The perils of Gabapentin

One of the things that I always highlight when teaching fellows and residents is the importance of appropriate drug dosing for patients on dialysis and one of the drugs that is most often inappropriately dosed in my experience is gabapentin. Today, an article in JASN highlights again the importance of not overusing this drug in the dialysis population. 

Gabapentin and pregabalin are often used in patients with CKD primarily to treat neuropathic pain and restless leg syndrome and given the high prevalence of diabetes in this population, the proportion who receive these drugs is very high. In patients with normal renal function, the maximum dose of gabapentin is 3600mg daily in divided doses. However, gabapentin is renally cleared and so the dose needs to be adjusted according to the GFR. For patients on dialysis, the recommended dose is 100-300mg post dialysis on dialysis days only. However, this is routinely exceeded in clinical practice. 

The study in JASN looked at medicare prescriptions for gabapentin and pregabalin in dialysis patients examined the relationship between the doses used and a variety of outcomes including altered mental status, falls and fractures. 20% of the dialysis population received at least one prescription for these drugs in 2011. Even at the lowest doses (less than 300mg daily), there was an association between the use of these drugs and AMS and falls while doses greater than 300mg daily were associated with a 40% increase in the risk of fracture. Similar results were found for the higher doses of pregabalin. 

Of course, this was an observational study and there may have been unmeasured confounders that may have biased the results but the authors did account for other medications that can increase the risk of falls. 

Overall, this should serve as a reminder to the community that we need to more carefully police the dosing of medications in our dialysis population, particularly when they are admitted to hospital.

ESRD Quality Incentive Program

Quality Incentives for ESRD Care

Reimbursing physicians based on the quality of care they provide is not a new idea. In the 1700s B.C. in ancient Babylon, Hammurabi’s Code stated “If a physician operates on a man for a severe wound with a bronze lancet and causes the man’s death…they shall cut off his hand.” Over the past decade, we have seen a revolution in quality measurement and physician reimbursement based on outcomes. Nephrology has been a leader in this movement, particularly in ESRD care. 

How did the ESRD Quality Incentive Program Begin?

The Centers for Medicare and Medicaid Services (CMS) has been paying for dialysis since 1972. The Social Security Amendments of 1972, Section 299I established that people with “chronic renal disease and who requires hemodialysis…shall be deemed disabled for the purposes of coverage.” However, it wasn’t until 2008 that reimbursement was linked to quality measures.  On July 15, 2008, Congress passed the Medicare Improvements for Patients and Providers Act (MIPPA). MIPPA added a sub-section to the Social Security Act called the ESRD Quality Incentive Program (ESRD QIP), which changed how dialysis was reimbursed by linking quality incentives to dialysis payments. ESRD QIP went into effect in 2012.

What is the ESRD QIP?

The ESRD QIP is the first mandatory pay-for-performance initiative set by Medicare. Dialysis units are required to report a number of quality measures to Medicare. These measures are divided into “clinical” measures and “reporting” measures.  Clinical measures are scored based on two factors:

1) Achievement — compares a unit’s performance with dialysis units nationally

2) Improvement — compares a unit’s performance to their previous year’s performance

Reporting measures only require dialysis units to submit their data, but are not graded based on performance.  In 2018, there are 11 clinical measures and 5 reporting measures:  

The 11 clinical measures are divided into 3 subdomains assigned different weights: Safety (20%), Patient and Family Engagement/Care Coordination (30%), and Clinical Care (50%). Each measure is given a score of 0-10, and a Total Performance Score is calculated by weighting the individual scores. A full summary of the 2018 program can be found here.

What’s the Incentive?

Dialysis units face a payment penalty of up to 2% of total reimbursement based on their Total Performance Score:

Total Performance Score	Payment Reduction
49 to 100	No reduction
39 to 48	0.5%
29 to 38	1.0%
19 to 28	1.5%
0 to 18	2.0%

Performance on quality measures is converted into a Star Rating, which in addition to the Total Performance Score, is posted on CMS’s Dialysis Facility Compare website.  Check out your dialysis unit’s performance here.

Why should you care about ESRD QIP? 

Renal fellows (you!) will be future leaders and medical directors of dialysis units.  We will be reporting these quality measures to CMS, leading quality improvement projects to improve the metrics, and conducting research to determine whether these metrics are valuable in improving patient care.  These quality measures directly impact how dialysis units take care of patients and where resources are allocated to collect data and improve performance. For example, dialysis unit social workers may be tasked with administering the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) and working with patients and families to improve patient satisfaction.

What has been the effect of ESRD QIP?  

ESRD QIP was designed to improve the quality of care for dialysis patients.  Has it delivered on this promise?  In our next post, we will cover data on the effect of ESRD QIP on quality measures, focusing on the Standardized Readmission Ratio (SRR).

Read more about the ESRD QIP in this JASN article and on the CMS website. 

Sri Lekha Tummalapalli, MD, MBA

NSMC Intern 2018

Nephrology Fellow, UCSF