Dear Mark and Rebecca:

We read with interest your article about the Nonprofit Kidney Care Alliance (NKCA) study on the impact of patient demographic on the Five-Star Ratings.

We are not surprised that Alex Brill’s analysis determined that geography and patient demographics have a material impact on clinical outcomes, which is ultimately reflected in Five-Star ratings. There are considerable challenges for all providers of health care and patients in settings where access to care is limited, ongoing social support in the community is lacking and health literacy may be suboptimal.

It is still incumbent on providers to partner with patients and identify and nurture community resources to ensure that outcomes are optimized for all patients regardless of socioeconomic status. Of all the four- and five-star centers in the industry, 54 percent are DaVita centers.

Germane to the Brill study is the fact that, we serve a disproportionally high volume of patients in areas of low socioeconomic status and even in these areas we outperformed others in the Star ratings.

We believe that by focusing on engaging patients and health care providers and implementing care processes we can improve quality, even in the most difficult circumstances.

As additional metrics become part of publicly reported data for dialysis facilities and other providers, appropriate adjustment for these factors should be implemented, as recommended by the National Quality Forum for all comparative quality metrics to ensure apples-to-apples comparison of performance.

—Allen R. Nissenson, MD, FACP, FASN, FNKF, DaVita Kidney Care Chief Medical Officer and
Mahesh Krishnan, M.D., MPH, MBA, FASN, DaVita Kidney Care international chief medical officer group vice president of research and development


Almachraki  et al. The Impact of Socioeconomic Status as an Unmeasured Confounder for Claims Based, Comparative Analysis of Dialysis Provider Type and Its Effect on Dialysis Unit Economics. Poster Presented at the Amercian Society of Nephrology Meetings, November 2014, Philadelphia PA.