Invited commentary

Abstract

Woo et al suggest that evidence-based guidelines for hemodialysis access are based on population data rather than patient-level data and that clinical practice guidelines offer general recommendations that may not be actionable on an individual patient level. To that point, population health is defined as “…the health outcomes of a group of individuals, including the distribution of such outcomes within the group,”1Kindig D. What are we talking about when we talk about population health? Health Affairs Blog.http://healthaffairs.org/blog/2015/04/06/what-are-we-talking-about-when-we-talk-about-population-healthGoogle Scholar suggesting variation across the population. Although population health was initially used to define the health of geographic populations, population health management and population management are now used to describe activities focused on more medically specific clinical populations. In addressing population health management (in this case end-stage kidney disease in patients on hemodialysis access), the increasing challenge is to balance the unique needs of the individual patient with the evidence-based optimal management of the population.2Sox H.C. Resolving the tension between population health and individual health care.JAMA. 2013; 310: 1933-1934Crossref PubMed Scopus (41) Google Scholar As the authors have suggested, a multitude of characteristics may influence the outcome of the access procedure, including gender, race, age, medical comorbidities, vascular anatomy, obesity, and socioeconomic status. The business literature would tell us that we need to be careful setting and rewarding performance metrics. Foremost, it must be remembered that a performance metric is not a goal. It is a means to an end and should not become the goal. The Centers for Medicare and Medicaid Services established a target of 66% arteriovenous fistulas in the hemodialysis population. This is a population-based performance metric; the goal is to provide optimal hemodialysis access for each patient with end-stage kidney disease. In his article, “On the folly of rewarding A, while hoping for B,”3Kerr S. On the folly of rewarding A, while hoping for B.Acad Manage J. 1975; 818: 769-783Crossref Scopus (912) Google Scholar Steven Kerr cautions that individuals seek to know what is rewarded and then do those things to the exclusion of activities not rewarded. He writes that establishing simple, quantifiable metrics with which to reward performance may be successful in highly predictable areas but are likely to cause “goal displacement” when applied to decisions dependent on more complex assessments with multiple variables; in the case of hemodialysis access, those variables would include patient demographics, anatomy, and comorbidities. Likierman4Likierman A. The five traps of performance management.Harv Bus Rev. 2009; 87: 96-101, 141PubMed Google Scholar and Ordóñez et al5Ordóñez L.D. Schweitzer M.E. Galinsky A.D. Bazerman M.H. Goals gone wild: the systematic side effects of over-prescribing goal setting.http://hbs.edu/faculty/Publication Files/09-083.pdfGoogle Scholar have expressed similar concerns. They caution that metrics can cause people to narrow their focus and that such intense focus can obscure important issues that may seem unrelated to the ultimate goal. Metrics are only proxies for performance. As Woo et al suggest, patient-specific circumstances exist where arteriovenous fistulas may not be the best option for a patient. Let's be careful not to lose the patient for the population and the ultimate goal of a functional access, free of complications and interventions, as we set performance metrics and their rewards. Establishing patient-specific criteria for selecting the optimal upper extremity vascular access procedureJournal of Vascular SurgeryVol. 65Issue 4PreviewThe Kidney Disease Outcome Quality Initiative and Fistula First Breakthrough Initiative call for the indiscriminate creation of arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs) without providing patient-specific criteria for vascular access selection. Although the U.S. AVF rate has increased dramatically, several reports have found that this singular focus on increasing AVFs has resulted in increased AVF nonmaturation/early failure and a high prevalence of catheter dependence. The objective of this study was to determine the appropriateness of vascular access procedures in clinical scenarios constructed with combinations of relevant factors potentially influencing outcomes. Full-Text PDF Open Archive