Continuous quality improvement in nephrology: a systematic review

Julie Wright Nunes, F. Jacob Seagull, Panduranga Rao, Jonathan H. Segal, Nandita S. Mani, Michael Heung

Continuous quality improvement (CQI) has been successfully applied in business and engineering for over 60 years. While using CQI techniques within nephrology has received increased attention, little is known about where, and with what measure of success, CQI can be attributed to improving outcomes within nephrology care. This is particularly important as payors' focus on value-based healthcare and reimbursement is tied to achieving quality improvement thresholds. We conducted a systematic review of CQI applications in nephrology. Studies were identified from PubMed, MEDLINE, Scopus, Web of Science, CINAHL, Google Scholar, ProQuest Dissertation Abstracts and sources of grey literature (i.e., available in print/electronic format but not controlled by commercial publishers) between January 1, 2004 and October 13, 2014. We developed a systematic evaluation protocol and pre-defined criteria for review. All citations were reviewed by two reviewers with disagreements resolved by consensus. We initially identified 468 publications; 40 were excluded as duplicates or not available/not in English. An additional 352 did not meet criteria for full review due to: 1. Not meeting criteria for inclusion = 196 (e.g., reviews, news articles, editorials) 2. Not nephrology-specific = 153, 3. Only available as abstracts = 3. Of 76 publications meeting criteria for full review, the majority [45 (61%)] focused on ESRD care. 74% explicitly stated use of specific CQI tools in their methods. The highest number of publications in a given year occurred in 2011 with 12 (16%) articles. 89% of studies were found in biomedical and allied health journals and most studies were performed in North America (52%). Only one was randomized and controlled although not blinded. Despite calls for healthcare reform and funding to inspire innovative research, we found few high quality studies either rigorously evaluating the use of CQI in nephrology or reporting best practices. More rigorous research is needed to assess the mechanisms and attributes by which CQI impacts outcomes before there is further promotion of its use for improvement and reimbursement purposes.