Long-term Clinical Outcomes Among Responders and Nonresponders to the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Survey

Rationale & Objective: The In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey, introduced into the End-Stage Renal Disease Quality Incentive Program, is the only patient-reported outcome currently used for value-based reimbursement in dialysis. Current response rates are similar to 30% and differences in long-term clinical outcomes between survey responders and nonresponders are unknown. Study Design: Retrospective cohort study. Setting & Participants: Patients from all Dialysis Clinic Incorporated facilities from across the United States who met survey eligibility (aged =18 years and had been treated at their facility for at least 3 months). Exposures: Patient-level demographic, clinical, and treatment-related characteristics. Outcomes: Mortality, all-cause hospitalization, and kidney transplantation. Analytical Approach: Time-to-event analyses using competing-risks models. Sensitivity analyses performed after multiple imputation for missing covariate data. Results: Among 10,395 eligible patients, 3,794 (36%) responded to the survey. During a median follow-up of 33 months, 4,588 patients died, 7,638 patients were hospitalized at least once, and 789 patients received a transplant. In multivariable models, survey response was associated with lower mortality (subdistribution hazard ratio [sHR], 0.80; 95% CI, 0.75-0.86) and hospitalization (sHR, 0.94; 95% CI, 0.89-0.99) and higher likelihood for a kidney transplant (sHR, 1.27; 95% CI, 1.10-1.46). Results were consistent across sensitivity analyses aftermultiple imputation formissing covariates. Limitations: Small amount of missing covariate data, baseline covariate data assigned at the first month of the 3-month survey administration period, reasons for nonresponse unknown. Conclusions: Response to the ICH CAHPS survey is associated with lower risk for mortality and hospitalization and higher likelihood for kidney transplantation. These findings suggest that survey responders are healthier than nonresponders, emphasizing the need for caution when interpreting facility-level survey results to inform quality improvement and public policy efforts and the critical need to better capture patient-reported outcomes from more vulnerable patients.