Clinical Outcomes of a Novel Multidisciplinary Care Program in Advanced Kidney Disease (PEAK)
Daniil Shimonov, Sri Lekha Tummalapalli, Stephanie Donahue, Vidya Narayana, Sylvia Wu, Lisa S Walters, Roberta Billman, Barbara Desiderio, Sandra Pressman, Oliver Fielding, Kariel Sweeney, Daniel Cukor, Daniel M Levine, Thomas S Parker, Vesh Srivatana, Jeffrey Silberzweig, Frank Liu, Andrew Bohmart...
INTRODUCTION: Multidisciplinary care (MDC) for late-stage chronic kidney disease (CKD) has been associated with improved patient outcomes compared with traditional nephrology care; however, the optimal MDC model is unknown. In 2015, we implemented a novel MDC model for patients with late-stage CKD informed by the Chronic Care Model conceptual framework, including an expanded MDC team, care plan meetings, clinical risk prediction, and a patient dashboard.
METHODS: We conducted a single-center, retrospective cohort study of adults with late-stage CKD (estimated glomerular filtration rate [eGFR] < 30 ml/min per 1.73 m2) enrolled from May 2015 to February 2020 in the Program for Education in Advanced Kidney Disease (PEAK). Our primary composite outcome was an optimal transition to end-stage kidney disease (ESKD) defined as starting in-center hemodialysis (ICHD) as an outpatient with an arteriovenous fistula (AVF) or graft (AVG), or receiving home dialysis, or a preemptive kidney transplant. Secondary outcomes included home dialysis initiation, preemptive transplantation, vascular access at dialysis initiation, and location of ICHD initiation. We used logistic regression to examine trends in outcomes. Results were stratified by race, ethnicity, and insurance payor, and compared with national and regional averages from the United States Renal Data System (USRDS) averaged from 2015 to 2019.
RESULTS: Among 489 patients in the PEAK program, 37 (8%) died prior to ESKD and 151 (31%) never progressed to ESKD. Of the 301 patients (62%) who progressed to ESKD, 175 (58%) achieved an optimal transition to ESKD, including 54 (18%) on peritoneal dialysis, 16 (5%) on home hemodialysis, and 36 (12%) to preemptive transplant. Of the 195 patients (65%) starting ICHD, 51% started with an AVF or AVG and 52% started as an outpatient. The likelihood of starting home dialysis increased by 1.34 times per year from 2015 to 2020 (95% confidence interval [CI]: 1.05-1.71, P = 0.018) in multivariable adjusted results. Optimal transitions to ESKD and home dialysis rates were higher than the national USRDS data (58% vs. 30%; 23% vs. 11%) across patient race, ethnicity, and payor.
CONCLUSION: Patients enrolled in a novel comprehensive MDC model coupled with risk prediction and health information technology were nearly twice as likely to achieve an optimal transition to ESKD and start dialysis at home, compared with national averages.
Optimal Care for Kidney Health: Development of a Merit-based Incentive Payment System (MIPS) Value Pathway
Sri Lekha Tummalapalli, Sarah A Struthers, David L White, Amy Beckrich, Yasmin Brahmbhatt, Kevin F Erickson, Pranav S Garimella, Edward R Gould, Nupur Gupta, Krista L Lentine, Susie Q Lew, Frank Liu, Sumit Mohan, Michael Somers, Daniel E Weiner, Scott D Bieber, Mallika L Mendu...
J Am Soc Nephrol. 2023 Aug 1;34(8):1315-1328. doi: 10.1681/ASN.0000000000000163. Epub 2023 Jul 3.
ABSTRACT
The Merit-based Incentive Payment System (MIPS) is a mandatory pay-for-performance program through the Centers for Medicare & Medicaid Services (CMS) that aims to incentivize high-quality care, promote continuous improvement, facilitate electronic exchange of information, and lower health care costs. Previous research has highlighted several limitations of the MIPS program in assessing nephrology care delivery, including administrative complexity, limited relevance to nephrology care, and inability to compare performance across nephrology practices, emphasizing the need for a more valid and meaningful quality assessment program. This article details the iterative consensus-building process used by the American Society of Nephrology Quality Committee from May 2020 to July 2022 to develop the Optimal Care for Kidney Health MIPS Value Pathway (MVP). Two rounds of ranked-choice voting among Quality Committee members were used to select among nine quality metrics, 43 improvement activities, and three cost measures considered for inclusion in the MVP. Measure selection was iteratively refined in collaboration with the CMS MVP Development Team, and new MIPS measures were submitted through CMS's Measures Under Consideration process. The Optimal Care for Kidney Health MVP was published in the 2023 Medicare Physician Fee Schedule Final Rule and includes measures related to angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use, hypertension control, readmissions, acute kidney injury requiring dialysis, and advance care planning. The nephrology MVP aims to streamline measure selection in MIPS and serves as a case study of collaborative policymaking between a subspecialty professional organization and national regulatory agencies.
Keys to Driving Implementation of the New Kidney Care Models
Abhijit V Kshirsagar, Daniel E Weiner, Mallika L Mendu, Frank Liu, Susie Q Lew, Terrence J O'Neil, Scott D Bieber, David L White, Jonathan Zimmerman, Sumit Mohan...
Clin J Am Soc Nephrol. 2022 Jul;17(7):1082-1091. doi: 10.2215/CJN.10880821. Epub 2022 Mar 14.
ABSTRACT
Contemporary nephrology practice is heavily weighted toward in-center hemodialysis, reflective of decisions on infrastructure and personnel in response to decades of policy. The Advancing American Kidney Health initiative seeks to transform care for patients and providers. Under the initiative's framework, the Center for Medicare and Medicaid Innovation has launched two new care models that align patient choice with provider incentives. The mandatory ESRD Treatment Choices model requires participation by all nephrology practices in designated Hospital Referral Regions, randomly selecting 30% of all Hospital Referral Regions across the United States for participation, with the remaining Hospital Referral Regions serving as controls. The voluntary Kidney Care Choices model offers alternative payment programs open to nephrology practices throughout the country. To help organize implementation of the models, we developed Driver Diagrams that serve as blueprints to identify structures, processes, and norms and generate intervention concepts. We focused on two goals that are directly applicable to nephrology practices and central to the incentive structure of the ESRD Treatment Choices and Kidney Care Choices: (1) increasing utilization of home dialysis, and (2) increasing the number of kidney transplants. Several recurring themes became apparent with implementation. Multiple stakeholders from assorted backgrounds are needed. Communication with primary care providers will facilitate timely referrals, education, and comanagement. Nephrology providers (nephrologists, nursing, dialysis organizations, others) must lead implementation. Patient engagement at nearly every step will help achieve the aims of the models. Advocacy with federal and state regulatory agencies will be crucial to expanding home dialysis and transplantation access. Although the models hold promise to improve choices and outcomes for many patients, we must be vigilant that they not do reinforce existing disparities in health care or widen known racial, socioeconomic, or geographic gaps. The Advancing American Kidney Health initiative has the potential to usher in a new era of value-based care for nephrology.
A Mobile Health-Based Survey to Assess COVID-19 Vaccine Intent and Uptake Among Patients on Dialysis
Sri Lekha Tummalapalli, Daniel Cukor, Andrew Bohmart, Daniel M Levine, Thomas S Parker, Frank Liu, Alan Perlman, Vesh Srivatana, Meghan Reading Turchioe, Said A Ibrahim, Jeffrey Silberzweig...
Kidney Int Rep. 2022 Mar;7(3):633-637. doi: 10.1016/j.ekir.2021.12.006. Epub 2021 Dec 13.
Characteristics of Acute Kidney Injury in Hospitalized COVID-19 Patients in an Urban Academic Medical Center
John R Lee, Jeffrey Silberzweig, Oleh Akchurin, Mary E Choi, Vesh Srivatana, Jonathan Lin, Frank Liu, Line Malha, Michelle Lubetzky, Darshana M Dadhania, Divya Shankaranarayanan, Daniil Shimonov, Sanjay Neupane, Thalia Salinas, Aarti Bhasin, Elly Varma, Lorenz Leuprecht, Supriya Gerardine, Perola Lamba, Parag Goyal, Eric Caliendo, Victoria Tiase, Rahul Sharma, Joel C Park, Peter A D Steel, Manikkam Suthanthiran, Yiye Zhang...
Clin J Am Soc Nephrol. 2021 Feb 8;16(2):284-286. doi: 10.2215/CJN.07440520. Epub 2020 Sep 18.
Measuring Quality in Kidney Care: An Evaluation of Existing Quality Metrics and Approach to Facilitating Improvements in Care Delivery
Mallika L Mendu, Sri Lekha Tummalapalli, Krista L Lentine, Kevin F Erickson, Susie Q Lew, Frank Liu, Edward Gould, Michael Somers, Pranav S Garimella, Terrence O'Neil, David L White, Rachel Meyer, Scott D Bieber, Daniel E Weiner...
J Am Soc Nephrol. 2020 Mar;31(3):602-614. doi: 10.1681/ASN.2019090869. Epub 2020 Feb 13.
ABSTRACT
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.
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