The Star Rating System for dialysis clinics has been under fire since it was introduced in January 2014. But despite this scrutiny and expert panel review, questions about the system’s value remain. A four-star facility in New England was recently slapped with a $5,000 fine for numerous core survey deficiencies (the star system doesn’t include such criteria). Two dialysis units affiliated with a prominent academic medical center, whose nephrology program was recently ranked #8 in the country by U.S. News & World Report, have both garnered just one star, two years running.

What exactly is going on here? What is this rating system really rating?

Measuring the right things

Part of the problem is that the metrics currently used to measure dialysis center quality in the star rating system are either highly prone to random, statistical “noise” and/or are not measuring outcomes or processes that are within the control of dialysis facilities. The star ratings also don’t look at important factors like patient satisfaction or facility conditions (like those conditions that led to that $5,000 fine). When the star rating systems for Medicare-certified institutions were mandated by the Affordable Care Act, CMS quite naturally looked to data already being collected for the Dialysis Facility Compare website that could be applied to the star rating system. Unfortunately, these are often not the measures that are most important to patients, or the most valid measures of facility quality – both of which were principles outlined by CMS for the star ratings. Rating system for other health care providers, like home health and nursing homes, include measures such as patient satisfaction, staffing ratios, and facility inspections.

How to fix it

Here are three principles for measure selection that may improve the overall validity of star ratings as composite measures of dialysis facility quality of care, and need not burden the system with additional data collection in order to implement.

Use measures that reflect what dialysis centers directly control. Current standardized measures of mortality, hospital admissions, and transfusions are all arguably measures of clinical outcomes over which the dialysis center has little control. Attempts to adjust these measures for characteristics of the patients being treated rely on questionable or in many cases old and out-of-date data.1 Alternatively, process measures like ultrafiltration rates and outcomes such as access-related infection rates and septicemia are examples of quality of care metrics that might justifiably be seen as the direct responsibility of the dialysis facility, and for which there are known serious negative consequences if not managed properly.

Include the patient’s voice. The star ratings were intended as a consumer tool, but currently the consumer (i.e., the patient) has no input into the ratings. A recent article in Health Affairs reported that factors used in quality ratings for hospitals differed significantly depending on whether the rating criteria were consumer-driven or institutionally-driven.2  Shouldn’t quality ratings include patient input?

Include measures of facility conditions. Quality ratings for facilities also should include measures of the physical conditions and day-to-day operating practices in those facilities. Would you eat at a restaurant that used dirty plates and had a cold dining room with a leaky roof? But patients do not have access to this information about dialysis centers.

Patients deserve a clearer picture of the quality of care

It has been said that every system is designed perfectly to achieve the results it gets.3 The star rating system for dialysis facilities was cobbled together from a smattering of ready-at-hand measures that are easily pulled out of claims databases. The results are what you might expect. With a focus on patient-centered outcomes that directly relate to quality of care delivered by dialysis providers, I think we can do better.


  1. Eggers PW. CMS 2728: What good is it? Clin J Am Soc Nephrol. 2010;5(11):1908-1909.
  2. Ranard BL, Werner RM, Antanavicius T et al. Yelp reviews of hospital care can supplement and inform traditional surveys of the patient experience of care. Health Aff. 2016;35(4):697-705.

Weil AR. The patient engagement imperative. Health Aff (Millwood). 2016;35(4):563-563