Patient Satisfaction Lower in Certain Dialysis Settings

Veronica Hackethal, MD

September 11, 2018

For-profit dialysis centers, freestanding facilities, and large dialysis chains score lower on measures of patient satisfaction than their counterparts, according to a study published online September 10 in JAMA Internal Medicine.

Dialysis facilities with larger proportions of African Americans and Native Americans also reported worse patient experiences.

"The perceived quality of dialysis care delivered in certain settings appears to be of concern, and opportunities appear to exist for improved implementation of patient experience surveys in dialysis pay-for-performance programs," write Brian Brady, MD, from Stanford University School of Medicine, California, and colleagues.

To evaluate patient experience at dialysis facilities on a national level, the researchers conducted a cross-sectional study using patient data from a national end-stage renal disease registry and from Medicare administrative claims data. Of 4977 dialysis facilities, 2939 (59.1%) reported In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) scores between April 8, 2015, and January 11, 2016, and were included in the analysis.

The researchers assessed the link between facility ICH-CAHPS scores and patient, facility, and geographic characteristics. The primary outcome was the mean ICH-CAHPS score, which covers the following six categories: nephrologists' communication and caring, dialysis center care and operations, providing information to patients, overall rating of nephrologists, dialysis center staff, and dialysis facilities. The researchers adjusted results for patient age, sex, race/ethnicity, insurance, income, duration of dialysis, comorbidities, and eight variables related to facility characteristics.

Adjusted mean ICH-CAHPS scores were significantly lower for for-profit centers, large dialysis chains (>200 facilities), and freestanding centers compared with their counterparts (−2.62 percentage points [95% confidence interval (CI), −3.70 to −1.54; P < .001]; −1.58 percentage points [95% CI, −2.24 to −0.92, P < .001]; and −2.35 percentage points [95% CI, −4.15 to −0.56; P = .01], respectively).

Facilities with more nurses per patient, and with privately insured patients, had higher adjusted mean ICH-CAHPS scores vs their counterparts (+0.2 percentage points [95% CI, 0.03 - 0.3]; and +1.2 percentage points [95% CI, 0.2 - 2.2], respectively).

Facilities with higher proportions of black and Native American patients had lower adjusted mean ICH-CAHPS scores than those with large proportions of white patients (−0.95 percentage points [95% CI, −1.12 to −0.78; P < .001]; and −1.00 percentage point [95% CI, −1.60 to −0.39; P = .001], respectively).

Geographic location and facility characteristics accounted for a large proportion of variation in ICH-CAHPS scores across facilities.

On the basis of these results, the authors mention several potential ways to improve care at dialysis centers. These include staffing centers with more nurses and including a focus on socioeconomics, culture, and beliefs to improve care for racial/ethnic minorities. In addition, the results about for-profit, freestanding, and large chains are consistent with economic theory suggesting that nonprofit providers emphasize quality care more than for-profit providers, they write.

"This is a timely and relevant study, given our growing recognition of the importance of patients' experience and voice in how we deliver care, as well as the incorporation of patient-centered measures into dialysis quality assessment and reimbursement," Connie Rhee, MD, told Medscape Medical News. Rhee, who was not involved in the study, is director of dialysis quality improvement and associate director of outpatient hemodialysis at the University of California, Irvine, School of Medicine.

In 2012, the Centers for Medicare & Medicaid Services began the end-stage renal disease Quality Incentive Program, the first legislatively mandated pay-for-performance program in the country. In the Quality Incentive Program, reimbursement is determined by facility performance on a range of quality measures.

In 2016, the Centers for Medicare & Medicaid Services began including patient experience in reimbursement calculations when it included the ICH-CAHPS survey in the Quality Incentive Program. The ICH-CAHPS is the first patient experience survey specific to end-stage renal disease and was developed jointly by the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research.

However, questions remain about how well the ICH-CAHPS can capture and prioritize patient perceptions about their care, Rhee added.

"Development of the ICH-CAHPS survey was conducted in a small fraction of the US dialysis population, and field testing was subject to low response rates, which may impact its interpretation and generalizability," she said.

Also, the study lacked facility-level information on survey completion. Both Rhee and the authors pointed out that responses by patients who did not complete the surveys could be inherently different from those who did, which could affect results.

"This study adds important new knowledge to the field, given sparse assessment of the ICH-CAHPS survey in large populations to date," Rhee concluded.

But she added that further studies are needed to evaluate factors related to the ICH-CAHPS survey, as well as patient, facility, and geographic factors and how they correlate with ICH-CAHPS scores.

The study was supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases, and the Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety. Chertow reports board of director membership for Satellite Healthcare. Rhee has disclosed no relevant financial relationships.

JAMA Intern Med. Published online September 10, 2018. Abstract

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