University of North Carolina Kidney Center and Division of Nephrology & Hypertension, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
Quality Committee, American Society of Nephrology, Washington, DC.
Clin J Am Soc Nephrol. 2022 Jul;17(7):1082-1091. doi: 10.2215/CJN.10880821. Epub 2022 Mar 14.
Contemporary nephrology practice is heavily weighted toward in-center hemodialysis, reflective of decisions on infrastructure and personnel in response to decades of policy. The Advancing American Kidney Health initiative seeks to transform care for patients and providers. Under the initiative's framework, the Center for Medicare and Medicaid Innovation has launched two new care models that align patient choice with provider incentives. The mandatory ESRD Treatment Choices model requires participation by all nephrology practices in designated Hospital Referral Regions, randomly selecting 30% of all Hospital Referral Regions across the United States for participation, with the remaining Hospital Referral Regions serving as controls. The voluntary Kidney Care Choices model offers alternative payment programs open to nephrology practices throughout the country. To help organize implementation of the models, we developed Driver Diagrams that serve as blueprints to identify structures, processes, and norms and generate intervention concepts. We focused on two goals that are directly applicable to nephrology practices and central to the incentive structure of the ESRD Treatment Choices and Kidney Care Choices: () increasing utilization of home dialysis, and () increasing the number of kidney transplants. Several recurring themes became apparent with implementation. Multiple stakeholders from assorted backgrounds are needed. Communication with primary care providers will facilitate timely referrals, education, and comanagement. Nephrology providers (nephrologists, nursing, dialysis organizations, others) must lead implementation. Patient engagement at nearly every step will help achieve the aims of the models. Advocacy with federal and state regulatory agencies will be crucial to expanding home dialysis and transplantation access. Although the models hold promise to improve choices and outcomes for many patients, we must be vigilant that they not do reinforce existing disparities in health care or widen known racial, socioeconomic, or geographic gaps. The Advancing American Kidney Health initiative has the potential to usher in a new era of value-based care for nephrology.
当代肾脏病学实践主要侧重于中心血液透析，这反映了基础设施和人员方面的决策，以应对数十年来的政策。推进美国肾脏健康倡议旨在改变患者和提供者的护理方式。在该倡议的框架下，医疗保险和医疗补助服务中心创新中心推出了两种新的护理模式，使患者选择与提供者激励机制保持一致。强制性终末期肾病治疗选择模式要求所有肾脏病学实践都参与指定的医院转诊区域，随机选择全美 30%的医院转诊区域参与，其余医院转诊区域作为对照。自愿性肾脏护理选择模式为全国的肾脏病学实践提供了可供选择的支付计划。为了帮助组织实施这些模式，我们开发了驾驶员图，作为识别结构、流程和规范并生成干预概念的蓝图。我们专注于两个直接适用于肾脏病学实践并对终末期肾病治疗选择和肾脏护理选择激励结构至关重要的目标：()增加家庭透析的使用，和 ()增加肾脏移植的数量。在实施过程中出现了几个反复出现的主题。需要来自不同背景的多个利益相关者。与初级保健提供者的沟通将促进及时转诊、教育和共同管理。肾脏病学提供者（肾脏病学家、护理人员、透析组织等）必须领导实施。患者在几乎每一步的参与都将有助于实现模型的目标。与联邦和州监管机构的倡导将是扩大家庭透析和移植机会的关键。虽然这些模式有望改善许多患者的选择和结果，但我们必须警惕它们不会加剧现有的医疗保健差距，也不会扩大已知的种族、社会经济或地理差距。推进美国肾脏健康倡议有可能为肾脏病学带来一个新的基于价值的护理时代。
