Changes in Dialysis Center Quality Associated With the End-Stage Renal Disease Quality Incentive Program : An Observational Study With a Regression Discontinuity Design

Ann Intern Med. 2021 Aug;174(8):1058-1064. doi: 10.7326/M20-6662. Epub 2021 Jun 1.

Abstract

Background: In 2012, the Centers for Medicare & Medicaid Services started levying performance-based financial penalties against outpatient dialysis centers under the mandatory End-Stage Renal Disease Quality Incentive Program.

Objective: To determine whether penalization was associated with improvement in dialysis center quality.

Design: Leveraging the threshold for penalization (total performance score < 60), a regression discontinuity design was used to examine the effect of penalization on quality over 2 years. Publicly available Medicare data from 2015-2018 were used. The effect of penalization at dialysis centers with different characteristics (for example, size or chain affiliation) was also examined.

Setting: United States.

Participants: Outpatient dialysis centers (n = 5830).

Measurements: Dialysis center total performance scores (a composite metric ranging from 0 to 100 based on clinical quality and adherence to reporting requirements) and individual measures that contribute to the total performance score.

Results: There were 1109 (19.0%) outpatient dialysis centers that received penalties in 2017 on the basis of performance in 2015. Penalized centers were located in ZIP codes with a higher average proportion of non-White residents (36.4% vs. 31.2%; P < 0.001) and residents with lower median income ($49 290 vs. $51 686; P < 0.001). Penalization was not associated with improvement in total performance scores in 2017 (0.4 point [95% CI, -2.5 to 3.2 points]) or 2018 (0.3 point [CI, -2.8 to 3.4 points]). This was consistent across dialysis centers with different characteristics. There was also no association between penalization and improvement in specific measures.

Limitation: The study could not account for how centers respond to penalization.

Conclusion: Penalization under the End-Stage Renal Disease Quality Incentive Program was not associated with improvement in the quality of outpatient dialysis centers.

Primary funding source: None.

Publication types

  • Observational Study

MeSH terms

  • Ambulatory Care Facilities / standards*
  • Centers for Medicare and Medicaid Services, U.S.*
  • Female
  • Humans
  • Kidney Failure, Chronic / therapy*
  • Male
  • Quality Indicators, Health Care*
  • Reimbursement, Incentive
  • Renal Dialysis / standards*
  • United States