The Peer Kidney Care Initiative is a new entity that only several months ago was no more than a simple idea: How to extend the work of the Chief Medical Officers (CMOs) with more data than individual dialysis providers already possessed. Discussion ensued with the Chronic Disease Research Group (CDRG) in Minneapolis, directed by Allan Collins, MD. From this discussion has emerged the Peer Kidney Care Initiative, or by its concise name, “Peer.” Peer currently include 13 member providers.

The goals of Peer are twofold. First, to conduct research and publish findings about topics that are important to dialysis providers and second, to develop analytics that help member providers and facility staff to better understand and improve the care of dialysis patients. Importantly, Peer is a collaborative effort, an extension of the existing collaboration among the CMOs, whereby dialysis providers might learn from one another about practices that can reduce morbidity and mortality and even increase satisfaction among their patients.

Peer sprouted from the CMO Initiative, which began with a March 2013 meeting convened by physicians Doug Johnson (Dialysis Clinic, Inc.), Allen Nissenson (DaVita Kidney Care), and Tom Parker (Renal Ventures Management). At that meeting, the CMOs and operations personnel discussed numerous domains, including dialysis initiation, nutrition, re-hospitalization, vascular access, and volume management. A second meeting of the CMO Initiative, held in March 2014, featured further discussion regarding dialysate composition, infection control, staffing patterns, and sudden cardiac death; expert faculty were invited to address these domains and others. At the second meeting, attendees also began to discuss a comprehensive effort to improve patient outcomes through collaborative analytics and standardized reporting, with Medicare data as the foundation.

Collins, an invited speaker at the meeting and former director of the United States Renal Data System (USRDS) Coordinating Center, provided useful insight into how the richness of data might be harnessed to track local and national progress toward improving patient outcomes. During the ensuing months, the CDRG, a non-profit research group with a long history of publishing epidemiologic studies of chronic kidney disease, particularly using administrative data (e.g., Medicare claims), and the leaders of the CMO Initiative organized the Peer Kidney Care Initiative.

Peer is managed by a steering committee that includes Collins and officials from nine dialysis providers. The committee is charged with identifying analytic priorities and reviewing findings, and governs by consensus. The CDRG serves as the independent, analytic arm of Peer; Peer analytics are led by epidemiologist Eric Weinhandl, MS, PhD candidate. In its nascent stage, Peer will be devoted primarily to the analysis of Medicare records in the dialysis patient population, including claims for inpatient care, outpatient care, and prescription drugs, as well as data ascertained from required forms, notably the Medical Evidence Report (CMS-2728) and the Death Notification (CMS-2746). In the future, Peer intends to incorporate data from providers’ electronic health records, including biochemical and ultrafiltration results.

Do we need a new data bank?

From a critical perspective, some might question the utility of Peer, given the number of public reporting mechanisms for outcome surveillance in the dialysis patient population, including the USRDS, Dialysis Facility Compare, the ESRD Quality Incentive Program, and most recently, the 5-Star Quality Rating System that is scheduled to launch this month. However, none of these mechanisms permit direct input from dialysis providers, particularly regarding the utility of proposed quality metrics. “At minimum, Peer offers a fresh perspective about what constitutes quality of care and how quality might be quantified,” Collins says. Weinhandl adds that for all that existing reporting mechanisms offer, much more can be done with administrative data to generate actionable insights. “In dialysis patients with Medicare coverage, particularly in the majority subset enrolled in Part D, we can see across the continuum of care, from the dialysis facility to acute care settings, outpatient clinics, and pharmacies. Relatively little of these data sees the light of day.” Collins argues that there is an important distinction between performance adjudication and quality improvement. “Standardized hospitalization and mortality ratios might be useful summary metrics for the assessment of dialysis facility performance, but for facility staff, these metrics are black boxes that offer few leads about the ‘how to’ of improving patient outcomes. Peer can fill that gap.”


As an example of analytics focusing on directly actionable concerns, the Peer Kidney Care Initiative has recently explored seasonality of infection requiring hospitalization among dialysis patients. Between 2008 and 2011, the rate of admission for diagnoses of pneumonia and influenza varied seasonally in dialysis patients, with unsurprising peaks in winter months (figure). Meanwhile, the rate of admission for diagnoses of vascular access infection and peritonitis also oscillated, with peaks in summer months. Causes of the latter pattern are uncertain, but may include the impact of perspiration on bacterial growth. In any case, the data illustrate the need for dialysis providers to adapt infection control practices to the season at hand. Before and during the winter, providers could increase their attention to influenza and pneumococcal vaccinations in patients and staff; utilize physical barriers, such as masks and isolation rooms, to contain infection; and improve the hygiene of both the physical space and staff, including physicians. During the summer, providers could retrain staff on cannulation practice, increase monitoring for signs of access infection, and more aggressively treat suspected infections. “Although use of fistulas has expanded in the last decade, the incidence of infectious complications is unchanged. We need to make progress and attention to seasonality is one path forward,” notes Collins.

Providers also see the value. “For Satellite Healthcare, Peer represents a valuable opportunity to actively engage with other providers to drive data analyses that can spur action,” said CMO Brigitte Schiller, MD. “While there are increasing amounts of data reported to the public, detailed claims data is not readily accessible or it is provided in a way that is difficult to determine what actions to take. Having access to these analyses will enhance our capabilities to conduct patient-centered initiatives that improve outcomes and care.”

In the future, Peer will begin releasing data to the public through multiple channels. Work on a first major report about the state of dialysis patient care is already underway. That report and other analytics will be available at, a site that both the CDRG and member providers plan to cement as the definitive source of information about the quality of dialysis patient care in the United States. Frequent additions to the site are planned. Peer will also publish its findings in abstracts for presentation at nephrology conferences and manuscripts in peer-reviewed journals.

Parker, one of the founders of the CMO Initiative, said, “The CMO group has made enormous progress by sharing information, protocols, and procedures and addressing common issues associated with providing renal replacement therapy. The Peer Kidney Care Initiative and our alliance with the CDRG will provide even more data and knowledge to advance the one goal that we all have: to ensure improvement in the welfare of patients who entrust us with their care. It is our sole purpose.”