Introduction to Peer.

The Peer Kidney Care Initiative is the result of collaboration among the Chief Medical Officers (CMOs) of thirteen dialysis provider organizations in the United States, including all of the ten largest organizations, according to number of patients treated. The overarching emphases of Peer are on the ways by which provider organizations are addressing the challenges of mortality, morbidity, quality of life, and patient satisfaction, both collaboratively and within each provider organization, and on how provider organizations can learn from one another through examination of available data, all with the goal of advancing patient care. Objectivity is an important aim of Peer, with foci on the successes in the industry and on directions for improvement.


The first meeting of the CMOs was held in Chicago in March 2013, and organized by DaVita HealthCare Partners, Dialysis Clinic, Inc. (DCI), Fresenius Medical Care, and Renal Ventures Management, with Tom F. Parker III, MD, and Doug Johnson, MD, providing the initial structure. This was entirely a clinical meeting, attended by those involved daily in patient care issues. Material was presented on the morbidity associated with fluid overload and left ventricular hypertrophy, as well as on infectious complications, sudden cardiac death, catheters for vascular access, and other topics affecting outcomes. Members of the group shared information on the different approaches used by each dialysis provider to address these and other clinical challenges.

The second meeting of the CMOs was held in Baltimore in March 2014. Participants described their efforts during the prior year and discussed new directions to further address fluid overload and congestive heart failure, infectious complications, sudden cardiac death, dialysis bath composition, and reduction of readmission rates. The predominant feeling was that traditional quality measures are insufficient tools for achieving desired improvements. Members of the group began considering a more comprehensive effort aimed at change via collaborative data sharing, relying on both Medicare and provider data to guide efforts at the local and national levels.

The Chronic Disease Research Group (CDRG), which previously served as the contractor for the United States Renal Data System (USRDS) Coordinating Center, participated in these first meetings, presenting an array of issues related to morbidity and mortality that providers could consider for focused attention. In the months following the second meeting, the CMOs and CDRG developed the Peer Kidney Care Initiative, a collaborative group aimed at assessing a wide range of areas of care, with a focus on enhancing patient outcomes and reducing hospitalizations and premature deaths. Guided by the providers and the appointed Steering Committee, CDRG serves as the independently operated Data Coordinating Center. In this first report, Peer examines Medicare data.

Although organizations such as the USRDS have long presented data on patient care and outcomes, areas that relate more directly to the delivery of care have only occasionally received attention. Overall mortality on an annual basis, for example, has been reported for 25 years, yet few if any organizations have reported variation in mortality within each year. In this first report, we show that mortality patterns vary seasonally, with the highest rates occurring in January through March of each year, an intuitive finding in light of the seasonal virulence of influenza and other upper respiratory infections in the general population. We also show that counts of incident ESRD patients are cyclical, as are rates of various cause-specific hospital admissions, including acute coronary syndrome, arrhythmia, heart failure, and chronic pulmonary disease. These patterns raise questions about preventive care and interventions, at the levels of the dialysis facility and provider organization alike, that might blunt the impact of this seasonal burden.

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