Value-Based Care in Nephrology: The Kidney Care Choices Model and Other Reforms

Implementing value-based healthcare: a scoping review of key elements, outcomes, and challenges for sustainable healthcare systems

Introduction

Value-Based Health Care (VBHC) is an increasingly important healthcare paradigm that focuses on maximizing health outcomes relative to the cost of care delivered. Various healthcare organizations have adopted VBHC principles, but significant barriers remain in adapting care models, engaging stakeholders, and measuring outcomes. Moreover, the lack of standardized methods for measuring outcomes and financial sustainability further complicates the transition to VBHC. Understanding the factors that facilitate or hinder VBHC adoption is crucial to informing policy and practice for broader implementation. The objective is to map the literature addressing VBHC concerning population, study characteristics, funding models, outcome measures, and barriers and facilitators.

Methods

Following the JBI methodology and the PRISMA-ScR reporting guidance, a scoping review was undertaken to include primary and secondary research on VBHC across various healthcare settings. Searches were undertaken in nine relevant databases. Peer-reviewed quantitative and qualitative studies published in English were included and analyzed. A total of 145 studies were included after screening 2,725 studies.

Results

The findings show that the United States leads VBHC research, contributing 65% of the studies, followed by European countries. Cohort and cross-sectional studies were predominant, focusing on various populations, including hospitals, surgical patients, and cancer patients. Key findings highlight that Value-Based Purchasing and Time-Driven Activity-Based Costing models were the most frequently reported funding models. Traditional in-hospital care remains the dominant delivery model, with increasing interest in telemedicine. Outcome measure were diverse, ranging from patient-reported outcomes to cost savings for both patients and providers. Barriers to VBHC implementation include insufficient funding, fee-for-service model persistence, and resistance from healthcare professionals. Facilitators included strong leadership, multidisciplinary collaboration, and the use of digital tools.

Conclusion

The review highlights the need for consistent outcome measurements, financial incentives, and improved data transparency to ensure the successful and scalable implementation of VBHC across healthcare systems. While VBHC shows promise in improving healthcare efficiency and quality, challenges remain in aligning financial and operational structures to fully support this paradigm shift.

Referral and Beyond: Restructuring the Kidney Transplant Process to Support Greater Access in the United States

Advocates for improved equity in kidney transplants in the United States have recently focused their efforts on initiatives to increase referral for transplant evaluation. However, because donor kidneys remain scarce, increased referrals are likely to result in an increasing number of patients proceeding through the evaluation process without ultimately receiving a kidney. Unfortunately, the process of referral and evaluation can be highly resource-intensive for patients, families, transplant programs, and payers. Patients and families may incur out-of-pocket expenses and be required to complete testing and treatments that they might not have chosen in the course of routine clinical care. Kidney transplant programs may struggle with insufficient capacity, inefficient workflow, and challenging programmatic finances, and payers will need to absorb the increased expenses of upfront pretransplant costs. Increased referral in isolation may risk simply transmitting system stress and resulting disparities to downstream processes in this complex system. We argue that success in efforts to improve access through increased referrals hinges on adaptations to the pretransplant process more broadly. We call for an urgent re-evaluation and redesign at multiple levels of the pretransplant system in order to achieve the aim of equitable access to kidney transplantation for all patients with kidney failure.

Patient-Centered Quality Measures for Dialysis Care: A Report of a Kidney Disease Outcomes Quality Initiative (KDOQI) Scientific Workshop Sponsored by the National Kidney Foundation

Providing high-quality patient-centered care is the central mission of dialysis facilities. Assessing quality and patient-centeredness of dialysis care is necessary for continuous dialysis facility improvement. Based predominantly on readily measured items, current quality measures in dialysis care emphasize biochemical and utilization outcomes, with very few patient-reported items. Additionally, current metrics often do not account for patient preferences and may compromise patient-centered care by limiting the ability of providers to individualize care targets, such as dialysis adequacy, based on patient priorities rather than a fixed numerical target. Developing, implementing, and maintaining a quality program using readily quantifiable data while also allowing for individualization of care targets that emphasize the goals of patients and their care partners provided the motivation for a September 2022 Kidney Disease Outcomes Quality Initiative (KDOQI) Workshop on Patient-Centered Quality Measures for Dialysis Care. Workshop participants focused on 4 questions: (1) What are the outcomes that are most important to patients and their care partners? (2) How can social determinants of health be accounted for in quality measures? (3) How can individualized care be effectively addressed in population-level quality programs? (4) What are the optimal means for collecting valid and robust patient-reported outcome data? Workshop participants identified numerous gaps within the current quality system and favored a conceptually broader, but not larger, quality system that stresses highly meaningful and adaptive measures that incorporate patient-centered principles, individual life goals, and social risk factors. Workshop participants also identified a need for new, low-burden tools to assess patient goals and priorities.

Clinical Utility of Infrapopliteal Calcium Score for the Evaluation of Severity of Peripheral Artery Disease

PURPOSE

To identify associations between computed tomography (CT)-based lower-extremity calcium score (LECS) across different anatomic segments and the presence, severity, and clinical outcomes of peripheral artery disease (PAD).

MATERIALS AND METHODS

In a mixed retrospective and prospective cohort study, 139 patients without prior lower-extremity intervention who underwent CT angiography of the aorta and lower extremities were identified. Subjects were classified as asymptomatic, claudicants, or having chronic limb-threatening ischemia (CLTI). LECS was measured using the Agatston method. Univariate and multivariate analyses were performed across categories of PAD severity. Receiver operating characteristic (ROC) analysis was performed, and an optimal cutoff point for LECS was identified. Claudicants were followed prospectively for CLTI and mortality.

RESULTS

Higher infrapopliteal calcium score (CS) was independently associated with CLTI versus claudication (odds ratio [OR], 3.24 per unit increase in log10-transformed CS; P < .001) in addition to hemodialysis dependence and poor functional status. One hundred eighty-eight Agatston units was identified as the optimal cutoff for infrapopliteal CS in assessing the risk of CLTI versus claudication (area under the ROC curve, 0.84 [SD ± 0.049]). This cutoff was validated in an independent cohort to be associated with progression to CLTI (OR, 12.8; P = .0039). In the claudicant group followed prospectively, infrapopliteal CS ≥188 predicted increased risk of CLTI or death after adjusting for functional status and hemodialysis dependence (Cox hazard ratio, 4.92; P = .0202).

CONCLUSIONS

Higher infrapopliteal CS was associated with CLTI among those with symptomatic PAD. An infrapopliteal CS cutoff of 188 Agatston units may serve as a useful tool to identify patients with increased risk of CLTI and mortality.

Home-Based Dialysis: A Primer for the Internist

Home-based dialysis modalities offer both clinical and practical advantages to patients. The use of the home-based modalities, peritoneal dialysis and home hemodialysis, has been increasing over the past decade after a long period of decline. Given the increasing frequency of use of these types of dialysis, it is important for clinicians to be familiar with how these types of dialysis are performed and key clinical aspects of care related to their use in patients with end-stage kidney disease.

Chronic kidney disease and value-based care: Lessons from innovation, iteration, and ideation in primary care

Value-based primary care has reduced health care costs, improved the quality of rendered care, and enhanced the patient experience. Value-based care emphasizes prevention, outreach, follow-up, patient engagement, and comprehensive, whole-person health. Primary care Accountable Care Organizations have leveraged technology-enabled workflows, practice transformation, and cutting-edge data and analytics to achieve success. These efforts are increasingly aided by predictive modeling used in the context of patient identification and prioritization algorithms. Value-based kidney care programs can glean salient takeaways from successful value-based primary care methods and models. The kidney care community is experiencing unprecedented transformation as novel payer programs and financial models burgeon. The authors contend these efforts can be accelerated by the adoption of techniques honed in value-based primary care. To optimize value-based kidney care, though, nephrology thought leaders must transcend the archetype of value-based primary care. To do so, the nephrology community must: (1) impel behavioral change among fee-for-service adherents; (2) harness emerging policy, guidelines, and quality measures; (3) adopt innovative tools, technologies, and therapies. In aggregating lessons from value-based primary care-and leveraging novel methodologies and approaches-the kidney care community will be better equipped to achieve the quadruple aim for kidney care.

A Novel Nephropsychology Clinic: Partnering With Patients in the Era of Value-Based Care in Nephrology

CKD and end-stage kidney disease are highly prevalent and complex chronic conditions with a high disease burden that corresponds to a high cost of care. Mental health conditions have a high prevalence in this population and add to the burden of disease, increase the cost of care, and are co-related with worse clinical outcomes. Despite these clear co-relations, mental health disorders remain underdiagnosed and undertreated in this population, secondary to multiple reasons, including patient-specific factors as well as systematic issues, including difficulty in accessing mental health experts. Here we describe a novel collaborative care model for patients with advanced CKD within the nephrology clinic space, in the form of a nephropsychology clinic. We present the details of our clinic, our preliminary findings, and propose that an integrated behavioral health model offers convenience for the patient and improves workflow for the physician, allowing a pathway to timely mental health interventions.

System-Level Strategies to Improve Home Dialysis: Policy Levers and Quality Initiatives

Advocacy and policy change are powerful levers to improve quality of care and better support patients on home dialysis. While the kidney community increasingly recognizes the value of home dialysis as an option for patients who prioritize independence and flexibility, only a minority of patients dialyze at home in the United States. Complex system-level factors have restricted further growth in home dialysis modalities, including limited infrastructure, insufficient staff for patient education and training, patient-specific barriers, and suboptimal physician expertise. In this article, we outline trends in home dialysis use, review our evolving understanding of what constitutes high-quality care for the home dialysis population (as well as how this can be measured), and discuss policy and advocacy efforts that continue to shape the care of US patients and compare them with experiences in other countries. We conclude by discussing future directions for quality and advocacy efforts.

Taurolidine/Heparin Lock Solution and Catheter-Related Bloodstream Infection in Hemodialysis: A Randomized, Double-Blind, Active-Control, Phase 3 Study

BACKGROUND

Catheter-related bloodstream infections (CRBSIs) are one of the most prevalent, fatal, and costly complications of hemodialysis with a central venous catheter (CVC). The LOCK IT-100 trial compared the efficacy and safety of a taurolidine/heparin catheter lock solution that combines taurolidine 13.5 mg/ml and heparin (1000 units/ml) versus heparin in preventing CRBSIs in participants receiving hemodialysis via CVC.

METHODS

LOCK IT-100 was a randomized, double-blind, active-control, multicenter, phase 3 study that enrolled adults with kidney failure undergoing maintenance hemodialysis via CVC from 70 US sites. Participants were randomized 1:1 to taurolidine/heparin catheter lock solution or heparin control catheter lock solution (1000 units/ml). The primary end point was time to CRBSI as assessed by a blinded Clinical Adjudication Committee. Secondary end points were catheter removal for any reason and loss of catheter patency. On the basis of a prespecified interim analysis, the Data and Safety Monitoring Board recommended terminating the trial early for efficacy with no safety concerns.

RESULTS

In the full analysis population ( N =795), nine participants in the taurolidine/heparin arm ( n =397; 2%) and 32 participants in the heparin arm ( n =398; 8%) had a CRBSI. Event rates per 1000 catheter days were 0.13 and 0.46, respectively, with the difference in time to CRBSI being statistically significant, favoring taurolidine/heparin ( P < 0.001). The hazard ratio was 0.29 (95% confidence interval, 0.14 to 0.62), corresponding to a 71% reduction in risk of CRBSIs with taurolidine/heparin versus heparin. There were no significant differences between study arms in time to catheter removal for any reason or loss of catheter patency. The safety of taurolidine/heparin was comparable with that of heparin, and most treatment-emergent adverse events were mild or moderate.

CONCLUSIONS

Taurolidine/heparin reduced the risk of developing a CRBSI in study participants receiving hemodialysis via CVC compared with heparin with a comparable safety profile.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Study Assessing Safety & Effectiveness of a Catheter Lock Solution in Dialysis Patients to Prevent Bloodstream Infection, NCT02651428 .

The expanded role of the transplant pharmacist: A 10-year follow-up

The role of the transplant pharmacist is recognized by transplant programs, governmental groups, and professional organizations as an essential part of the transplant multidisciplinary team. This role has evolved drastically over the last decade with the advent of major advances in the science of transplantation and the growth of the field, which necessitate expanded pharmacy services to meet the needs of patients. Data now exist within all realms of the phases of care for a transplant recipient regarding the utility and benefit of a solid organ transplant (SOT) pharmacist. Furthermore, governing bodies now have the opportunity to use Board Certification in Solid Organ Transplant Pharmacotherapy as a mechanism to identify and recognize specialty knowledge and expertise within the field of SOT pharmacotherapy. The purpose of this paper is to provide an overarching review of the current and future state of SOT pharmacy while also identifying major changes to the profession, forthcoming challenges, and expected areas of growth.

Current trends in hospice care usage for dialysis patients in the USA

BACKGROUND

The predictors and latest trends in hospice utilization, adequate duration of hospice care, and dialysis discontinuation without hospice enrollment among patients with end stage kidney disease are not fully known; the aim of this study was to assess them, analysing data from the United States Renal Data System.

METHODS

Data from the United States Renal Data System for patients with kidney failure who died between January 1, 2012, and December 31, 2019, were analyzed. Chi-square and logistic regression were used to evaluate associations between outcomes of interest and predictors, while Joinpoint regression was used to examine trends.

RESULTS

Among 803,049 patients, the median (IQR) age was 71 (17) years, 57% were male, 27% enrolled in hospice, 8% discontinued dialysis before death without hospice enrollment, and 7% remained in hospice for ≥ 15 days. Patients 65 years and older (adjusted odds ratio [aOR]: 2.75, 95% CI 2.71-2.79) and White race (aOR: 1.79, 95% CI 1.77-1.81) were more likely to enroll in hospice. White patients (aOR: 0.75, 95% CI 0.73-0.76) and those who never received a kidney transplant (aOR: 0.75, 95% CI 0.73-0.78) were less likely to have adequate duration of hospice care. Hospice enrollment and standardized duration of hospice care increased over time, with an average annual percentage change of 1.1% (95% CI 0.6-1.6) and 5% (95% CI 2.6-7.4), respectively.

CONCLUSIONS

Approximately one in every four patients with kidney failure who died between 2012 and 2019 had a history of hospice enrollment, while one in every 12 discontinued dialysis before death without hospice enrollment. There was an upward trend in the duration of hospice care.

Optimal Care for Kidney Health: Development of a Merit-based Incentive Payment System (MIPS) Value Pathway

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.

Optimizing Multidisciplinary Care of Patients with Chronic Kidney Disease and Type 2 Diabetes Mellitus

Diabetes is the leading cause of chronic kidney disease (CKD), a condition associated with significant morbidity and mortality. As these patients have a high risk of developing cardiovascular disease and end-stage kidney disease, there is a need for early detection and early initiation of appropriate therapeutic interventions that slow disease progression and prevent adverse outcomes. Due to the complex nature of diabetes and CKD management, a holistic, patient-centered, collaborative care approach delivered by a coordinated multidisciplinary team (ideally including a clinical pharmacist as part of a comprehensive medication management program) is needed. In this review, we discuss the barriers to effective care, the current multidisciplinary approach used for CKD prevention and treatment, and the potential ways that the multidisciplinary management of CKD associated with type 2 diabetes mellitus can be refined to improve patient outcomes.

Caring for Patients With Advanced Chronic Kidney Disease: Dietary Options and Conservative Care Instead of Maintenance Dialysis

An expert advisory board discussed the prevention and treatment of chronic kidney disease (CKD), with a focus on dietary options. This is timely, given the uptake of value based models for kidney care in the United States. Timing of dialysis start is influenced by patients' clinical status and complex patient-clinician interactions. Patients value personal freedom and quality of life and may want to delay dialysis, whilst physicians are sometimes more concerned with clinical outcomes. Kidney-preserving therapy can prolong the dialysis-free period and preserve residual kidney function, thus patients are asked to adjust their lifestyle and diet, to follow a low- or very low-protein diet, with or without ketoacid analogues. Multi-modal approaches include pharmacotherapies, management of symptoms, and a gradual, individualized dialysis transition. Patient empowerment is vital, including CKD education and involvement in decision making. These ideas may help patients, their families, and clinical teams to improve the management of CKD.

Pharmacy Practice Standards for Outpatient Nephrology Settings

Patients with kidney disease represent a medically complex group of patients with high medication burdens that could benefit from clinical pharmacy services as part of the interdisciplinary care team to optimize medication use. The "Advancing American Kidney Health" executive order includes new value-based reimbursement models to be tested by the Center for Medicare and Medicaid Innovation beginning January 2021 and January 2022. Advancing American Kidney Health executive order poses opportunities for the inclusion of comprehensive medication management. Following an iterative process integrating input from a diverse expert panel, published standards, clinical practice guidelines, peer review, and stakeholder feedback, our group developed practice standards for pharmacists caring for patients with kidney disease in health care settings. The standards focus on activities that are part of direct patient care and also include activities related to public health and advocacy, population health, leadership and management, and teaching, education and dissemination of knowledge. These standards are intended to be used by a variety of professionals, from pharmacists starting new practices to practice managers looking to add a pharmacist to the clinical team, to create standardization in services provided.

Education Standards for Pharmacists Providing Comprehensive Medication Management in Outpatient Nephrology Settings

Chronic kidney disease is a public health problem that has generated renewed interest due to poor patient outcomes and high cost. The Advancing American Kidney Health initiative aimed to transform kidney care with goals of decreasing the incidence of kidney failure and increasing the number of patients receiving home dialysis or a kidney transplant. New value-based models of kidney care that specify inclusion of pharmacists as part of the kidney care team were developed to help achieve these goals. To support this Advancing American Kidney Health-catalyzed opportunity for pharmacist engagement, the pharmacy workforce must have a fundamental knowledge of the core principles needed to provide comprehensive medication management to address chronic kidney disease and the common comorbid conditions and secondary complications. The Advancing Kidney Health through Optimal Medication Management initiative was created by nephrology pharmacists with the vision that every person with kidney disease receives optimal medication management through team-based care that includes a pharmacist to ensure medications are safe, effective, and convenient. Here, we propose education standards for pharmacists providing care for individuals with kidney disease in the outpatient setting to complement proposed practice standards.

Hidden Costs Associated with Conversion from Peritoneal Dialysis to Hemodialysis

Background

Increasing use of peritoneal dialysis (PD) will likely lead to increasing numbers of patients transitioning from PD to hemodialysis (HD). We describe the characteristics of patients who discontinued PD and converted to HD, trajectories of acute-care encounter rates and the total cost of care both before and after PD discontinuation, and the incidence of modality-related outcomes after PD discontinuation.

Methods

We analyzed data in the United States Renal Data System to identify patients aged ≥12 years who were newly diagnosed with ESKD in 2001-2017, initiated PD during the first year of ESKD, and discontinued PD in 2009-2018. We estimated monthly rates of hospital admissions, observation stays, emergency department encounters, and Medicare Parts A and B costs during the 12 months before and after conversion from PD to HD, and the incidence of home HD initiation, death, and kidney transplantation after conversion to in-facility HD.

Results

Among 232,699 patients who initiated PD, there were 124,213 patients who discontinued PD. Among them, 68,743 (55%) converted to HD. In this subgroup, monthly rates of acute-care encounters and total costs of care to Medicare sharply increased during the 6 months preceding PD discontinuation, peaking at 96.2 acute-care encounters per 100 patient-months and $20,701 per patient in the last month of PD. After conversion, rates decreased, but remained higher than before conversion. Among patients who converted to in-facility HD, the cumulative incidence of home HD initiation, death, and kidney transplantation at 24 months was 3%, 25%, and 7%, respectively.

Conclusions

The transition from PD to HD is characterized by high rates of acute-care encounters and health-care expenditures. Quality improvement efforts should be aimed at improving transitions and encouraging both home HD and kidney transplantation after PD discontinuation.