An Environmental Scan and Evaluation of Home Dialysis Quality Indicators Currently Used in Canada

Background: Quality indicators are important tools to measure and ultimately improve the quality of care provided. Performance measurement may be particularly helpful to grow disciplines that are underutilized and cost-effective, such as home dialysis (peritoneal dialysis and home hemodialysis). Objective: To identify and catalog home dialysis quality indicators currently used in Canada, as well as to evaluate these indicators as a starting point for future collaboration and standardization of quality indicators across Canada. Design: An environmental scan of quality indicators from provincial organizations, quality organizations, and stakeholders. Setting: Sixteen-member pan-Canadian panel with expertise in both nephrology and quality improvement. Patients: Our environmental scan included indicators relevant to patients on home dialysis. Measurements: We classified existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks. Methods: To evaluate the indicators, a 6-person subcommittee conducted a modified version of the Delphi consensus technique based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for further examination. We rated items from 1 to 9 on 6 domains (1-3 does not meet criteria to 7-9 meets criteria) as well as a global final rating (1-3 unnecessary to 7-9 necessary) to distinguish high-quality from low-quality indicators. Results: Overall, we identified 40 quality indicators across 7 provinces, with 22 (55%) rated as “necessary” to distinguish high quality from poor quality care. Ten indicators were measured by more than 1 province, and 5 of these indicators were rated as necessary (home dialysis prevalence, home dialysis incidence, anemia target achievement, rates of peritonitis associated with peritoneal dialysis, and home dialysis attrition). None of these indicators captured the IOM domains of timely, patient-centered, or equitable care. Limitations: The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals. Conclusions: These results provide Canadian home dialysis programs with a starting point on how to measure quality of care along with the current gaps. This work is an initial and necessary step toward future collaboration and standardization of quality indicators across Canada, so that home dialysis programs can access a smaller number of highly rated balanced indicators to motivate and support patient-centered quality improvement initiatives.