Academic journal article Health Care Financing Review

Measuring and Improving the Health Status of End Stage Renal Disease Patients

Academic journal article Health Care Financing Review

Measuring and Improving the Health Status of End Stage Renal Disease Patients

Article excerpt


The entire Medicare ESRD patient population is not "elderly, poor, or disabled," but it certainly includes many individuals who share those characteristics. The elderly (over 65 years of age) make up a large and growing proportion of the ESRD patient population: 47.1 percent of all new (incident) ESRD patients in 1993 were elderly; as were 32.1 percent of the prevalent patients at the end of 1993 (United States Renal Data System, 1996). There are no direct measurements of income of ESRD patients, but the economic consequences of kidney failure are very severe. More over, a disproportionate share of ESRD patients are drawn from minority populations known to have a higher than average incidence of poverty. African-Americans, with a kidney failure rate nearly four times that of the white population, constitute a major group within the ESRD patient population: 29.1 percent of all incident ESRD patients in 1993 and 31.4 percent of prevalent patients at the end of 1993 were African-American (United States Renal Data System, 1996). Klag and colleagues reported recently that lower income was as great a risk factor as high blood pressure among African-American male ESRD patients Wag et al., 1997).

The original language of the Social Security Amendments of 1972, which extended Medicare benefits to the disabled, declared that ESRD patients "were deemed to be disabled" for purposes of Medicare coverage under Parts A and B. More importantly, a significant number of ESRD patients also receive disability benefits from Social Security, a result of the functional consequences of this organ's failure. Some of the ESRD patient population are elderly, poor, or disabled, some are not. All these individuals, however, clearly represent a vulnerable chronic disease patient population.


The Omnibus Budget Reconciliation Act of 1987, in which Congress requested the Institute of Medicine (IOM) to study aspects of the Medicare ESRD program, included the following two issues among those on which it sought advice: "the quality of care provided to ESRD beneficiaries, as measured by clinical indicators, functional status of patients, and patient satisfaction;" and "the effect of reimbursement on quality of care" (Rettig and Levinsky, 1991). At that time, little formal attention had been given within nephrology to the measurement of quality of care. Clinicians were concerned with patient mortality, as a measurable outcome, and the adequacy of dialysis, a process measure closely associated with mortality. "Adequacy," which was then emerging as a major preoccupation of nephrologists, addresses the optimal "dose" of dialysis.

Not surprisingly, given the salience of reimbursement issues, the IOM committee devoted more attention in its report to the impact of reimbursement on quality (three chapters) than to the formal evaluation of quality of care (one chapter) (Rettig and Levinsky, 1991). Data existed on mortality, on hospitalization, and on changing staffing patterns, and these could be examined for the effects of reimbursement changes. On measurement of quality of care, the report drew on the classical framework articulated by Donabedian of examining quality in terms of patient outcomes, processes of care, and structural variables (Donabedian, 1966). In addition, the committee commented on the quality assurance efforts of the federal government, focusing primarily on the Health Care Financing Administration but also including the National Institutes of Health. The IOM report made a number of recommendations, including a proposal to establish "a continuing program of ESRD QA research" (Rettig and Levinsky, 1991).

Concurrent with the IOM ESRD study were several other IOM efforts related to quality of care and health status measurement. An IOM report, authorized by OBRA 1986, Medicare: A Strategy for Quality Assurance, published in 1990, was well received by the nephrology community (Lohr, 1990). …

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