For patients with end-stage renal disease, dialysis treatments are vital and often are paid for by Medicare. In 2012, Medicare implemented a Quality Incentive Program scoring system, and in 2016, patient-reported experiences became a clinical measure in this scoring system so dialysis facilities are now evaluated and reimbursed based on surveys of patient experiences with the care that they received.

In a recently published study in JAMA Internal Medicine, researchers at Baylor College of Medicine examined associations between dialysis facility performance with patient experience measures and patient, facility and geographic characteristics.

“There is a survey called the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems, or ICH-CAHPS survey, developed specifically for patients who are receiving in-center hemodialysis,” said principal investigator Dr. Kevin Erickson, assistant professor of medicine in the section of nephrology at Baylor. “Dialysis facilities with more than 30 patients are required to hire a third-party vendor to administer the survey to their patients, and based on the average score at each facility that would get factored into their payment by Medicare.”

For this study, researchers linked ICH-CAHPS scores administered at US dialysis facilities with information from a national registry of patients receiving dialysis. The registry included patient characteristics and facility characteristics. Geographic characteristics were assessed by examining dialysis facility zip codes, US Census-based information on population density and two geographic units that are used in health services research: hospital service areas and hospital referral regions.

Researchers determined three main results. First, where a dialysis facility is located plays a key role in its ICH-CAHPS score. Second, patient characteristics at facilities explained some of the variations in ICH-CAHPS scores, which suggests that the experience of certain patient populations can be improved. Lastly, there are several facility characteristics that are associated with scores; particularly that dialysis facilities that were for-profit, owned by a large dialysis chain or that were freestanding all had lower scores on average. This indicates that there may be room to improve care delivery in these settings.

This is important because over the past few years there has been a general shift in dialysis care toward a larger share of care delivered by for-profit and chain-owned organizations.

“This is the first time that CAHPS survey results have been mandated within a national pay-for-performance program, and our findings indicate that there are opportunities to improve how these scores are used going forward,” Erickson said.

Additionally, in order to receive an ICH-CAHPS score, dialysis facilities must have at least 30 survey responses over the course of a year, but many facilities did not meet this requirement. Researchers wanted to explore why that might be the case. They looked at predictors of a facility having a missing score to see if there were any correlations between the factors that are associated with lower ICH-CAHPS performance and those that predict having a missing score. They found that there were a number of geographic and facility characteristics that predicted missing scores but there were no correlations to whether a facility was for-profit, chain owned or freestanding.

An issue that has been discussed when evaluating CAHPS scores is whether there should be risk adjustment and to what extent. For example, some facilities disproportionately care for patients who tend to give lower scores. Should that be taken into consideration when looking at the survey results? For this particular program, CMS does account for some patient-related characteristics that appear on the survey, but researchers’ findings suggest that they should also consider controlling for geographic location in some way. Instead of being compared against the scores of facilities across the entire U.S., perhaps facilities should be compared to other facilities located nearby, especially if facilities cannot control the influence of location on patient-reported experiences.

“Finding ways to improve the survey and make it so that facilities are being evaluated fairly but so that it captures elements of quality and true patient experiences is going to be important going forward not only for nephrology, but also for many other areas of healthcare that are involved in pay-for-performance programs,” Erickson said.

Other contributors to this work include Dr. Brian M. Brady, Dr. Bo Zhao, Dr. Jingbo Niu, Dr. Wolfgang C. Winkelmayer, Dr. Arnold Milstein and Dr. Glenn M. Chertow. The authors are affiliated with one or more of the following institutions: Stanford University, Baylor College of Medicine and Rice University.

This study was supported by grant K23 1K23DK101693-01 from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (Dr. Erickson). This material was also supported by grant CIN13-413 for the use of facilities and resources of the Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety.