight Japanese, Canadian, and other regional examples where policies have been developed to increase renal physical activity and rehabilitation. We present recommendations targeting multiple stakeholders including nephrologists, nurses, allied health clinicians, organizations providing renal care and education, and renal program funders.

CONCLUSIONS

We strongly recommend the nephrology community and people living with kidney disease take action to change policy now, rather than idly waiting for indisputable clinical trial evidence that increasing physical activity, strength, fitness, and function improves the lives of people living with kidney disease.

Medicare Bundled Payment Policy on Anemia Care, Major Adverse Cardiovascular Events, and Mortality among Adults Undergoing Hemodialysis

BACKGROUND AND OBJECTIVES

In 2011, the Centers for Medicare & Medicaid Services implemented bundling of all services for patients receiving dialysis, including erythropoietin-stimulating agents use, and the Food and Drug Administration recommended conservative erythropoietin-stimulating agent dosing.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective cohort study investigated anemia care and clinical outcomes before and after the Centers for Medicare & Medicaid Services bundled payment and the revised Food and Drug Administration-recommended erythropoietin-stimulating agent labeling for Medicare-insured adults receiving hemodialysis using data from the United States Renal Data System from January 1, 2006 to December 31, 2016. Clinical outcomes included major adverse cardiovascular event (stroke, acute myocardial infarction, and all-cause mortality), cardiovascular mortality, and heart failure. Measurements were compared between prepolicy (2006-2010) and postpolicy (2012-2016) implementation using interrupted time series and Cox proportional hazards regression models.

RESULTS

Of 481,564 patients, erythropoietin-stimulating agent use immediately decreased by 84.8 per 1000 persons (P<0.001), with a significant decrease in the slope of the trend line (both P=0.001). Blood transfusion use rapidly increased by 8.34 per 1000 persons in April 2012 and then gradually decreased (both P=0.001). The percentage of patients with hemoglobin >11 g/dl decreased from 68% in January 2006 to 28% in December 2016, whereas those with hemoglobin <9 g/dl increased from 5% to 9%. Overall major adverse cardiovascular event (adjusted hazard ratio, 0.95; 95% confidence interval, 0.94 to 0.96), stroke (adjusted hazard ratio, 0.83; 95% confidence interval, 0.80 to 0.86), all-cause mortality (adjusted hazard ratio, 0.87; 95% confidence interval, 0.86 to 0.89), cardiovascular mortality (adjusted hazard ratio, 0.81; 95% confidence interval, 0.79 to 0.83), and heart failure (adjusted hazard ratio, 0.86; 95% confidence interval, 0.84 to 0.88) risks were lower. Acute myocardial infarction risk (adjusted hazard ratio, 1.04; 95% confidence interval, 1.01 to 1.06) was higher after policies changed.

CONCLUSIONS

The Medicare reimbursement policy and Food and Drug Administration-recommended erythropoietin-stimulating agent dosing changes were associated with lower erythropoietin-stimulating agent use and lower hemoglobin levels. These changes in anemia care were associated with lower risks of major adverse cardiovascular event, stroke, mortality, and heart failure but higher risk of acute myocardial infarction among adults receiving hemodialysis.

Value-Based Care and Kidney Disease: Emergence and Future Opportunities

The United States health care system has increasingly embraced value-based programs that reward improved outcomes and lower costs. Health care value, defined as quality per unit cost, was a major goal of the 2010 Patient Protection and Affordable Care Act amid high and rising US health care expenditures. Many early value-based programs were specifically designed for patients with end-stage renal disease (ESRD) and targeted toward dialysis facilities, including the ESRD Prospective Payment System, ESRD Quality Incentive Program, and ESRD Seamless Care Organizations. While a great deal of attention has been paid to these ESRD-focused programs, other value-based programs targeted toward hospitals and health systems may also affect the quality and costs of care for a broader population of patients with kidney disease. Value-based care for kidney disease is increasingly relevant in light of the Advancing American Kidney Health initiative, which introduces new value-based payment models: the mandatory ESRD Treatment Choices Model in 2021 and voluntary Kidney Care Choices Model in 2022. In this review article, we summarize the emergence and impact of value-based programs on the quality and costs of kidney care, with a focus on federal programs. Key opportunities in value-based kidney care include shifting the focus toward chronic kidney disease, enhancing population health management capabilities, improving quality measurement, and leveraging programs to advance health equity.

Trends in Dialysis Industry Consolidation After Medicare Payment Reform, 2006-2016

Question

Findings

Meaning

Importance

Objective

Design, Setting, and Participants

Exposures

Main Outcomes and Measures

Results

Conclusions and Relevance

Changes in Dialysis Center Quality Associated With the End-Stage Renal Disease Quality Incentive Program : An Observational Study With a Regression Discontinuity Design

BACKGROUND

In 2012, the Centers for Medicare & Medicaid Services started levying performance-based financial penalties against outpatient dialysis centers under the mandatory End-Stage Renal Disease Quality Incentive Program.

OBJECTIVE

To determine whether penalization was associated with improvement in dialysis center quality.

DESIGN

Leveraging the threshold for penalization (total performance score < 60), a regression discontinuity design was used to examine the effect of penalization on quality over 2 years. Publicly available Medicare data from 2015-2018 were used. The effect of penalization at dialysis centers with different characteristics (for example, size or chain affiliation) was also examined.

SETTING

United States.

PARTICIPANTS

Outpatient dialysis centers (n = 5830).

MEASUREMENTS

Dialysis center total performance scores (a composite metric ranging from 0 to 100 based on clinical quality and adherence to reporting requirements) and individual measures that contribute to the total performance score.

RESULTS

There were 1109 (19.0%) outpatient dialysis centers that received penalties in 2017 on the basis of performance in 2015. Penalized centers were located in ZIP codes with a higher average proportion of non-White residents (36.4% vs. 31.2%; P < 0.001) and residents with lower median income ($49 290 vs. $51 686; P < 0.001). Penalization was not associated with improvement in total performance scores in 2017 (0.4 point [95% CI, -2.5 to 3.2 points]) or 2018 (0.3 point [CI, -2.8 to 3.4 points]). This was consistent across dialysis centers with different characteristics. There was also no association between penalization and improvement in specific measures.

LIMITATION

The study could not account for how centers respond to penalization.

CONCLUSION

Penalization under the End-Stage Renal Disease Quality Incentive Program was not associated with improvement in the quality of outpatient dialysis centers.

PRIMARY FUNDING SOURCE

None.

A Narrative Review of Qualitative Studies Describing Access to Kidney Transplantation

BACKGROUND

This review used the Information-Motivation-Behavioral Skills (IMB) model of health behavior change to conceptualize the determinants of kidney transplant access behavior for adult patients with end-stage renal disease (ESRD).

METHODS

A narrative review of qualitative studies of patient access to kidney transplantation was undertaken. Only articles in English were accessed. The existing literature was critically analyzed using theoretical constructs of the IMB model and thematic synthesis was performed.

RESULTS

Results suggest patients having more information (greater transplant knowledge), more personal motivation (higher transplant outcomes expectations), more social motivation (more social and provider support), and more selfefficacy (confidence in navigating the transplant continuum) may be more likely to perform transplant access behaviors.

CONCLUSION

Our findings provide a framework for considering patients' levels of knowledge, motivation, and self-efficacy in future educational and behavioral interventions for ESRD patients.

A Person-Centered Interdisciplinary Plan-of-Care Program for Dialysis: Implementation and Preliminary Testing

RATIONALE & OBJECTIVE

Despite growing interest in individualizing care, routine dialysis processes, including the interdisciplinary plan of care, often fail to account for patient-identified priorities. To better align dialysis care with patient priorities and improve care planning experiences, we implemented a person-centered care plan program at a single clinic. We also sought to gain insight into key implementation considerations and areas for program improvement.

STUDY DESIGN

6-month quality improvement project with research substudy.

SETTING & PARTICIPANTS

49 hemodialysis patients and 14 care team members at a North Carolina dialysis clinic.

QUALITY IMPROVEMENT ACTIVITIES

Implementation of My Dialysis Plan, a person-centered care plan program.

OUTCOMES

Participant perspectives and care plan meeting characteristics (quality improvement); pre- to postprogram change in patient-reported autonomy support, patient-centeredness of care, and dialysis care individualization (research).

ANALYTICAL APPROACH

We used the Consolidated Framework for Implementation Research to guide implementation and evaluation. We conducted pre-, intra-, and post-project interviews with clinic stakeholders (patients, clinic personnel, and medical providers) to identify implementation barriers, facilitators, and perceptions. We compared pre- and post-project care plan meeting content and patient-reported outcome survey scores.

RESULTS

We conducted 54 care plans with 49 patients. Overall, care teams successfully used My Dialysis Plan to elicit and link patient priorities to actionable aspects of dialysis care. Participants identified interdisciplinary team commitment, accountability, and the structured yet flexible meeting approach as key implementation elements. Throughout the project, stakeholder input guided program modifications (eg, implementation practices and resources) to better meet clinic needs, but follow-up on care plan-identified action items remained challenging. Among the 28 substudy participants, there was no difference in pre- to post-project patient-reported outcome survey scores.

LIMITATIONS

Single clinic implementation.

CONCLUSIONS

My Dialysis Plan has the potential to enhance dialysis care individualization and care plan experiences. Evaluation of program impact on patient-reported and clinical outcomes is needed.

Performance-based risk-sharing agreements in renal care: current experience and future prospects

INTRODUCTION

Performance-based risk-sharing agreements (PBRSAs), between payers, health care providers, and technology manufacturers can be useful when there is uncertainty about the (cost-) effectiveness of a new technology or service. However, they can be challenging to design and implement.

AREAS COVERED

A total of 18 performance-based agreements were identified through a literature review. All but two of the agreements identified were pay-for-performance schemes, agreed between providers and payers at the national level. No examples were found of agreements between health care providers and manufacturers at the local level. The potential for these local agreements was illustrated by hypothetical case studies of water quality management and an integrated chronic kidney disease program.

EXPERT OPINION

Performance-based risk-sharing agreements can work to the advantage of patients, health care providers, payers, and technology manufacturers, particularly if they facilitate the introduction of technologies or systems of care that might not have been introduced otherwise. However, the design, conduct, and implementation of PBRSAs in renal care pose a number of challenges. Efforts should be made to overcome these challenges so that more renal care patients can benefit from technological advances and new models of care.

Storytelling to Inspire Dialysis Patients to Learn about Living Donor Kidney Transplant

BACKGROUND

Policy changes including the Advancing American Kidney Health initiative and CMS's ESRD Quality Incentive Program recommend increasing educational initiatives within dialysis centers to increase living kidney donor transplant (LDKT) rates. LDKT education can be challenging in dialysis centers due to limited provider time to educate, patient fears or reluctance to learn about LDKT, and difficulty educating potential living donors. New educational innovations that increase dialysis patient curiosity about pursuing LDKT are needed.

SUMMARY

Digital first-person storytelling, or the sharing of narratives by individuals in their own words, is a culturally competent, health literate, patient-driven approach to expanding patient understanding about LDKT that can supplement traditional educational strategies without additional burden for dialysis providers. The Living Donation Storytelling Project is an online digital library of over 150 video stories told by diverse kidney recipients, donors, those in search of a donor, and their family/friends. By honestly discussing how they overcame fears and challenges related to LDKT, these stories address sensitive topics that can be hard for providers to introduce by using easily accessible learning methodology that may better connect with racial/ethnic minorities, scared patients, and patients facing health literacy challenges. Key Messages: Supplementing traditional educational approaches with digital storytelling may help overcome time limitations in educating for busy providers, boost providers' own knowledge about LDKT, serve as a free supplemental resource for patients, reduce fears and increase self-efficacy about transplant, help more patients to share about transplant with their social networks, and ultimately increase LDKT rates.

Optimizing Peritoneal Dialysis-Associated Peritonitis Prevention in the United States: From Standardized Peritoneal Dialysis-Associated Peritonitis Reporting and Beyond

Peritoneal dialysis (PD)-associated peritonitis is the leading cause of permanent transition to hemodialysis among patients receiving PD. Peritonitis is associated with higher mortality risk and added treatment costs and limits more widespread PD utilization. Optimizing the prevention of peritonitis in the United States will first require standardization of peritonitis definitions, key data elements, and outcomes in an effort to facilitate nationwide reporting. Standardized reporting can also help describe the variability in peritonitis rates and outcomes across facilities in the United States in an effort to identify potential peritonitis prevention strategies and engage with stakeholders to develop strategies for their implementation. Here, we will highlight considerations and challenges in developing standardized definitions and implementation of national reporting of peritonitis rates by PD facilities. We will describe existing peritonitis prevention evidence gaps, highlight successful infection-reporting initiatives among patients receiving in-center hemodialysis or PD, and provide an overview of nationwide quality improvement initiatives, both in the United States and elsewhere, that have translated into a reduction in peritonitis incidence. We will discuss opportunities for collaboration and expansion of the Nephrologists Transforming Dialysis Safety (NTDS) initiative to develop knowledge translation pathways that will lead to dissemination of best practices in an effort to reduce peritonitis incidence.

An Environmental Scan and Evaluation of Home Dialysis Quality Indicators Currently Used in Canada

Background

Quality indicators are important tools to measure and ultimately improve the quality of care provided. Performance measurement may be particularly helpful to grow disciplines that are underutilized and cost-effective, such as home dialysis (peritoneal dialysis and home hemodialysis).

Objective

To identify and catalog home dialysis quality indicators currently used in Canada, as well as to evaluate these indicators as a starting point for future collaboration and standardization of quality indicators across Canada.

Design

An environmental scan of quality indicators from provincial organizations, quality organizations, and stakeholders.

Setting

Sixteen-member pan-Canadian panel with expertise in both nephrology and quality improvement.

Patients

Our environmental scan included indicators relevant to patients on home dialysis.

Measurements

We classified existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks.

Methods

To evaluate the indicators, a 6-person subcommittee conducted a modified version of the Delphi consensus technique based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for further examination. We rated items from 1 to 9 on 6 domains (1-3 does not meet criteria to 7-9 meets criteria) as well as a global final rating (1-3 unnecessary to 7-9 necessary) to distinguish high-quality from low-quality indicators.

Results

Overall, we identified 40 quality indicators across 7 provinces, with 22 (55%) rated as "necessary" to distinguish high quality from poor quality care. Ten indicators were measured by more than 1 province, and 5 of these indicators were rated as necessary (home dialysis prevalence, home dialysis incidence, anemia target achievement, rates of peritonitis associated with peritoneal dialysis, and home dialysis attrition). None of these indicators captured the IOM domains of timely, patient-centered, or equitable care.

Limitations

The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals.

Conclusions

These results provide Canadian home dialysis programs with a starting point on how to measure quality of care along with the current gaps. This work is an initial and necessary step toward future collaboration and standardization of quality indicators across Canada, so that home dialysis programs can access a smaller number of highly rated balanced indicators to motivate and support patient-centered quality improvement initiatives.

An Environmental Scan of Canadian Quality Metrics for Patients on In-Center Hemodialysis

Background:

Quality metrics or indicators help guide quality improvement work by reporting on measurable aspects of health care upon which improvement efforts can focus. For recipients of in-center hemodialysis (ICHD) in Canada, it is unclear what ICHD quality indicators exist and whether they adequately cover different domains of health care quality.

Objectives:

To identify and evaluate current Canadian ICHD quality metrics to document a starting point for future collaborations and standardization of quality improvement in Canada.

Design:

Environmental scan of quality metrics in ICHD, and subsequent indicator evaluation using a modified Delphi approach.

Setting:

Canadian ICHD units.

Participants:

Sixteen-member pan-Canadian working group with expertise in ICHD and quality improvement.

Measurements:

We classified the existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks.

Methods:

Each metric was rated by a 5-person subcommittee using a modified Delphi approach based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for additional comments.

Results:

We identified 27 metrics that are tracked across 8 provinces, with only 9 (33%) tracked by multiple provinces (ie, more than 1 province). We rated 9 metrics (33%) as “necessary” to distinguish high-quality from low-quality care, of which only 2 were tracked by multiple provinces (proportion of patients by primary access and rate of vascular access-related bloodstream infections). Most (16/27, 59%) indicators assessed the IOM domains of safe or effective care, and none of the “necessary” indicators measured the IOM domains of timely, patient-centered, or equitable care.

Limitations:

The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals, with more representation from academic sites.

Conclusions:

Quality indicators in Canada mainly focus on safe and effective care, with little provincial overlap. These results highlight current gaps in quality of care measurement for ICHD, and this initial work should provide programs with a starting point to combine highly rated indicators with newly developed indicators into a concise balanced scorecard that supports quality improvement initiatives across all aspects of ICHD care.

Trial Registration:

not applicable.

KDOQI US Commentary on the 2020 ISPD Practice Recommendations for Prescribing High-Quality Goal-Directed Peritoneal Dialysis

The recently published 2020 International Society for Peritoneal Dialysis (ISPD) practice recommendations regarding prescription of high-quality goal-directed peritoneal dialysis differ fundamentally from previous guidelines that focused on "adequacy" of dialysis. The new ISPD publication emphasizes the need for a person-centered approach with shared decision making between the individual performing peritoneal dialysis and the clinical care team while taking a broader view of the various issues faced by that individual. Cognizant of the lack of strong evidence for the recommendations made, they are labeled as "practice points" rather than being graded numerically. This commentary presents the views of a work group convened by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) to assess these recommendations and assist clinical providers in the United States in interpreting and implementing them. This will require changes to the current clinical paradigm, including greater resource allocation to allow for enhanced services that provide a more holistic and person-centered assessment of the quality of dialysis delivered.

Trends in Mineral Metabolism Treatment Strategies in Patients Receiving Hemodialysis in the United States

BACKGROUND AND OBJECTIVES

With multiple medications indicated for mineral metabolism, dialysis providers can apply various strategies to achieve target phosphate and parathyroid hormone (PTH) levels. We describe common prescribing patterns and practice variation in mineral metabolism treatment strategies over the last decade.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In a cohort of adults initiating hemodialysis at Dialysis Clinic, Inc. facilities, we assessed prescriptions of vitamin D sterols, phosphate binders, and cinacalcet longitudinally. To identify the influence of secular trends in clinical practice, we stratified the cohort by dialysis initiation year (2006-2008, 2009-2011, and 2012-2015). To measure practice variation, we estimated the median odds ratio for prescribing different mineral metabolism treatment strategies at 12 months post-dialysis initiation across facilities using mixed effects multinomial logistic regression. Sensitivity analyses evaluated strategies used after detection of first elevated PTH.

RESULTS

Among 23,549 incident patients on hemodialysis, there was a decline in vitamin D sterol-based strategies and a corresponding increase in strategies without PTH-modifying agents (i.e., phosphate binders alone or no mineral metabolism medications) and cinacalcet-containing treatment strategies between 2006 and 2015. The proportion with active vitamin D sterol-based strategies at dialysis initiation decreased across cohorts: 15% (2006-2008) to 5% (2012-2015). The proportion with active vitamin D sterol-based strategies after 18 months of dialysis decreased across cohorts: 52% (2006-2008) to 34% (2012-2015). The odds of using individual strategies compared with reference (active vitamin D sterol with phosphate binder) varied from 1.5- to two-fold across facilities in 2006-2008 and 2009-2011 cohorts, and increased to two- to three-fold in the 2012-2015 cohort. Findings were similar in sensitivity analyses starting from first elevated PTH measurement.

CONCLUSIONS

Over time, mineral metabolism management involved less use of vitamin D sterol-based strategies, greater use of both more conservative and cinacalcet-containing strategies, and increased practice variation, suggesting growing equipoise.

Engaging patients and family members to design and implement patient-centered kidney disease research

We need more research projects that partner and engage with patients and family members as team members. Doing this requires that patients and family members set research priorities and fully participate in research teams. Models for this patient and family member engagement as research partners can help increase patient centered outcomes research. In this article, we describe how we have successfully engaged patients with kidney disease and family members as Co-Investigators on a 5-year research project testing a health system intervention to improve kidney disease care. Background This article describes a method for successful engagement of patients and family members in all stages of a 5-year comparative effectiveness research trial to improve transitions of care for patients from chronic kidney disease to end-stage kidney disease. Methods This project utilized the Patient-Centered Outcomes Research Institute's conceptual model for engagement with patients and family members. We conducted a qualitative analysis of grant planning meetings to determine patient and family member Co-Investigators' priorities for research and to include these engagement efforts in the research design. Patient and family member Co-Investigators partnered in writing this paper. Results Patients and family members were successfully engaged in remote and in-person meetings to contribute actively to research planning and implementation stages. Three patient-centered themes emerged from our data related to engagement that informed our research plan: kidney disease treatment decision-making, care transitions from chronic to end-stage kidney disease, and patient-centered outcomes. Conclusions The model we have employed represents a new paradigm for kidney disease research in the United States, with patients and family members engaged as full research partners. As a result, the study tests an intervention that directly responds to their needs, and it prioritizes the collection of outcomes data most relevant to patient and family member Co-Investigators. Trial registration NCT02722382 .

Using Patient Experience Survey Data to Improve In-Center Hemodialysis Care: A Practical Review

Patient experience is an integral aspect of the care we deliver to our dialysis patients. Standardized evaluation of patient experience with in-center hemodialysis started in the United States in 2012 with the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey. Over time there have been a few changes to this survey, how it is administered, and how it fits within the Centers for Medicare & Medicaid Services End-Stage Renal Disease Quality Incentive Program. Although the importance of this survey has been growing, knowledge of this survey among nephrologists has lagged. We provide a review of the survey development and how its use has evolved since 2012. We discuss in detail research done on this survey to date, including survey psychometric evaluation. We highlight gaps in our knowledge that need further research and end with general recommendations to improve patient experience within hemodialysis facilities, which we believe is a worthy goal for all members of the dialysis team.

Long-term Clinical Outcomes Among Responders and Nonresponders to the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Survey

Rationale & Objective

The In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey, introduced into the End-Stage Renal Disease Quality Incentive Program, is the only patient-reported outcome currently used for value-based reimbursement in dialysis. Current response rates are ∼30% and differences in long-term clinical outcomes between survey responders and nonresponders are unknown.

Study Design

Retrospective cohort study.

Setting & Participants

Patients from all Dialysis Clinic Incorporated facilities from across the United States who met survey eligibility (aged ≥18 years and had been treated at their facility for at least 3 months).

Exposures

Patient-level demographic, clinical, and treatment-related characteristics.

Outcomes

Mortality, all-cause hospitalization, and kidney transplantation.

Analytical Approach

Time-to-event analyses using competing-risks models. Sensitivity analyses performed after multiple imputation for missing covariate data.

Results

Among 10,395 eligible patients, 3,794 (36%) responded to the survey. During a median follow-up of 33 months, 4,588 patients died, 7,638 patients were hospitalized at least once, and 789 patients received a transplant. In multivariable models, survey response was associated with lower mortality (subdistribution hazard ratio [sHR], 0.80; 95% CI, 0.75-0.86) and hospitalization (sHR, 0.94; 95% CI, 0.89-0.99) and higher likelihood for a kidney transplant (sHR, 1.27; 95% CI, 1.10-1.46). Results were consistent across sensitivity analyses after multiple imputation for missing covariates.

Limitations

Small amount of missing covariate data, baseline covariate data assigned at the first month of the 3-month survey administration period, reasons for nonresponse unknown.

Conclusions

Response to the ICH CAHPS survey is associated with lower risk for mortality and hospitalization and higher likelihood for kidney transplantation. These findings suggest that survey responders are healthier than nonresponders, emphasizing the need for caution when interpreting facility-level survey results to inform quality improvement and public policy efforts and the critical need to better capture patient-reported outcomes from more vulnerable patients.

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

Exploring Care Attributes of Nephrologists Ranking Favorably on Measures of Value

BACKGROUND

Despite growth in value-based payment, attributes of nephrology care associated with payer-defined value remains unexplored.

METHODS

Using national health insurance claims data from private preferred provider organization plans, we ranked nephrology practices using total cost of care and a composite of common quality metrics. Blinded to practice rankings, we conducted site visits at four highly ranked and three average ranked practices to identify care attributes more frequently present in highly ranked practices. A panel of nephrologists used a modified Delphi method to score each distinguishing attribute on its potential to affect quality and cost of care and ease of transfer to other nephrology practices.

RESULTS

Compared with average-value peers, high-value practices were located in areas with a relatively higher proportion of black and Hispanic patients and a lower proportion of patients aged >65 years. Mean risk-adjusted per capita monthly total spending was 24% lower for high-value practices. Twelve attributes comprising five general themes were observed more frequently in high-value nephrology practices: preventing near-term costly health crises, supporting patient self-care, maximizing effectiveness of office visits, selecting cost-effective diagnostic and treatment options, and developing infrastructure to support high-value care. The Delphi panel rated four attributes highly on effect and transferability: rapidly adjustable office visit frequency for unstable patients, close monitoring and management to preserve kidney function, early planning for vascular access, and education to support self-management at every contact.

CONCLUSIONS

Findings from this small-scale exploratory study may serve as a starting point for nephrologists seeking to improve on payer-specified value measures.

Low Quality of International Classification of Diseases, 10th Revision, Procedural Coding System Data Undermines the Validity of the Standardized Transfusion Ratio: Time to Chart a New Course?

The validity of the standardized transfusion ratio, a quality measure for dialysis facilities, may have been affected by the transition from International Classification of Diseases, Ninth Revision (ICD-9) to International Classification of Diseases, Tenth Revision (ICD-10) procedure coding in October 2015. We analyzed Medicare Part A claims for inpatient care among dialysis patients in 2014-2017 and investigated billing patterns for blood transfusion during the last year of ICD-9 coding and the first and second years of ICD-10 coding. We identified 2205 hospitals with a steady volume of dialysis patient admissions. In nearly one-third (31.7%) of hospitals, the apparent incidence of blood transfusion during hospitalization fell >50% between the last year of ICD-9 coding and the first year of ICD-10 coding. Between the first and second years of ICD-10 coding, the apparent incidence of blood transfusion during hospitalization fell >20% in 24.5% of hospitals and rose >25% in 14.8% of hospitals. Furthermore, hospital-specific changes in the apparent incidence of blood transfusion among dialysis patients and all Medicare beneficiaries were highly correlated. These findings suggest that the standardized transfusion ratio reflects differential misclassification of transfusions among hospitals. Alternative measures to judge the quality of anemia management, such as attainment of hemoglobin within a target range, may be more appropriate.

Patient-Reported Experiences of Dialysis Care Within a National Pay-for-Performance System

IMPORTANCE

Medicare's End-Stage Renal Disease Quality Incentive Program incorporates measures of perceived value into reimbursement calculations. In 2016, patient experience became a clinical measure in the Quality Incentive Program scoring system. Dialysis facility performance in patient experience measures has not been studied at the national level to date.

OBJECTIVE

To examine associations among dialysis facility performance with patient experience measures and patient, facility, and geographic characteristics.

DESIGN

In this cross-sectional analysis, patients from a national end-stage renal disease registry receiving in-center hemodialysis in the United States on December 31, 2014, were linked with dialysis facility scores on the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) survey. Of 4977 US dialysis facilities, 2939 (59.1%) reported ICH-CAHPS scores from April 8, 2015, through January 11, 2016. Multivariable linear regression models with geographic random effects were used to examine associations of facility ICH-CAHPS scores with patient, dialysis facility, and geographic characteristics and to identify the amount of total between-facility variation in patient experience scores explained by these categories. Data were analyzed from September 15, 2017, through June 1, 2018.

EXPOSURES

Dialysis facility, geographic characteristic, and 10% change in patient characteristics.

MAIN OUTCOMES AND MEASURES

Dialysis facility ICH-CAHPS scores and the total between-facility variation explained by different categories of characteristics.

RESULTS

Of the 2939 facilities included in the analysis, adjusted mean ICH-CAHPS scores were 2.6 percentage points (95% CI, 1.5-3.7) lower in for-profit facilities, 1.6 percentage points (95% CI, 0.9-2.2) lower in facilities owned by large dialysis organizations, and 2.3 percentage points (95% CI, 0.5-4.2) lower in free-standing facilities compared with their counterparts. More nurses per patient was associated with 0.2 percentage points (95% CI, 0.03-0.3) higher scores; a privately insured patient population was associated with 1.2 percentage points (95% CI, 0.2-2.2) higher scores. Facilities with higher proportions of black patients had 0.95 percentage points (95% CI, 0.78-1.12) lower scores; more Native American patients, 1.00 percentage point (95% CI, 0.39-1.60) lower facility scores. Geographic location and dialysis facility characteristics explained larger proportions of the overall between-facility variation in ICH-CAHPS scores than did patient characteristics.

CONCLUSIONS AND RELEVANCE

This study suggests that for-profit operation, free-standing status, and large dialysis organization designation were associated with less favorable patient-reported experiences of care. Patient experience scores varied geographically, and black and Native American populations reported less favorable experiences. The study findings suggest that perceived quality of care delivered in these settings are of concern, and that there may be opportunities for improved implementation of patient experience surveys as is highlighted.

Quality measures in acute kidney injury

PURPOSE OF REVIEW

Quality measure assessment and reporting is evolving in end-stage renal disease care and is inchoate in ambulatory nephrology clinic care. Acute kidney injury (AKI) quality measures have not received sufficient attention, yet deserve consideration in view of the substantial proportion of effort nephrology providers devote to AKI care.

RECENT FINDINGS

Accumulating literature permits consideration of timing of nephrology consultation, follow-up after AKI hospitalization, early detection, medication dosing, hospital readmissions and length of stay, cost, and mortality as potential AKI quality measures.

SUMMARY

We review candidate AKI quality measures and assess the strength of evidence supporting the use of each measure as a standard for AKI care.

The Role of Big Data in the Development and Evaluation of US Dialysis Care

Rapid growth in electronic communications and digitalization, combined with advances in data management, analysis, and storage, have led to an era of "Big Data." The Social Security Amendments of 1972 turned end-stage renal disease (ESRD) care into a single-payer system for most patients requiring dialysis in the United States. As a result, there are few areas of medicine that have been as influenced by Big Data as dialysis care, for which Medicare's large administrative data sets have had a central role in the evaluation and development of public policy for several decades. In the 1970/1980s, Medicare data helped identify concerning trends in costs, access to dialysis care, and quality of care delivered. As the research community and policymakers made Medicare's administrative data increasingly accessible for investigation, analyses of Medicare claims have had a large role in facilitating policy synthesis and refinement. Efforts to address the skyrocketing cost of injectable drugs in the 1990s and 2000s exemplify this expanded role of Big Data. Although there are opportunities for large government and nongovernmental administrative data sets to continue serving a critical role in the evaluation and development of ESRD policies, it is important to understand challenges and limitations associated with their use.

Systems Thinking and Leadership: How Nephrologists Can Transform Dialysis Safety to Prevent Infections

Infections are the second leading cause of death for patients with ESKD. Despite multiple efforts, nephrologists have been unable to prevent infections in dialysis facilities. The American Society of Nephrology and the Centers for Disease Control and Prevention have partnered to create Nephrologists Transforming Dialysis Safety to promote nephrologist leadership and engagement in efforts to "Target Zero" preventable dialysis infections. Because traditional approaches to infection control and prevention in dialysis facilities have had limited success, Nephrologists Transforming Dialysis Safety is reconceptualizing the problem in the context of the complexity of health care systems and organizational behavior. By identifying different parts of a problem and attempting to understand how these parts interact and produce a result, systems thinking has effectively tackled difficult problems in dynamic settings. The dialysis facility is composed of different physical and human elements that are interconnected and affect not only behavior but also, the existence of a culture of safety that promotes infection prevention. Because dialysis infections result from a complex system of interactions between caregivers, patients, dialysis organizations, and the environment, attempts to address infections by focusing on one element in isolation often fail. Creating a sense of urgency and commitment to eradicating dialysis infections requires leadership and motivational skills. These skills are not taught in the standard nephrology or medical director curriculum. Effective leadership by medical directors and engagement in infection prevention by nephrologists are required to create a culture of safety. It is imperative that nephrologists commit to leadership training and embrace their potential as change agents to prevent infections in dialysis facilities. This paper explores the systemic factors contributing to the ongoing dialysis infection crisis in the United States and the role of nephrologists in instilling a culture of safety in which infections can be anticipated and prevented.

Process evaluation of the RaDIANT community study: a dialysis facility-level intervention to increase referral for kidney transplantation

BACKGROUND

The Reducing Disparities in Access to kidNey Transplantation Community Study (RaDIANT) was an End-Stage Renal Disease (ESRD) Network 6-developed, dialysis facility-level randomized trial testing the effectiveness of a 1-year multicomponent education and quality improvement intervention in increasing referral for kidney transplant evaluation among selected Georgia dialysis facilities.

METHODS

To assess implementation of the RaDIANT intervention, we conducted a process evaluation at the conclusion of the intervention period (January-December 2014). We administered a 20-item survey to the staff involved with transplant education in 67 dialysis facilities randomized to participate in intervention activities. Survey items assessed facility participation in the intervention (fidelity and reach), helpfulness and willingness to continue intervention activities (sustainability), suggestions for improving intervention components (sustainability), and factors that may have influenced participation and study outcomes (context). We defined high fidelity to the intervention as completing 11 or more activities, and high participation in an activity as having at least 75% participation across intervention facilities.

RESULTS

Staff from 65 of the 67 dialysis facilities completed the questionnaire, and more than half (50.8%) reported high adherence (fidelity) to RaDIANT intervention requirements. Nearly two-thirds (63.1%) of facilities reported that RaDIANT intervention activities were helpful or very helpful, with 90.8% of facilities willing to continue at least one intervention component beyond the study period. Intervention components with high participation emphasized staff and patient-level education, including in-service staff orientations, patient and family education programs, and patient educational materials. Suggested improvements for intervention activities emphasized addressing financial barriers to transplantation, with financial education materials perceived as most helpful among RaDIANT educational materials. Variation in facility-level fidelity of the RADIANT intervention did not significantly influence the mean difference in proportion of patients referred pre- (2013) and post-intervention (2014).

CONCLUSIONS

We found high fidelity to the RaDIANT multicomponent intervention at the majority of intervention facilities, with sustainability of select intervention components at intervention facilities and feasibility for dissemination across ESRD Networks. Future modification of the intervention should emphasize financial education regarding kidney transplantation and amend intervention components that facilities perceive as time-intensive or non-sustainable.

TRIAL REGISTRATION

Clinicaltrials.gov number NCT02092727 . Registered 13 Mar 2014 (retrospectively registered).

Ability to Work among Patients with ESKD: Relevance of Quality Care Metrics

Enabling patient ability to work was a key rationale for enacting the United States (US) Medicare program that provides financial entitlement to renal replacement therapy for persons with end-stage kidney disease (ESKD). However, fewer than half of working-age individuals in the US report the ability to work after starting maintenance hemodialysis (HD). Quality improvement is a well-established objective in oversight of the dialysis program, but a more patient-centered quality assessment approach is increasingly advocated. The ESKD Quality Incentive Program (QIP) initiated in 2012 emphasizes clinical performance indicators, but a newly-added measure requires the monitoring of patient depression—an issue that is important for work ability and employment. We investigated depression scores and four dialysis-specific QIP measures in relation to work ability reported by a multi-clinic cohort of 528 working-age maintenance HD patients. The prevalence of elevated depression scores was substantially higher among patients who said they were not able to work, while only one of the four dialysis-specific clinical measures differed for patients able/not able to work. Ability to work may be among patients’ top priorities. As the parameters of quality assessment continue to evolve, increased attention to patient priorities might facilitate work ability and employment outcomes.

Target weight achievement and ultrafiltration rate thresholds: potential patient implications

BACKGROUND

Higher ultrafiltration (UF) rates and extracellular hypo- and hypervolemia are associated with adverse outcomes among maintenance hemodialysis patients. The Centers for Medicare and Medicaid Services recently considered UF rate and target weight achievement measures for ESRD Quality Incentive Program inclusion. The dual measures were intended to promote balance between too aggressive and too conservative fluid removal. The National Quality Forum endorsed the UF rate measure but not the target weight measure. We examined the proposed target weight measure and quantified weight gains if UF rate thresholds were applied without treatment time (TT) extension or interdialytic weight gain (IDWG) reduction.

METHODS

Data were taken from the 2012 database of a large dialysis organization. Analyses considered 152,196 United States hemodialysis patients. We described monthly patient and dialysis facility target weight achievement patterns and examined differences in patient characteristics across target weight achievement status and differences in facilities across target weight measure scores. We computed the cumulative, theoretical 1-month fluid-related weight gain that would occur if UF rates were capped at 13 mL/h/kg without concurrent TT extension or IDWG reduction.

RESULTS

Target weight achievement patterns were stable over the year. Patients who did not achieve target weight (post-dialysis weight ≥ 1 kg above or below target weight) tended to be younger, black and dialyze via catheter, and had shorter dialysis vintage, greater body weight, higher UF rate and more missed treatments compared with patients who achieved target weight. Facilities had, on average, 27.1 ± 9.7% of patients with average post-dialysis weight ≥ 1 kg above or below the prescribed target weight. In adjusted analyses, facilities located in the midwest and south and facilities with higher proportions of black and Hispanic patients and higher proportions of patients with shorter TTs were more likely to have unfavorable facility target weight measure scores. Without TT extension or IDWG reduction, UF rate threshold (13 mL/h/kg) implementation led to an average theoretical 1-month, fluid-related weight gain of 1.4 ± 3.0 kg.

CONCLUSIONS

Target weight achievement patterns vary across clinical subgroups. Implementation of a maximum UF rate threshold without adequate attention to extracellular volume status may lead to fluid-related weight gain.