- Email: [email protected]
The Quality Pyramid: The 2010 National Kidney Foundation Presidential Address
NKF Presidential Address The Quality Pyramid: The 2010 National Kidney Foundation Presidential Address This address was delivered at the 2010 Spring Clinical Meetings held in Orlando, Florida. The 2011 Spring Clinical Meetings will take place April 26-30, 2011 in Las Vegas, Nevada.
T
he mission of the National Kidney Foundation (NKF) is to prevent kidney disease, improve the health and well-being of individuals and families affected by kidney disease, and increase the availability of all organs for transplant. In working to achieve our mission, we constantly strive for higher levels of quality in the Foundation’s activities. The definition of quality per the Institute of Medicine is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”1 As the NKF advances quality kidney health care with this definition in mind, it is easy to recognize a pyramid built by the NKF to achieve quality kidney health care. This pyramid includes people, data and evidence, policy, and programs (Fig 1).
PEOPLE ARE THE FOUNDATION OF THE PYRAMID NKF has brought varied and interested individuals into new and traditional roles in quality health care. As significant, NKF has made efforts to acknowledge people in new and different ways. In 2010, NKF introduced the Fellow of the NKF program, spurred on by 3 enterprising kidney doctors from the Delaware Valley with a unique proposal to honor community and program-based efforts supplied by key individuals within NKF. NKF has also nominated (and had accepted) key individuals for multiple national panels, including most recently the Technical Expert Panels convened by the US Centers for Medicare and Medicaid Services to address issues in end-stage renal disease and work groups for the National Quality Forum (NQF), a nonprofit organization focused on
PROGRAMS
quality improvement in the American health care system. NKF also has continued its tradition of bringing together key opinion leaders on specific interdisciplinary topics through controversies or consensus conferences. These forums take advantage of collective expertise to deliver new perspectives on critical aspects of kidney health care. NKF is working hard to extend the influence of its exemplary and accomplished volunteers through new fundraising efforts and different venues for patient and family interactions. One example is the greatest single-year growth in “Kidney Walks” this past year as part of the portfolio of NKF fundraising efforts.
DATA AND EVIDENCE: THE NEXT LEVEL OF THE PYRAMID Over the last decade, NKF has championed the idea that chronic kidney disease (CKD) is a growing public health concern. With that change in approach, NKF has recognized its important role advocating the development and dissemination of evidence-based kidney health care. NKF has led the way in the kidney community with guideline development and methodology, repeatedly examining evidence and reviewing criteria for conflicts of interest and other cogent topics. Finding new ways to disseminate information and having a variety of accessible resources is critical. The web-based programs for continuing medical education and continuing professional development are one route. The NKF website (www.kidney.org) has had a 15% increase in web traffic in the last 2 years and Kidney Learning Solutions—the NKF’s educational resources initiative—has experienced more than 4-fold growth in e-learners for various continuing medical education and continuing professional development activities since 2006. NKF has continued its tradition of coalescing evidence and kidney health care leadership in what has
● Consistent with NKF mission
POLICY
● Engage individuals
DATA & EVIDENCE
● Move data and evidence into pracce
PEOPLE
● Expand current professional knowledge
Figure 1. NKF and quality kidney health care. Am J Kidney Dis. 2011;57(2):185-187
Address correspondence to Bryan N. Becker, MD, MMM, Section of Nephrology, Department of Medicine, University of Illinois at Chicago College of Medicine, 1853 W. Polk St 131 CMW Chicago, IL 60612. E-mail: [email protected] © 2011 by the National Kidney Foundation, Inc. 0272-6386/$36.00 doi:10.1053/j.ajkd.2010.12.003 185
Bryan N. Becker
Figure 2. Selected NKF programs and policy.
now become a standard for forward-thinking guideline development. The word “KDOQI” (Kidney Disease Outcomes Quality Initiative) carries with it brand equity and NKF has demonstrated further backing of global guidelines through its unflagging support of KDIGO (Kidney Disease: Improving Global Outcomes). The guideline process, methodical and trustworthy, yielded published guidelines in the past year relating to CKD–mineral and bone disorder and care of the kidney transplant recipient, and is proceeding on schedule for new guidelines focusing on acute kidney injury and glomerulonephritis. KDOQI had taken on a new responsibility providing commentaries of the applicability of the KDIGO guidelines for the North American kidney community.2-5
MOVING UP TO POLICY It is through policy that people, the data, and the evidence can start to enact a lasting change in kidney health care overall. NKF has developed a diverse policy team that examines new and ongoing issues pertaining to kidney health care. The evolution of broader population-based data from the National Health and Nutrition Examination Survey (NHANES) analyses and CKD guidelines focused a lens on CKD that remains prominent and ever-increasing in its intensity and ability to identify gaps in care. With NKF’s input, the US Department of Health and Human Services’ disease prevention program Healthy People 2010 included, for the first time, CKD-specific objectives including reducing the extent of kidney failure due to diabetes and increasing the proportion of patients with diabetes mellitus and CKD who receive recommended medical evaluation. These ob186
jectives remain in place for Healthy People 2020, along with broader population objectives in line with our improved understanding of CKD: reducing the percentage of the US population with CKD, reducing the death rate among people with CKD, and increasing the number of individuals with CKD who are aware that they have impaired kidney function.6
PROGRAMS: MOVING POLICY TO THE PEOPLE WE SERVE NKF has created a stable of core programs that highlight key areas of CKD recognition, awareness, and monitoring (Fig 2). The Kidney Early Evaluation Program (KEEP), now moving into its second decade, is the nation’s largest CKD screening program with more than 140,000 individuals in the screening cohort.7 For the first time ever, KEEP developed a longitudinal component and defined new health risk assessments based on KEEP data. The most striking feature of this screening program is the degree to which it has reinforced the need for CKD awareness among all at-risk individuals. Of the individuals screened in KEEP, 26% have CKD and only 2% know that they do. A parallel program in concert with the US Centers for Disease Control and Prevention (CDC), the CKD Health Risk Information Sharing Project or CHERISH, has stimulated interest in examining pragmatic approaches to CKD screening through departments of health in various states. This program, modeled on KEEP, met its primary objectives and expanded site number in late 2009 with intent to further review the project data in 2010.8-9 Am J Kidney Dis. 2011;57(2):185-187
NKF Presidential Address
NKF also was a strong supporter for the Medicare Improvements for Patients and Providers Act (MIPPA). This legislation contained a Medicare education benefit for CKD stage 4 patients to help them understand the necessary steps in medical care to achieve a smooth transition to dialysis and/or transplant. NKF developed a 64-component curriculum, “Your Treatment–Your Choice,” and piloted the program with 500 patients to validate the efficacy of the curriculum and to provide a finished product to the CKD community for patients desirous of using this Medicare benefit.
VIEWING THE FUTURE FROM THE TOP OF THE PYRAMID NKF is a learning organization. It uses this pyramid to identify new issues and formulate approaches to those issues with the purpose of advancing kidney health care. As NKF looks to the future, 2 central observations regarding transplantation have increased clarity. 1. There remains a significant shortage of organs for kidney transplant and tremendous opportunities for reducing the variation in organ donation and improving the capacity use of our transplant efforts in the United States. 2. Posttransplant medical care is of increasing importance with a continued need to ensure access to immunosuppressive medications for all kidney transplant patients at all times during the functional lifetime of their transplant and recognition of new medical complications such as posttransplant diabetes mellitus and novel infectious complications. With these factors in mind, NKF has taken its comprehensive program to reduce length of time kidney transplant candidates must wait for an organ (the END THE WAIT! initiative) and formalized its structure into an official NKF committee to support dialogue, data collection, and multi-stakeholder input to successfully expand transplant efforts in the United States. Another issue of increased prominence in the kidney health care arena is that infectious complications remain the “hidden” epidemic among end-stage renal disease patients, accounting for significant costs and a tremendous toll in terms of mortality. NKF is examining how to integrate best practices in reducing infection risk, be it through reduced catheter use or through other techniques, and disseminate those via the Education subcommittee of KDOQI. This takes that notion of quality and makes it realizable by working to delivery current and new knowledge related to health
Am J Kidney Dis. 2011;57(2):185-187
services and outcomes to members of the kidney health care community. The framework of the quality pyramid has served our organization well as a model for linking exceptional people with high-impact value in the context of kidney health care. The continued vigor of the Foundation, its signature programs, and its ability to develop and contribute to policy is dependent on that most precious of resources, people. The efforts of volunteers across all kidney health care disciplines have been integral to the NKF, now in its 60th year, towards achieving its mission. Most assuredly, such efforts, heralded or with the quiet dignity of so many of our volunteers and constituents, will continue to be the foundation of our foundation for the next 60 years as well. Bryan N. Becker, MD, MMM University of Illinois-Chicago Chicago, Illinois
ACKNOWLEDGEMENTS Dr Becker served as President of the National Kidney Foundation for the 2009-2010 term. Financial Disclosure: Dr Becker is a member of the board of directors of Forward Health Group.
REFERENCES 1. Lohr, KN, ed. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academy Press; 1990. 2. Rocco MV, Berns JS. KDOQI in the era of global guidelines. Am J Kidney Dis. 2009;54(5):781-787. 3. Gordon CE, Balk EM, Becker BN, et al. KDOQI US commentary on the KDIGO clinical practice guideline for the prevention, diagnosis, evaluation, and treatment of hepatitis C in CKD. Am J Kidney Dis. 2008;52(5):811-825. 4. Uhlig K, Berns JS, Kestenbaum B, et al. KDOQI US commentary on the 2009 KDIGO clinical practice guideline for the diagnosis, evaluation, and treatment of CKD–mineral and bone disorder (CKD-MBD). Am J Kidney Dis. 2010;55(5):773-799. 5. Bia M, Adey DB, Bloom RD, Chan L, Kulkarni S, Tomlanovich S. KDOQI US commentary on the 2009 KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Kidney Dis. 2010;56(2):189-218. 6. US Department of Health and Human Services. Health People 2020 Proposed Objectives: Chronic Kidney Disease. Available at: http://www.healthypeople.gov/hp2020/Objectives/Topic Area.aspx?id⫽15&TopicArea⫽Chronic⫹Kidney⫹Diseases. Accessed December 1, 2010. 7. McCullough PA, Vassalotti JA, Collins AJ, Chen S-C, Bakris GL. National Kidney Foundation’s Kidney Early Evaluation Program (KEEP) annual data report 2009: executive summary. Am J Kidney Dis. 2010;55(3)(suppl 2):S1-S3. 8. Vassalotti JA, Fox CH, Becker BN. Risk factors and screening for chronic kidney disease. Adv Chronic Kidney Dis. 2010;17(3): 237-45. 9. Collins AJ, Vassalotti JA, Wang C, et al. Who should be targeted for CKD screening? Impact of diabetes, hypertension, and cardiovascular disease. Am J Kidney Dis. 2009;53(3)(suppl 3):S71S77.
187
T
he mission of the National Kidney Foundation (NKF) is to prevent kidney disease, improve the health and well-being of individuals and families affected by kidney disease, and increase the availability of all organs for transplant. In working to achieve our mission, we constantly strive for higher levels of quality in the Foundation’s activities. The definition of quality per the Institute of Medicine is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”1 As the NKF advances quality kidney health care with this definition in mind, it is easy to recognize a pyramid built by the NKF to achieve quality kidney health care. This pyramid includes people, data and evidence, policy, and programs (Fig 1).
PEOPLE ARE THE FOUNDATION OF THE PYRAMID NKF has brought varied and interested individuals into new and traditional roles in quality health care. As significant, NKF has made efforts to acknowledge people in new and different ways. In 2010, NKF introduced the Fellow of the NKF program, spurred on by 3 enterprising kidney doctors from the Delaware Valley with a unique proposal to honor community and program-based efforts supplied by key individuals within NKF. NKF has also nominated (and had accepted) key individuals for multiple national panels, including most recently the Technical Expert Panels convened by the US Centers for Medicare and Medicaid Services to address issues in end-stage renal disease and work groups for the National Quality Forum (NQF), a nonprofit organization focused on
PROGRAMS
quality improvement in the American health care system. NKF also has continued its tradition of bringing together key opinion leaders on specific interdisciplinary topics through controversies or consensus conferences. These forums take advantage of collective expertise to deliver new perspectives on critical aspects of kidney health care. NKF is working hard to extend the influence of its exemplary and accomplished volunteers through new fundraising efforts and different venues for patient and family interactions. One example is the greatest single-year growth in “Kidney Walks” this past year as part of the portfolio of NKF fundraising efforts.
DATA AND EVIDENCE: THE NEXT LEVEL OF THE PYRAMID Over the last decade, NKF has championed the idea that chronic kidney disease (CKD) is a growing public health concern. With that change in approach, NKF has recognized its important role advocating the development and dissemination of evidence-based kidney health care. NKF has led the way in the kidney community with guideline development and methodology, repeatedly examining evidence and reviewing criteria for conflicts of interest and other cogent topics. Finding new ways to disseminate information and having a variety of accessible resources is critical. The web-based programs for continuing medical education and continuing professional development are one route. The NKF website (www.kidney.org) has had a 15% increase in web traffic in the last 2 years and Kidney Learning Solutions—the NKF’s educational resources initiative—has experienced more than 4-fold growth in e-learners for various continuing medical education and continuing professional development activities since 2006. NKF has continued its tradition of coalescing evidence and kidney health care leadership in what has
● Consistent with NKF mission
POLICY
● Engage individuals
DATA & EVIDENCE
● Move data and evidence into pracce
PEOPLE
● Expand current professional knowledge
Figure 1. NKF and quality kidney health care. Am J Kidney Dis. 2011;57(2):185-187
Address correspondence to Bryan N. Becker, MD, MMM, Section of Nephrology, Department of Medicine, University of Illinois at Chicago College of Medicine, 1853 W. Polk St 131 CMW Chicago, IL 60612. E-mail: [email protected] © 2011 by the National Kidney Foundation, Inc. 0272-6386/$36.00 doi:10.1053/j.ajkd.2010.12.003 185
Bryan N. Becker
Figure 2. Selected NKF programs and policy.
now become a standard for forward-thinking guideline development. The word “KDOQI” (Kidney Disease Outcomes Quality Initiative) carries with it brand equity and NKF has demonstrated further backing of global guidelines through its unflagging support of KDIGO (Kidney Disease: Improving Global Outcomes). The guideline process, methodical and trustworthy, yielded published guidelines in the past year relating to CKD–mineral and bone disorder and care of the kidney transplant recipient, and is proceeding on schedule for new guidelines focusing on acute kidney injury and glomerulonephritis. KDOQI had taken on a new responsibility providing commentaries of the applicability of the KDIGO guidelines for the North American kidney community.2-5
MOVING UP TO POLICY It is through policy that people, the data, and the evidence can start to enact a lasting change in kidney health care overall. NKF has developed a diverse policy team that examines new and ongoing issues pertaining to kidney health care. The evolution of broader population-based data from the National Health and Nutrition Examination Survey (NHANES) analyses and CKD guidelines focused a lens on CKD that remains prominent and ever-increasing in its intensity and ability to identify gaps in care. With NKF’s input, the US Department of Health and Human Services’ disease prevention program Healthy People 2010 included, for the first time, CKD-specific objectives including reducing the extent of kidney failure due to diabetes and increasing the proportion of patients with diabetes mellitus and CKD who receive recommended medical evaluation. These ob186
jectives remain in place for Healthy People 2020, along with broader population objectives in line with our improved understanding of CKD: reducing the percentage of the US population with CKD, reducing the death rate among people with CKD, and increasing the number of individuals with CKD who are aware that they have impaired kidney function.6
PROGRAMS: MOVING POLICY TO THE PEOPLE WE SERVE NKF has created a stable of core programs that highlight key areas of CKD recognition, awareness, and monitoring (Fig 2). The Kidney Early Evaluation Program (KEEP), now moving into its second decade, is the nation’s largest CKD screening program with more than 140,000 individuals in the screening cohort.7 For the first time ever, KEEP developed a longitudinal component and defined new health risk assessments based on KEEP data. The most striking feature of this screening program is the degree to which it has reinforced the need for CKD awareness among all at-risk individuals. Of the individuals screened in KEEP, 26% have CKD and only 2% know that they do. A parallel program in concert with the US Centers for Disease Control and Prevention (CDC), the CKD Health Risk Information Sharing Project or CHERISH, has stimulated interest in examining pragmatic approaches to CKD screening through departments of health in various states. This program, modeled on KEEP, met its primary objectives and expanded site number in late 2009 with intent to further review the project data in 2010.8-9 Am J Kidney Dis. 2011;57(2):185-187
NKF Presidential Address
NKF also was a strong supporter for the Medicare Improvements for Patients and Providers Act (MIPPA). This legislation contained a Medicare education benefit for CKD stage 4 patients to help them understand the necessary steps in medical care to achieve a smooth transition to dialysis and/or transplant. NKF developed a 64-component curriculum, “Your Treatment–Your Choice,” and piloted the program with 500 patients to validate the efficacy of the curriculum and to provide a finished product to the CKD community for patients desirous of using this Medicare benefit.
VIEWING THE FUTURE FROM THE TOP OF THE PYRAMID NKF is a learning organization. It uses this pyramid to identify new issues and formulate approaches to those issues with the purpose of advancing kidney health care. As NKF looks to the future, 2 central observations regarding transplantation have increased clarity. 1. There remains a significant shortage of organs for kidney transplant and tremendous opportunities for reducing the variation in organ donation and improving the capacity use of our transplant efforts in the United States. 2. Posttransplant medical care is of increasing importance with a continued need to ensure access to immunosuppressive medications for all kidney transplant patients at all times during the functional lifetime of their transplant and recognition of new medical complications such as posttransplant diabetes mellitus and novel infectious complications. With these factors in mind, NKF has taken its comprehensive program to reduce length of time kidney transplant candidates must wait for an organ (the END THE WAIT! initiative) and formalized its structure into an official NKF committee to support dialogue, data collection, and multi-stakeholder input to successfully expand transplant efforts in the United States. Another issue of increased prominence in the kidney health care arena is that infectious complications remain the “hidden” epidemic among end-stage renal disease patients, accounting for significant costs and a tremendous toll in terms of mortality. NKF is examining how to integrate best practices in reducing infection risk, be it through reduced catheter use or through other techniques, and disseminate those via the Education subcommittee of KDOQI. This takes that notion of quality and makes it realizable by working to delivery current and new knowledge related to health
Am J Kidney Dis. 2011;57(2):185-187
services and outcomes to members of the kidney health care community. The framework of the quality pyramid has served our organization well as a model for linking exceptional people with high-impact value in the context of kidney health care. The continued vigor of the Foundation, its signature programs, and its ability to develop and contribute to policy is dependent on that most precious of resources, people. The efforts of volunteers across all kidney health care disciplines have been integral to the NKF, now in its 60th year, towards achieving its mission. Most assuredly, such efforts, heralded or with the quiet dignity of so many of our volunteers and constituents, will continue to be the foundation of our foundation for the next 60 years as well. Bryan N. Becker, MD, MMM University of Illinois-Chicago Chicago, Illinois
ACKNOWLEDGEMENTS Dr Becker served as President of the National Kidney Foundation for the 2009-2010 term. Financial Disclosure: Dr Becker is a member of the board of directors of Forward Health Group.
REFERENCES 1. Lohr, KN, ed. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academy Press; 1990. 2. Rocco MV, Berns JS. KDOQI in the era of global guidelines. Am J Kidney Dis. 2009;54(5):781-787. 3. Gordon CE, Balk EM, Becker BN, et al. KDOQI US commentary on the KDIGO clinical practice guideline for the prevention, diagnosis, evaluation, and treatment of hepatitis C in CKD. Am J Kidney Dis. 2008;52(5):811-825. 4. Uhlig K, Berns JS, Kestenbaum B, et al. KDOQI US commentary on the 2009 KDIGO clinical practice guideline for the diagnosis, evaluation, and treatment of CKD–mineral and bone disorder (CKD-MBD). Am J Kidney Dis. 2010;55(5):773-799. 5. Bia M, Adey DB, Bloom RD, Chan L, Kulkarni S, Tomlanovich S. KDOQI US commentary on the 2009 KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Kidney Dis. 2010;56(2):189-218. 6. US Department of Health and Human Services. Health People 2020 Proposed Objectives: Chronic Kidney Disease. Available at: http://www.healthypeople.gov/hp2020/Objectives/Topic Area.aspx?id⫽15&TopicArea⫽Chronic⫹Kidney⫹Diseases. Accessed December 1, 2010. 7. McCullough PA, Vassalotti JA, Collins AJ, Chen S-C, Bakris GL. National Kidney Foundation’s Kidney Early Evaluation Program (KEEP) annual data report 2009: executive summary. Am J Kidney Dis. 2010;55(3)(suppl 2):S1-S3. 8. Vassalotti JA, Fox CH, Becker BN. Risk factors and screening for chronic kidney disease. Adv Chronic Kidney Dis. 2010;17(3): 237-45. 9. Collins AJ, Vassalotti JA, Wang C, et al. Who should be targeted for CKD screening? Impact of diabetes, hypertension, and cardiovascular disease. Am J Kidney Dis. 2009;53(3)(suppl 3):S71S77.
187