Quality and accountability in the ESRD program

The quality of care received by patients with end-stage renal disease (ESRD) in the United States has received considerable public attention during the past several years because of a number of social, economic, and political factors. There has been a lingering impression that the poorer survival of dialysis patients in the United States, compared with their counterparts in other industrialized countries, is because of process factors for which there are opportunities for improvement, rather than just an adverse case mix. Recent reports by the Office of the Inspector General and the General Accounting Office have recommended that the Health Care Financing Administration (HCFA) improve its oversight of dialysis providers and hold the providers more accountable for their patient care outcomes. This requires the development of validated clinical performance measures that, in turn, should be derived from evidence-based clinical practice guidelines. The dual oversight model, with the state survey agencies agencies performing a quality assurance function to require facilities to meet minimal standards of operation (Medicare's conditions of participation) to prevent patient harm, and with the ESRD Networks performing a quality improvement function to bring processes and outcomes for all patients to a higher level, appears to be sound. HCFA's move toward increased provider accountability has included the development of facility-specific profiles for processes of care (dialysis adequacy) and outcomes (hemoglobin level and standardized mortality ratio), which may trigger state surveyor activities and that will be available for public scrutiny on a HCFA-sponsored web site. The adoption and application of continuous quality improvement methodologies at the dialysis provider level will be an important strategy for favorably positioning the facility in a competitive and demanding health care marketplace.