Optimal Starts for End-Stage Renal Disease


Philip Madvig, MD; Joanna Mroz, MPH


Methods: Beginning in 2010, Kaiser Permanente Northern California (KPNC) underwent a performance improvement effort to increase the rate of optimal starts for new end-stage renal disease (ESRD) patients. Optimal starts are defined as patients who begin renal replacement therapy by one of these modalities: Peritoneal dialysis, home hemodialysis with permanent vascular access, in-center hemodialysis with permanent vascular access, or preemptive kidney transplantation. Optimal starts are associated with improved clinical, quality of life, and financial outcomes. The performance improvement approach included sequential implementation of several initiatives: Educational programs on peritoneal dialysis were developed and presented for nephrologists and renal case managers; a training program in peritoneal dialysis catheter insertion was provided for general surgeons; an ESRD tracking system was built within the KPNC electronic medical record (HealthConnect); regional leadership conducted site visits to each Medical Center; Medical Center performance was published monthly on the Region’s quality report card; and “playbooks” (standardized process guides) were created for optimal hemodialysis and peritoneal dialysis practices.
Results: Optimal Start performance improved from 39% in 2010 to 67% in 2015, and has remained high since.
Discussion: A multifaceted performance-improvement approach resulted in marked improvement in care for ESRD patients. Significant leadership effort and cultural change was needed as well as specific educational and training and information technology improvements. Efforts are underway to extend this work to all Kaiser Permanente Regions.


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