Freestanding Dialysis Facility Quality Incentive Program Scores and Mortality Among Incident Dialysis Patients in the United States

Am J Kidney Dis. 2020 Feb;75(2):177-186. doi: 10.1053/j.ajkd.2019.07.023. Epub 2019 Nov 1.


Rationale & objective: The Centers for Medicare & Medicaid Services introduced the Quality Incentive Program (QIP) along with the bundled payment reform to improve the quality of dialysis care in the United States. The QIP has been criticized for using easily obtained laboratory indicators without patient-centered measures and for a lack of evidence for an association between QIP indicators and patient outcomes. This study examined the association between dialysis facility QIP performance scores and survival among patients after initiation of dialysis.

Study design: Retrospective cohort study.

Setting & participants: Study participants included 84,493 patients represented in the US Renal Disease System's patient-level data who had initiated dialysis between January 1, 2013, and December 1, 2013, and who did not, during the first 90 days after dialysis initiation, die, receive a transplant, or become lost to follow-up. Patients were followed up for the study outcome through March 31, 2014.

Predictor: Dialysis facility QIP scores.

Outcome: Mortality.

Analytical approach: Using a unique facility identifier, we linked Medicare freestanding dialysis facility data from 2015 with US Renal Disease System patient-level data. Kaplan-Meier product limit estimator was used to describe the survival of study participants. Cox proportional hazards regression was used to assess the multivariable association between facility performance scores and patient survival.

Results: Excluding patients who died during the first 90 days of dialysis, 11.8% of patients died during an average follow-up of 5 months. Facilities with QIP scores<45 (HR, 1.39; 95% CI, 1.15-1.68) and 45 to<60 (HR, 1.21; 95% CI, 1.10-1.33) had higher patient mortality rates than facilities with scores≥90.

Limitations: Because the Centers for Medicare & Medicaid Services have revised QIP criteria each year, the findings may not relate to years other than those studied.

Conclusions: Dialysis facilities characterized by lower QIP scores were associated with higher rates of patient mortality. These findings need to be replicated to assess their consistency over time.

Keywords: Dialysis; Medicare; dialysis facility; end-stage renal disease (ESRD); health care disparities; health care quality; incentive; kidney failure; metric; mortality; pay-for-performance; performance score; quality assurance; quality incentive program (QIP); quality indicators; quality rating; reimbursement.

Publication types

  • Multicenter Study

MeSH terms

  • Ambulatory Care Facilities / standards*
  • Centers for Medicare and Medicaid Services, U.S. / standards*
  • Female
  • Follow-Up Studies
  • Humans
  • Incidence
  • Kidney Failure, Chronic / epidemiology
  • Kidney Failure, Chronic / therapy*
  • Male
  • Middle Aged
  • Quality Indicators, Health Care
  • Renal Dialysis / mortality*
  • Retrospective Studies
  • Survival Rate / trends
  • United States / epidemiology