Effectiveness of Quality Improvement Strategies for the Management of CKD: A Meta-Analysis

AACC/NKF Guidance Document on Improving Equity in Chronic Kidney Disease Care

BACKGROUND

Kidney disease (KD) is an important health equity issue with Black, Hispanic, and socioeconomically disadvantaged individuals experiencing a disproportionate disease burden. Prior to 2021, the commonly used estimated glomerular filtration rate (eGFR) equations incorporated coefficients for Black race that conferred higher GFR estimates for Black individuals compared to non-Black individuals of the same sex, age, and blood creatinine concentration. With a recognition that race does not delineate distinct biological categories, a joint task force of the National Kidney Foundation and the American Society of Nephrology recommended the adoption of the CKD-EPI 2021 race-agnostic equations.

CONTENT

This document provides guidance on implementation of the CKD-EPI 2021 equations. It describes recommendations for KD biomarker testing, and opportunities for collaboration between clinical laboratories and providers to improve KD detection in high-risk populations. Further, the document provides guidance on the use of cystatin C, and eGFR reporting and interpretation in gender-diverse populations.

SUMMARY

Implementation of the CKD-EPI 2021 eGFR equations represents progress toward health equity in the management of KD. Ongoing efforts by multidisciplinary teams, including clinical laboratorians, should focus on improved disease detection in clinically and socially high-risk populations. Routine use of cystatin C is recommended to improve the accuracy of eGFR, particularly in patients whose blood creatinine concentrations are confounded by processes other than glomerular filtration. When managing gender-diverse individuals, eGFR should be calculated and reported with both male and female coefficients. Gender-diverse individuals can benefit from a more holistic management approach, particularly at important clinical decision points.

What does the French REIN registry tell us about Stage 4-5 CKD care in older adults?

The aim of this paper is to illustrate all the clinical epidemiology searches made within the French network REIN to improve CKD stage 4-5 care in older adults. We summarize various studies describing clinical practice, care organization, prognosis and health economics evaluation in order to develop personalized care plans and decision-making tools. In France, for 20 years now, various databases have been mobilized including the national REIN registry which includes all patients receiving dialysis or transplantation. REIN data are indirectly linked to the French administrative healthcare database. They are also pooled with data from the PSPA cohort, a multicenter prospective cohort study of patients aged 75 or over with advanced CKD, monitored for 5 years, and the CKD-REIN clinical-based prospective cohort which included 3033 patients with CKD stage 3-4 from 2013 to 2016. During our various research work, we identified heterogeneous trajectories specific to this growing older population, raising ethical, organizational and economic issues. Renal registries will help clinicians, health providers and policy-makers if suitable decision- making tools are developed and validated.

The first appointment with a nephrologist: Brazilian patients' demographic and kidney function characteristics. A retrospective study

BACKGROUND

The number of nephrologists has risen slowly, compared with the prevalence of chronic kidney disease (CKD) in Brazil. Data on patients referred to nephrology outpatient clinics remains scarce.

OBJECTIVE

To determine the demographic and kidney function characteristics of patients at their first appointment with a nephrologist.

DESIGN AND SETTING

Retrospective study conducted at three nephrology outpatient clinics (public and private services), in São Paulo, Brazil.

METHODS

From December 2019 to February 2020, we collected patient data regarding demographics, kidney function parameters and comorbidities. We then analyzed data on 394 patients who met a nephrologist for their first appointment.

RESULTS

The main comorbidities were hypertension (63.7%), diabetes (33.5%) and nephrolithiasis (22.3%). Regarding CKD stages, 24.1%, 9.1%, 13.7%, 15.2%, 15.2% and 2.3% of the patients were in stages 1, 2, 3a, 3b, 4 and 5, respectively. Proteinuria was absent or mild, moderate and high in 17.3%, 15.2% and 11.7%, respectively; and 16.2% had not undergone previous investigation of serum creatinine or proteinuria (55.8%). For 17.5%, referral to a nephrologist occurred late. Patients in public services were older than those in private services (59 years versus 51 years, respectively; P = 0.001), more frequently hypertensive (69.7% versus 57.5%; P = 0.01) and reached a nephrologist later (22.4% versus 12.4%; P = 0.009).

CONCLUSION

Referrals to a nephrologist were not being made using any guidelines for CKD risk and many cases could have been managed within primary care. Late referral to a nephrologist happened in one-fifth of the cases and more frequently in the public service.

Quality Improvement in Canadian Nephrology: Key Considerations in Ensuring Thoughtful Ethical Oversight

Purpose of review:

Quality improvement (QI) work is a cornerstone of health care, and a growing area within nephrology. With such growth comes the need to ensure that QI activities are implemented in an ethically responsible manner. The existing institutional research board (IRB) framework has largely focused on reviewing the ethical suitability of traditional research projects, and it can be challenging to know if QI initiatives require formal ethics oversight. Several tools have been developed to assist in distinguishing between the two, such as the “A pRoject Ethics Community Consensus Initiative” tool. Our objective was to demonstrate how QI is distinct from research, to outline how QI-focused IRB process is used across Canada, and to develop a practical aid for clinicians embarking on QI-related projects.

Sources of information:

Publicly available institutional Web sites from academic and select nonacademic sites across Canada.

Methods:

Institutional Web sites across all academic centers within Canada were examined to determine local QI-specific ethics review processes. We have provided examples of QI processes from select community sites. We have developed a tool to assist clinicians navigate the ethical challenges of QI projects and to determine whether their project may require ethics approval.

Key findings:

This overview of the considerations of the research ethics approval process helps clinicians to determine whether IRB approval is required for QI studies. Examples of the current ethical processes employed in both academic and community institutions across Canada demonstrate the variability between centers. We have included examples of fictional nephrology-oriented QI initiatives to illustrate when ethics approval may be considered, along with a flowchart. This summary highlights the opportunity for QI-specific IRB review processes to be standardized across Canada, along with the need for creation of a separate stream with dedicated expertise for QI project review.

Limitations:

We did not do a formal environmental scan of the QI IRB review process in all hospital institutions across Canada.

Quality improvement studies in nursing homes: a scoping review

BACKGROUND

Quality improvement (QI) is used in nursing homes (NH) to implement and sustain improvements in patient outcomes. Little is known about how QI strategies are used in NHs. This lack of information is a barrier to replicating successful strategies. Guided by the Framework for Implementation Research, the purpose of this study was to map-out the use, evaluation, and reporting of QI strategies in NHs.

METHODS

This scoping review was completed to identify reports published between July 2003 through February 2019. Two reviewers screened articles and included those with (1) the term "quality improvement" to describe their methods, or reported use of a QI model (e.g., Six Sigma) or strategy (e.g., process mapping) (2), findings related to impact on service and/or resident outcomes, and (3) two or more NHs included. Reviewers extracted data on study design, setting, population, problem, solution to address problem, QI strategies, and outcomes (implementation, service, and resident). Vote counting and narrative synthesis were used to describe the use of QI strategies, implementation outcomes, and service and/or resident outcomes.

RESULTS

Of 2302 articles identified, the full text of 77 articles reporting on 59 studies were included. Studies focused on 23 clinical problems, most commonly pressure ulcers, falls, and pain. Studies used an average of 6 to 7 QI strategies. The rate that strategies were used varied substantially, e.g., the rate of in-person training (55%) was more than twice the rate of plan-do-study-act cycles (20%). On average, studies assessed two implementation outcomes; the rate these outcomes were used varied widely, with 37% reporting on staff perceptions (e.g., feasibility) of solutions or QI strategies vs. 8% reporting on fidelity and sustainment. Most studies (n = 49) reported service outcomes and over half (n = 34) reported resident outcomes. In studies with statistical tests of improvement, service outcomes improved more often than resident outcomes.

CONCLUSIONS

This study maps-out the scope of published, peer-reviewed studies of QI in NHs. The findings suggest preliminary guidance for future studies designed to promote the replication and synthesis of promising solutions. The findings also suggest strategies to refine procedures for more effective improvement work in NHs.

Neighborhood Socioeconomic Status and Quality of Kidney Care: Data From Electronic Health Records

Rational & Objective

Electronic health records can be leveraged to assess quality-of-care measures in patients with chronic kidney disease (CKD). Neighborhood socioeconomic status could be a potential barrier to receiving appropriate evidence-based therapy and follow-up. We examined whether neighborhood socioeconomic status is independently associated with quality of care received by patients with CKD.

Study Design

Observational study using electronic health record data.

Setting & Participants

Retrospective study of patients seen at a health care system in the 7-county Minneapolis/St Paul area.

Exposures

Census tract socioeconomic status measures (wealth, income, and education).

Outcomes

Indicators of CKD quality of care: (1) prescription for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in patients with stage ≥ 3 CKD or stage 1 or 2 CKD with urinary albumin-creatinine ratio (UACR) > 300 mg/d, (2) UACR measurement among patients with laboratory-based CKD (estimated glomerular filtration rate < 60 mL/min/1.72 m²), and (3) CKD identified on the problem list or coded for at an encounter among patients with laboratory-based CKD.

Analytic Approach

Multilevel Poisson regression with robust error variance with a random intercept at the census tract level.

Results

Of the 16,776 patients who should be receiving an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 65% were prescribed these medications. Among patients with laboratory-based CKD (n = 25,097), UACR was measured in 27% and CKD was identified in the electronic health record in 55%. We found no independent association between any neighborhood socioeconomic status measures and CKD quality-of-care indicators.

Limitations

1 health care system and selection bias.

Conclusions

We found no association of neighborhood socioeconomic status with quality of CKD care in our cohort. However, adherence to CKD guidelines is low, indicating an opportunity to improve care for all patients regardless of neighborhood socioeconomic status.

Reducing Caesarean Section Surgical Site Infection (SSI) by 50%: A Collaborative Approach

OBJECTIVE

Caesarean section surgical site infection (SSI) is a surgical wound site infection occurring within 30 days of surgery with a reported incidence of 3-15%. This quality improvement (QI) project aimed to reduce caesarean section SSI by 50% in a tertiary maternity center.

METHODS

Using multidisciplinary team approach, the project was designed with evidence-based interventions. The Royal College of Physicians of Ireland/Royal College of Surgeons in Ireland "Preventing Surgical Site Infections Key Recommendations for Practice" guideline was used as standard perioperative care. A care bundle was designed targeting preoperative personal patient preparation, preoperative prophylactic antibiotics, and strict skin preparation technique, all measured using a patient survey. The rate of SSI was followed for 14 months. The Model for Improvement methodology was used to implement change.

RESULTS

Surgical site infection rate decreased from 6.7% (n = 684 caesarean sections, n = 46 SSI) to 3.45% (n = 3,206 caesarean sections, n = 110 SSI), p = .0006. Reduction occurred in both elective (4.4%-2.7%) and emergency (9.1%-4.1%) caesarean section groups. There was excellent adherence to all three elements of the care bundle. The 50% reduction in caesarean section SSI was sustained over the 14-month period, significantly reducing maternal morbidity.

CONCLUSIONS

The success of this QI project is attributable to frontline ownership and empowerment of patients and staff.

An Environmental Scan of Ambulatory Care Quality Indicators for Patients With Advanced Kidney Disease Currently Used in Canada

Background:

Quality indicators can be used to identify gaps in care and drive frontline improvement activities. These efforts are important to prevent adverse events in the increasing number of ambulatory patients with advanced kidney disease in Canada, but it is unclear what indicators exist and the components of health care quality they measure.

Objective:

We sought to identify, categorize, and evaluate quality indicators currently in use across Canada for ambulatory patients with advanced kidney disease.

Design:

Environmental scan of quality indicators currently being collected by various organizations.

Setting:

We assembled a 16-member group from across Canada with expertise in nephrology and quality improvement.

Patients:

Our scan included indicators relevant to patients with chronic kidney disease in ambulatory care clinics.

Measurements:

We categorized the identified quality indicators using the Institute of Medicine and Donabedian frameworks.

Methods:

A 4-member panel used a modified Delphi process to evaluate the indicators found during the environmental scan using the American College of Physicians/Agency for Healthcare Research and Quality criteria. The ratings were then shared with the full panel for further comments and approval.

Results:

The environmental scan found 28 quality indicators across 7 provinces, with 8 (29%) rated as “necessary” to distinguish high-quality from poor-quality care. Of these 8 indicators, 3 were measured by more than 1 province (% of patients on a statin, number of patients receiving a preemptive transplant, and estimated glomerular filtration rate at dialysis start); no indicator was used by more than 2 provinces. None of the indicators rated as necessary measured timely or equitable care, nor did we identify any measures that assessed the setting in which care occurs (ie, structure measures).

Limitations:

Our list cannot be considered as an exhaustive list of available quality indicators at hand in Canada. Our work focused on quality indicators for nephrology providers and programs, and not indicators that can be applied across primary and specialty providers. We also focused on indicator constructs and not the detailed definitions or their application. Last, our panel does not represent the views of other important stakeholders.

Conclusions:

Our environmental scan provides a snapshot of the scope of quality indicators for ambulatory patients with advanced kidney disease in Canada. This catalog should inform indicator selection and the development of new indicators based on the identified gaps, as well as motivate increased pan-Canadian collaboration on quality measurement and improvement.

Trial registration:

Not applicable as this article is not a systematic review, nor does it report results of a health intervention on human participants.

Characteristics and Effectiveness of Dedicated Care Programs for Patients Starting Dialysis: A Systematic Review

BACKGROUND

Dedicated care programs that provide increased support to patients starting dialysis are increasingly being used to reduce the risk of complications. The objectives of this systematic review were to determine the characteristics of existing programs and their effect on patient outcomes.

METHODS

We searched Embase, MEDLINE, Web of Science, Cochrane CENTRAL, and CINAHL from database inception to November 20, 2019 for English-language studies that evaluated dedicated care programs for adults starting maintenance dialysis in the inpatient or outpatient setting. Any study design was eligible, but we required the presence of a control group and prespecified patient outcomes. We extracted data describing the nature of the interventions, their components, and the reported benefits.

RESULTS

The literature search yielded 12,681 studies. We evaluated 66 full texts and included 11 studies (n=6812 intervention patients); eight of the studies evaluated hemodialysis programs. All studies were observational, and there were no randomized controlled trials. The most common interventions included patient education (n=11) and case management (n=5), with nurses involved in nine programs. The most common outcomes were mortality (n=8) and vascular access (n=4), with only three studies reporting on the uptake of home dialysis and none on transplantation. We identified four high-quality studies that combined patient education and case management; in these programs, the relative reduction in 90-day mortality ranged from 22% (95% CI, -3% to 41%) to 49% (95% CI, 33% to 61%). Pooled analysis was not possible due to study heterogeneity.

CONCLUSIONS

Few studies have evaluated dedicated care programs for patients starting dialysis, especially their effect on home dialysis and transplantation. Whereas multidisciplinary care models that combine patient education with case management appear to be promising, additional prospective studies that involve patients in their design and execution are needed before widespread implementation of these resource-intensive programs.

Improving Blood Pressure Management in Primary Care Patients with Chronic Kidney Disease: a Systematic Review of Interventions and Implementation Strategies

INTRODUCTION

Chronic kidney disease (CKD) is widely prevalent, associated with morbidity and mortality, but may be lessened with timely implementation of evidence-based strategies including blood pressure (BP) control. Nonetheless, an evidence-practice gap persists. We synthesize the evidence for clinician-facing interventions to improve hypertension management in CKD patients in primary care.

METHODS

Electronic databases and related publications were queried for relevant studies. We used a conceptual model to address heterogeneity of interventions. We conducted a quantitative synthesis of interventions on blood pressure (BP) outcomes and a narrative synthesis of other CKD relevant clinical outcomes. Planned subgroup analyses were performed by (1) study design (randomized controlled trials (RCTs) or nonrandomized studies (NRS)); (2) intervention type (guideline-concordant decision support, shared care, pharmacist-facing); and (3) use of behavioral/implementation theory.

RESULTS

Of 2704 manuscripts screened, 73 underwent full-text review; 22 met inclusion criteria. BP target achievement was reported in 15 and systolic BP reduction in 6 studies. Among RCTs, all interventions had a significant effect on BP control, (pooled OR 1.21; 95% CI 1.07 to 1.38). Subgroup analysis by intervention type showed significant effects for guideline-concordant decision support (pooled OR 1.19; 95% CI 1.12 to 1.27) but not shared care (pooled OR 1.71; 95% CI 0.96 to 3.03) or pharmacist-facing interventions (pooled OR 1.04; 95% CI 0.82 to 1.34). Subgroup analysis finding was replicated with pooling of RCTs and NRS. The five contributing studies showed large and significant reduction in systolic BP (pooled WMD - 3.86; 95% CI - 7.2 to - 0.55). Use of a behavioral/implementation theory had no impact, while RCTs showed smaller effect sizes than NRS.

DISCUSSION

Process-oriented implementation strategies used with guideline-concordant decision support was a promising implementation approach. Better reporting guidelines on implementation would enable more useful synthesis of the efficacy of CKD clinical interventions integrated into primary care.

PROSPERO REGISTRATION NUMBER

CRD42018102441.

Systematic review of interventions to improve constant observation on adult inpatient psychiatric wards

Constant observation is frequently conducted on inpatient psychiatric units to manage patients at risk of harming themselves or others. Despite its widespread use, there is little evidence of the efficacy of the practice or of its impact on patients and nursing staff. Unnecessary use of this practice can be restrictive and distressing for all involved and can cause considerable strain on healthcare resources. We sought to review interventions aiming to improve the quality and safety of constant observation or to reduce unnecessary use of this restrictive practice on adult inpatient psychiatric wards. A systematic search conducted in December 2018 using PubMed, PsycINFO, CINAHL, EMBASE and Google Scholar identified 24 studies with interventions related to constant observation. Only 16 studies evaluated a total of 13 interventions. The most common intervention components were changes to team, education and training for staff, changes to record keeping and assessment, and involving patients in care. A range of outcome measures were used to evaluate interventions. Over half of the interventions showed some positive impact on constant observation. One study recorded patient feedback. All interventions were targeted towards mental health nurses. Overall, there is no consensus on how best to improve the safety and quality of constant observations or reduce its unnecessary use. Studies vary widely in design, intervention and outcome measures. Existing research does however suggest that teamwork interventions can improve the patient experience of constant observation and safely reduce their degree and frequency. Priorities for future research on constant observations are highlighted.

Quality of Care in Chronic Kidney Disease and Incidence of End-stage Renal Disease in Older Patients: A Cohort Study

Supplemental Digital Content is available in the text.

The quality of care received by a growing number of older patients with chronic kidney disease (CKD) has not been adequately examined.

Tunneled hemodialysis catheter care practices and blood stream infection rate in children: results from the SCOPE collaborative

OBJECTIVE

The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative seeks to reduce hemodialysis (HD) catheter-associated blood stream infections (CA-BSI) by increasing implementation of standardized HD catheter care bundles. We report HD catheter care practices and HD CA-BSI rates from SCOPE.

METHODS

Catheter care practices and infection events were collected prospectively during the study period, from collaborative implementation in June 2013 through May 2017. For comparative purposes, historical data, including patient demographics and HD CA-BSI events, were collected from the 12 months prior to implementation. Catheter care bundle compliance in 5 care bundle categories was monitored across the post-implementation reporting period at each center via monthly care observation forms. CA-BSI rates were calculated monthly, and reported as number of infections per 100 patient months. Changes in CA-BSI rates were assessed using generalized linear mixed model (GLMM) techniques.

RESULTS

Three hundred twenty-five patients with tunneled HD catheters [median (IQR) age 12 years (6, 16), M 53%, F 47%] at 15 centers were included. A total of 3996 catheter care observations over 4170 patient months were submitted with a median (IQR) 5 (2, 14) observations per patient. Overall bundle compliance was high at 87.6%, with a significant and progressive increase (p < 0.001) in compliance for 4/5 bundle categories over the 48-month study period. The adjusted CA-BSI rate significantly decreased over time from 3.3/100 patient months prior to implementation of the care bundles to 0.8/100 patient months 48 months after care bundle implementation (p < 0.001).

CONCLUSIONS

Using quality improvement methodology, SCOPE has demonstrated a significant increase in compliance with a majority of HD catheter care practices and a significant reduction in the rate of CA-BSI among children maintained on HD.

Implementation strategies for interventions to improve the management of chronic kidney disease (CKD) by primary care clinicians: protocol for a systematic review

INTRODUCTION

There is a considerable implementation gap in managing early stage chronic kidney disease (CKD) in primary care despite the high prevalence and risk for increased morbidity and mortality associated with CKD. This systematic review aims to synthesise the evidence of efficacy of implementation interventions aimed at primary care practitioners (PCPs) to improve CKD identification and management. We further aim to describe the interventions' behavioural change components.

METHODS AND ANALYSIS

We will conduct a systematic review of studies from 2000 to October 2017 that evaluate implementation interventions targeting PCPs and which include at least one clinically meaningful CKD outcome. We will search several electronic data bases and conduct reference mining of related systematic reviews and publications. An interdisciplinary team will independently and in duplicate, screen publications, extract data and assess the risk of bias. Clinical outcomes will include all clinically meaningful medical management outcomes relevant to CKD management in primary care such as blood pressure, chronic heart disease and diabetes target achievements. Quantitative evidence synthesis will be performed, where possible. Planned subgroup analyses include by (1) study design, (2) length of follow-up, (3) type of intervention, (4) type of implementation strategy, (5) whether a behavioural or implementation theory was used to guide study, (6) baseline CKD severity, (7) patient minority status, (8) study location and (9) academic setting or not.

ETHICS AND DISSEMINATION

Approval by research ethics board is not required since the review will only include published and publicly accessible data. Review findings will inform a future trial of an intervention to promote uptake of CKD diagnosis and treatment guidelines in our primary care setting and the development of complementary tools to support its successful adoption and implementation. We will publish our findings in a peer-reviewed journal and develop accessible summaries of the results.

PROSPERO REGISTRATION NUMBER

CRD42018102441.

Trends in Quality of Care for Patients with CKD in the United States

BACKGROUND AND OBJECTIVES

Improving the quality of CKD care has important public health implications to delay disease progression and prevent ESKD. National trends of the quality of CKD care are not well established. Furthermore, it is unknown whether gaps in quality of care are due to lack of physician awareness of CKD status of patients or other factors.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a national, serial, cross-sectional study of visits to office-based ambulatory care practices for adults with diagnosed CKD from the years 2006 to 2014. We assessed the following quality indicators: (1) BP measurement, (2) uncontrolled hypertension, (3) uncontrolled diabetes, (4) angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use among patients with hypertension, (5) statin use if age ≥50 years old, and (6) nonsteroidal anti-inflammatory drug use. Using multivariable linear regression and chi-squared analysis, we examined the change in quality performance over time.

RESULTS

Between 2006 and 2014, there were 7099 unweighted visits for patients with CKD representing 186,961,565 weighted visits. There was no difference in the prevalence of uncontrolled hypertension (>130/80 mm Hg) over time (46% in 2006-2008 versus 48% in 2012-2014; P=0.50). There was a high prevalence of uncontrolled diabetes in 2012-2014 (40% for hemoglobin A1c >7%). The prevalence of ACEi/ARB use decreased from 45% in 2006-2008 to 36% in 2012-2014, which did not reach statistical significance (P=0.07). Statin use in patients with CKD who were 50 years or older was low and remained unchanged from 29% in 2006-2008 to 31% in 2012-2014 (P=0.92).

CONCLUSIONS

In a nationally representative dataset, we found that patients with CKD had a high prevalence of uncontrolled hypertension and diabetes and a low use of statins that did not improve over time and was not concordant with guidelines.

Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Globally, the number of patients undergoing maintenance dialysis is increasing, yet throughout the world there is significant variability in the practice of initiating dialysis. Factors such as availability of resources, reasons for starting dialysis, timing of dialysis initiation, patient education and preparedness, dialysis modality and access, as well as varied "country-specific" factors significantly affect patient experiences and outcomes. As the burden of end-stage kidney disease (ESKD) has increased globally, there has also been a growing recognition of the importance of patient involvement in determining the goals of care and decisions regarding treatment. In January 2018, KDIGO (Kidney Disease: Improving Global Outcomes) convened a Controversies Conference focused on dialysis initiation, including modality choice, access, and prescription. Here we present a summary of the conference discussions, including identified knowledge gaps, areas of controversy, and priorities for research. A major novel theme represented during the conference was the need to move away from a "one-size-fits-all" approach to dialysis and provide more individualized care that incorporates patient goals and preferences while still maintaining best practices for quality and safety. Identifying and including patient-centered goals that can be validated as quality indicators in the context of diverse health care systems to achieve equity of outcomes will require alignment of goals and incentives between patients, providers, regulators, and payers that will vary across health care jurisdictions.