Social Risk Factors May Influence Dialysis Quality Measures and Financial Penalties Interview with:
"Plugged into dialysis" by Dan is licensed under CC BY 2.0Andrew C. Qi,  Medical student

Karen E. Joynt Maddox MD MPH
Assistant professor of medicine
Washington University School of Medicine
Saint Louis, Missouri. What is the background for this study?  

Response: The End-Stage Renal Disease Quality Incentive Program (ESRD QIP) is a Medicare program that evaluates dialysis facilities in the U.S. based on a set of quality measures, and penalizes low-performing facilities. We’ve seen a growing understanding of how social risk factors like poverty and race/ethnicity impact patient outcomes in other settings, making it difficult for providers caring for disadvantaged populations to perform as well in these kinds of pay-for-performance programs. We were interested in seeing if this was the case for dialysis facilities as well, especially since patients receiving dialysis are already a vulnerable population. What are the main findings? 

Response: We found that dialysis facilities serving low-income communities or a high proportion of patients who are Black or dually enrolled in Medicaid were disproportionately more likely to receive a financial penalty under the program, even after controlling for a number of characteristics intrinsic to the facilities themselves. Independent (i.e., non-chain), urban, and large (>30 dialysis stations) facilities were also more likely to be penalized. What should readers take away from your report?

Response: While we cannot say for certain whether these disparities reflect differences in the quality of care delivered versus patient factors beyond providers’ control, our findings suggest that social risk plays a major role in how well dialysis facilities perform. We hope that our study adds to the growing conversation about how to design pay-for-performance programs to take patients’ social context into account. What recommendations do you have for future research as a result of this work? 

Response: One interesting finding that we came across was that Puerto Rican dialysis facilities were penalized at a much higher frequency than elsewhere in the U.S. I think it’s an example where there are obvious and significant challenges both systemically and related to the patient demographics, and these haven’t really been accounted for in the existing risk adjustment.

Dr. Karen Joynt Maddox previously did contract work for the Department of Health and Human Services. 


Andrew C. QiAnne M. Butler, and Karen E. Joynt Maddox

Health Affairs 2019 38:71101-1109 


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