Kidney Patient-Centered Quality of Care, Part II: A Quality Framework for ESRD Patients

There is an urgent need to move beyond biochemical and surrogate outcomes to focus more on patient-centric care. Care coordination that incorporates nephrologist leadership as a delivery model is fundamental to improving outcomes, but it will not ensure the goal—to improve the lives of patients with kidney disease—without consensus on key clinical targets and metrics.

DaVita Patient-Focused Quality Pyramid

We have developed a patient-focused needs hierarchy, in the form of a pyramid, to describe the optimal approach to patient outcomes. For patients with advanced kidney disease, the ultimate goal is to improve the quality of their lives. We use “quality of life” as a term to describe aspects of patients’ lives that can be impacted through improving mortality, lowering hospitalizations and enhancing treatment experience. (See the DaVita Patient-Focused Quality Pyramid.)

1. Top tier: To improve the lives of patients with kidney disease it is necessary to improve survival, decrease hospitalizations and optimize the patient experience with care. These goals are on the highest tier of our pyramid as primary clinical outcomes.

2. Middle tier: Moving further down the hierarchy, there is a constellation of potential intermediate clinical outcomes: complex clinical areas that, if optimized, are most likely to drive the desired improvements in primary clinical outcomes. In the case of hospitalizations, for example, recent analysis of claims data shows that cardiovascular disease, often caused or worsened by acute or chronic fluid overload, infection and diabetes, accounts for the majority of hospitalizations.

3. Bottom tier: The fundamental indicators form the lower layer of the hierarchy and are the ones that have largely preoccupied the kidney care community and regulators over the past decades. Poor performance on these basic indicators will ensure poor intermediate clinical outcomes. However, excellent performance on these indicators—as is currently the case for a number of these for most providers of care—has not resulted in significant improvements in intermediate or primary outcomes. Thus, excellent performance on the basic indicators is necessary, but not sufficient to lead to excellent primary outcomes. The intermediate outcomes are more complex than the basic indicators, requiring systematic, organized clinical programs, multiple indicators, and often-fundamental changes in the culture of the dialysis facility and dialysis team if they are to be successfully improved.

How could this conceptualization of the clinical hierarchy for ESRD patients be put to practical use? The next blog post will review the most-important participants who can help drive quality improvement in a dialysis clinic.

Upcoming post: Part III: Key Participants Who Contribute to Quality Program Success

Some of the content of this post has been previously published. Source: Delivering Better Quality of Care: Relentless Focus and Starting with the End in Mind at DaVita. Allen R. Nissenson, MD. Seminars in Dialysis, Volume 29, Issue 2. © 2016. Publisher: Wiley-Blackwell. [Link to original article].