Quality Incentive Program Research Articles

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

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. To determine whether penalization was associated with improvement in dialysis center quality. 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. United States. Outpatient dialysis centers (n= 5830). 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. 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 ($49290 vs. $51686; 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. The study could not account for how centers respond to penalization. Penalization under the End-Stage Renal Disease Quality Incentive Program was not associated with improvement in the quality of outpatient dialysis centers. None.

Accuracy of Hemodialysis Bloodstream Infection Pathogen Reporting to the National Healthcare Safety Network: Results of an Academic Dialysis Program Audit

Patients with dialysis-dependent end-stage kidney disease experience high rates of infections.1 Bloodstream infections (BSIs) are the major cause of fatal infection and third leading cause of death.1 Since 1999, the Centers for Disease Control and Prevention has tracked dialysis infections by facility self-reporting to the National Healthcare Safety Network (NHSN).2 Maintaining accurate BSI data is necessary to inform infection prevention efforts. BSI rates also affect the Patient Safety domain of the Quality Incentive Program, negatively affecting facility revenue.

Perspectives on organic transition from transitioning farmers and farmers who decided not to transition

AbstractDespite continuous growth in demand for organic food and farm products, US domestic supply is not keeping pace. Increasing domestic supply requires, in part, that more farms transition to certified organic production. This in turn requires a better understanding of the transition process. This paper reports on a national survey of farmers transitioning to organic certification through participation in the United States Department of Agriculture's (USDA) Natural Resources Conservation Service (NRCS) Environmental Quality Incentives Program Organic Initiative (EQIP-OI). Our analysis focuses on what motivates farmers to undertake transition to organic certification and what obstacles they confront in the process. The survey population included farmers in the midst of the transition process and farmers who began transition but decided not to pursue organic farming, allowing us to compare both groups to farmers who successfully transitioned to certified organic. Because farmers do not control all of the factors that influence their success, we use a ‘spheres of influence’ framework to analyze obstacles at four levels: the farm, local and regional infrastructure, the marketplace and policy. Our results improve our understanding of the transition process and apply to a wide range of stakeholders and service providers who support farmers in different ways, through crop research, infrastructure development, market development and policy.

Assessing the Benefits and Economic Feasibility of Stand Improvement for Central Hardwood Forests

Abstract Stand improvement (SI) has been widely accepted as an effective forest management tool. Yet most studies on its economic feasibility for nonindustrial private forest (NIPF) landowners are outdated and focus on the single stand level. The objective of this study was to conduct an economic assessment of SI’s effects and feasibility in hardwood stands for a case study in the White River Basin in Indiana. It is shown that SI could make these forests more productive and sustainable than the prevalent “hands-off” practice by enhancing the timber value of the residual stand (TV), generating regular timber income, and to some degree, reversing the decline in oak dominance. On average, a 25% increment in the TV could be achieved. Although costly for some NIPFs, once combined with voluntary financial incentive programs, SI could meet landowners’ demands for low-cost, high-return investment options. In particular, participation in the Environmental Quality Incentive Program could, on average, increase the net present value of timber income from thinning activities by nearly $1,600 per hectare over the course of 30 years. The spatial analysis revealed that there existed considerable spatial heterogeneity in SI benefits and impacts, suggesting that public incentive programs should be spatially targeted to achieve greater efficiency.

Expanding Post-Discharge Readmission Metrics in Patients with Chronic Obstructive Pulmonary Disease.

Chronic obstructive pulmonary disease (COPD) is a common and costly reason for hospitalization and rehospitalization. The Hospital Readmissions Reduction Program penalizes hospitals for excess, non-elective, all-cause 30-day, inpatient rehospitalizations for COPD. We sought to determine how broadening the outcome definition would alter the numbers of patients being counted, specifically if observation stays and patients who died in the post-discharge period were included. We performed a retrospective cohort study of patients hospitalized for COPD between July 1, 2010 and December 31, 2017 in 21 hospitals in the Kaiser Permanente Northern California health care system. We classified encounters into 3 outcomes groups based on a 30-day post-discharge observation period: Group (1) non-elective, all-cause, inpatient rehospitalizations, which is the current metric; Group (2) composite outcome of Group 1 or all-cause mortality; and Group (3) composite outcome of Group 1 or non-elective, all-cause, observation rehospitalization. We used the Box-Cox method to find the transformation of the cumulative curves that resulted in the smallest mean standard error. We used the slope of the transformed curve against days to test for significant differences between pairs of cumulative density curves. Of 1,384,025 hospitalizations, 11,304 encounters from 8097 patients met criteria to be index hospitalizations. The event rate for non-elective, all-cause, inpatient rehospitalizations was 17.1% (95% CI 10.4-26.5). The event rate for all-cause mortality was 4.7% (95% CI 3.1-7.7). The event rate for non-elective observation rehospitalizations was 3.9% (95% CI 1.7-7.0). The slope and standard error for Group 1 were 1.17 and 0.01, respectively, while the slope and standard error for Group 2 were 1.62 and 0.01, respectively (P=0.02 comparing Groups 1 and 2). The slope and standard error for Group 3 were 1.45 and 0.01, respectively (P=0.02 comparing Groups 1 and 3). We show that adding outcomes such as mortality and observation rehospitalizations would change the counts of patients contributing to the Hospital Readmission Reduction Program penalty for COPD if the outcome were broadened. Including mortality or observation stays in the quality incentive program might incentivize hospitals and providers to prevent these events in addition to inpatient rehospitalizations.

Reducing Tobacco Use in Oregon Through Multisector Collaboration: Aligning Medicaid and Public Health Programs.

IntroductionTobacco use is the leading cause of preventable death and disease in the United States. Oregon’s coordinated care model for Medicaid provides an opportunity to consider novel ways to reduce tobacco use.Purpose and ObjectivesWe sought to evaluate the changes in tobacco cessation benefits, patient access to cessation interventions, and cigarette smoking prevalence before and after introduction of the statewide Coordinated Care Organization (CCO) cigarette smoking incentive metric for Medicaid members.Intervention ApproachMedicaid and public health collaborated to develop a novel population-level opportunity to reduce tobacco use. In 2016, an incentive metric for cigarette smoking was incorporated into Oregon’s CCO Quality Incentive Program, which holds Oregon’s CCOs accountable for providing comprehensive cessation benefits and for reducing tobacco use prevalence among members.Evaluation MethodsWe evaluated the changes in tobacco cessation benefits, patient–provider discussions of smoking cessation, and cigarette smoking prevalence before and after the introduction of the statewide CCO cigarette smoking incentive metric.ResultsAll 15 CCOs now cover cessation counseling (telephone, individual, and group) and pharmacotherapy (all 7 FDA-approved medications). The number of CCOs requiring prior authorization for at least 1 FDA-approved pharmacotherapy decreased substantially. From 2016 through 2018, the percentage of Medicaid members who reported that their health care providers recommended cessation assistance increased above baseline. The incentive metric and aligned interventions were associated with a reduction in cigarette smoking prevalence among Medicaid members, as indicated by the electronic health record metric. Thirteen of 15 CCOs demonstrated a reduction in smoking prevalence with the statewide prevalence rate decreased from 29.3% to 26.6%.Implications for Public HealthSince incentive metric implementation, progress has been made to reduce tobacco use among CCO members. Cross-agency partnerships between Medicaid and public health contributed to these successes.

Screening for Depression in People with Kidney Failure.

A large proportion of patients with CKD before and after initiation of maintenance dialysis suffer from major depressive disorder, such that about 20% of those with non-dialysis CKD and 25% of those with kidney failure are affected ([1][1]). More daunting is the actuality, validated in multiple

Depression Screening Tools for Patients with Kidney Failure: A Systematic Review.

Patients with kidney failure experience depression at rates higher than the general population. Despite the Centers for Medicare and Medicaid Services' ESRD Quality Incentive Program requirements for routine depression screening for patients with kidney failure, no clear guidance exists. For this systematic review, we searched MEDLINE, PsycINFO, and other databases from inception to June 2020. Two investigators screened all abstracts and full text. We included studies assessing patients with kidney failure and compared a tool to a clinical interview or another validated tool (e.g., Beck Depression Inventory II). We abstracted data related to sensitivity and specificity, positive and negative predictive value, and the area under the curve. We evaluated the risk of bias using the Quality Assessment of Diagnostic Accuracy Studies 2. A total of 16 studies evaluated the performance characteristics of depression assessment tools for patients with kidney failure. The Beck Depression Inventory II was by far the best studied. A wide range of thresholds were reported. Shorter tools in the public domain such as the Patient Health Questionnaire 9 and Geriatric Depression Scale 15 (adults over 60) performed well but were not well studied. Short tools such as the Beck Depression Inventory-Fast Screen may be a good option for an initial screen. There is limited research evaluating the diagnostic accuracy of most screening tools for depression in patients with kidney failure, and existing studies may not be generalizable to US populations. Studies suffer from limitations related to methodology quality and/or reporting. Future research should target widely used, free tools such as the Patient Health Questionnaire 2 and the Patient Health Questionnaire 9. Systematic Review Registration: PROSPERO CRD42020140227.

Comparison of ESRD Quality Incentive Program (QIP) Performance and Dialysis Facility Compare (DFC) Star Rating

Comparison of ESRD Quality Incentive Program (QIP) Performance and Dialysis Facility Compare (DFC) Star Rating

Associations of Dialysis Facility Clinical Performance with Patient Outcomes in the Medicare ESRD Quality Incentive Program (QIP)

Associations of Dialysis Facility Clinical Performance with Patient Outcomes in the Medicare ESRD Quality Incentive Program (QIP)

Mortality and Cost Track Yearly Changes in ESRD Quality Incentive Program Performance

Mortality and Cost Track Yearly Changes in ESRD Quality Incentive Program Performance

Do Dialysis Facilities Improve Quality After Receiving a Penalty Under the ESRD Quality Incentive Program?

Do Dialysis Facilities Improve Quality After Receiving a Penalty Under the ESRD Quality Incentive Program?

Estimates of Conservation Tillage Practices Using Landsat Archive

The USDA Environmental Quality Incentives Program (EQIP) provides financial assistance to encourage producers to adopt conservation practices. Historically, one of the most common practices is conservation tillage, primarily the use of no-till planting. The objectives of this research were to determine crop residue using remote sensing, an indicator of tillage intensity, without using training data and examine its performance at the field level. The Landsat Thematic Mapper Series platforms can provide global temporal and spatial coverage beginning in the mid-1980s. In this study, we used the Normalized Difference Tillage Index (NDTI), which has proved to be robust and accurate in studies built upon training datasets. We completed 10 years of residue maps for the 150,000 km2 study area in South Dakota, North Dakota, and Minnesota and validated the results against field-level survey data. The overall accuracy was between 64% and 78% with additional improvement when survey points with suspect geolocation and satellite tillage estimates with fewer than four dates of Landsat images were excluded. This study demonstrates that, with Landsat Archive available at no cost, researchers can implement retrospective, untrained estimates of conservation tillage with sufficient accuracy for some applications.

ESRD QIP Payment Reductions Are Associated with Mortality, Utilization, and Cost

Research ObjectiveCMS launched the ESRD Quality Incentive Program (QIP) in 2010. The ESRD QIP adjusts Medicare payments to dialysis facilities based on their performance on a set of quality measures. The measures are revised in most years. We assessed whether the magnitude of ESRD QIP payment reductions was associated with several important patient outcomes that are not an intrinsic part of the QIP measure set.Study DesignWe compared mortality, utilization of health care services, and Medicare payments per patient‐year during 2015‐2017 for dialysis facilities in each ESRD QIP payment reduction category (0%, 0.5%, 1.0%, 1.5%, and 2.0%) corresponding to their QIP performance for the same year. The data sources include Medicare claims and enrollment files. Results were expressed as unadjusted averages and as modeled measures of association that adjusted for important patient factors (age, sex, race, ethnicity, diabetes, duration of ESRD, and dual eligibility).Population StudiedThe patient cohort consisted of Medicare fee‐for‐service beneficiaries receiving chronic dialysis for ESRD on the first day of each year. Patients were attributed to the first facility that provided treatment during the year.Principal FindingsMost patients were treated in facilities that did not receive an ESRD QIP payment reduction (Table). There was a stepwise increase in mortality, hospitalization, hospital days, and Medicare payments per year in facilities with successively larger payment reductions. The increase in Medicare payments was largely for inpatient services. All findings were statistically significant in adjusted regression models (shown in the Table for mortality and total payment).ConclusionsMortality, utilization, and Medicare payments were substantially higher for patients treated in facilities whose contemporaneous performance on ESRD QIP measures resulted in a payment reduction. Moreover, these outcome measures increased stepwise with the magnitude of facility payment reductions. The findings are consistent with the hypothesis that the ESRD QIP measures and scoring system capture meaningful determinants of health care quality and value.Implications for Policy or PracticeThe findings support the validity of ESRD QIP. The findings offer an approach to ongoing monitoring and validation of QIP measures.Primary Funding SourceThe study was funded by the Centers for Medicare and Medicaid Services.

Policy and Pandemic: The Changing Practice of Nephrology During the Coronavirus Disease-2019 Outbreak.

The coronavirus (coronavirus disease-2019) pandemic has changed care delivery for patients with end-stage kidney disease. We explore the US healthcare system as it pertains to dialysis care, including existing policies, modifications implemented in response to the coronavirus disease-2019 crisis, and possible next steps for policy makers and nephrologists. This includes policies related to resource management, use of telemedicine, prioritization of dialysis access procedures, expansion of home dialysis modalities, administrative duties, and quality assessment. The government has already established policies that have instated some flexibilities to help providers focus their response to the crisis. However, future policy during and after the coronavirus disease-2019 pandemic can bolster our ability to optimize care for patients with end-stage kidney disease. Key themes in this perspective are the importance of policy flexibility, clear strategies for emergency preparedness, and robust health systems that maximize accessibility and patient autonomy.

Scaling Implementation of the Serious Illness Care Program Through Coaching

BackgroundWe designed group coaching calls to reinforce communication skill acquisition and Serious Illness Care Program uptake in adult primary care. MeasuresPercentage of primary care physicians (PCPs) who have documented a serious illness conversation in the electronic health record (EHR) approximately three and six months after the coaching intervention. Participant feedback surveys to better understand provider attitudes toward the coaching intervention. InterventionWe offered 60-minute group coaching calls to internal medicine PCPs, previously trained in serious illness conversation skills, as part of an institutional quality incentive program. The calls addressed communication challenges common to serious illness care and instructed participants about how to document and bill for conversations. OutcomesWe completed 31 coaching calls during three months, in which 170 of 228 PCPs attended in groups of two to nine participants per call (74.6% penetration rate). The percentage of PCPs who documented at least one serious illness conversation in the EHR increased from 18.4% to 41.2% six months after the intervention. Primary care internal medicine physicians found the one-hour coaching calls to be highly valuable, with 86.9% of respondents attesting they would recommend the calls to their colleagues. Content analysis of participant feedback identified the most useful coaching content elements to be self-reflection around the impact of prior conversation skills training, instruction around using the EHR to find and document advance care planning discussions, the opportunity to share individual challenges and successes with peers, and feedback/advice from communication experts in palliative care. Conclusions/Lessons LearnedGroup coaching of PCPs resulted in more than a twofold increase in documented serious illness conversations.

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

Rationale & ObjectiveThe 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 DesignRetrospective cohort study.Setting & ParticipantsPatients 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).ExposuresPatient-level demographic, clinical, and treatment-related characteristics.OutcomesMortality, all-cause hospitalization, and kidney transplantation.Analytical ApproachTime-to-event analyses using competing-risks models. Sensitivity analyses performed after multiple imputation for missing covariate data.ResultsAmong 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.LimitationsSmall amount of missing covariate data, baseline covariate data assigned at the first month of the 3-month survey administration period, reasons for nonresponse unknown.ConclusionsResponse 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.

Racial/Ethnic Inequities in Access to High-Quality Dialysis Treatment in Chicago: Does Neighborhood Racial/Ethnic Composition Matter?

Blacks and Hispanics face a higher incidence rate of end-stage renal disease (ESRD) and tend to experience poorer access to quality health care compared with Whites. Income, education, and insurance coverage differentials are typically identified as risk factors, but neighborhood-level analyses may provide additional insights. We examine whether neighborhood racial composition contributes to racial/ethnic inequities in access to high-quality dialysis care in Chicago. Data are drawn from the United States Renal Data System merged to the ESRD Quality Incentive Program file and the American Community Survey (2005-2009) for facility and neighborhood characteristics (N = 2797). Outcomes included (1) spatial access (travel time to dialysis facilities) and (2) realized access (actual use of quality care). Neighborhood racial/ethnic composition was categorized into four types: predominantly White, Black, and Hispanic neighborhoods, and racially integrated neighborhoods. Blacks lived closer to a dialysis facility but traveled the same distance to their own dialysis compared with Whites. Hispanics had longer travel time to any dialysis than Whites, and the difference between Hispanics and Whites became no longer significant after adjusting for neighborhood racial/ethnic composition. Blacks and Hispanics had better access to a high-quality facility if they lived in integrated neighborhoods (OR = 1.85 and 3.77, respectively, p < 0.01) or in neighborhoods with higher concentrations of their own race/ethnicity (OR = 1.68 for Blacks in Black neighborhoods and 1.92 for Hispanics in Hispanic neighborhoods, p < 0.05) compared with Whites in predominantly White neighborhoods. Expanding opportunities for Blacks and Hispanics to gain access to racially integrated and minority neighborhoods may help alleviate racial/ethnic inequities in access to quality care among kidney disease patients.

Promoting sustainable agriculture: Iowa stakeholders’ perspectives on the US Farm Bill conservation programs

Farmers perceive a tension between short-term profit and long-term sustainability, which can be bridged by external investments in conservation. In the USA, the Farm Bill plays an important role in providing this investment through conservation programs. Since the Farm Bill is influenced by various stakeholders, their perspectives tend to inform its programs and practices. We aim to understand influential stakeholders’ viewpoints on strengths and weaknesses of major conservation programs as a means for either incremental or transformative changes leading to policy improvements. Interviews were conducted with representatives from key stakeholder groups, including farmer and agribusiness groups, commodity groups, government agencies, and environmental NGOs. Results reveal that commodity group and agribusiness representatives maintain that current conservation programs have been effective at reducing soil erosion and proposing incremental changes to them. Specific issues include simplifying the conservation stewardship program, easing requirements attached to the environmental quality incentive program, avoiding excessive conservation reserve program payments to compete with tenant farmers for good agricultural lands, and preventing farmers from being out of compliance on highly erodible land. However, results also reveal that stakeholders now appear to be more concerned about water quality and nutrient management rather than soil erosion. Environmental NGOs and research groups present transformative ideas to address this issue. At the farm level, they promote both infrastructural improvements and conservation-conscious management practices. At the landscape level, many stakeholders recognize the need for holistic, scalable approaches to soil and water quality conservation. However, interviewed stakeholders unanimously foresee incremental, not transformative, changes to Farm Bill conservation programs and policies.

Achieving equity in dialysis care and outcomes: The role of policies.

Socially disadvantaged persons, including racial and ethnic minorities, individuals with low incomes, homeless persons, and non-US citizens bear a disproportionate burden of end-stage kidney disease (ESKD). Inequities in nephrology referral, vascular access, use of home dialysis modalities, kidney transplantation, and mortality are prominent. Public policies, including the Patient Protection and Affordable Care Act, end-stage renal disease Quality Incentive Program, and the Prospective Payment System, were enacted to improve healthcare access and dialysis care. Here, we highlight inequities in dialysis care and outcomes, how current ESKD and other public policies may influence or exacerbate these inequities, and gaps in the literature needed to inform future policies toward achieving equity in ESKD. We give special attention to the 2019 Advancing American Kidney Health Executive Order, which has high potential to radically transform dialysis care.