CMS-10823 Appendix D

Appendix D: Nephrologist Interview Protocol
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questions or concerns regarding where to submit your documents, please contact Christopher King at
[email protected] or (410) 786-6972.

Introduction
Hello. My name is [interviewer name] from Insight Policy Research, and I want to thank you again for
agreeing to speak with me today about your involvement in activities related to dialysis care. I’m joined
today by [note taker name] from Insight, who will be taking notes for the interview.
We were hired by the Centers for Medicare & Medicaid Services, otherwise known as CMS, to conduct
an evaluation of the ESRD Quality Incentive Program (QIP). CMS is interested in learning how this
initiative may have affected dialysis patients’ health, outcomes, satisfaction, access to care, quality of
care, and healthcare spending. CMS has also asked us to learn about other topics that are less directly
related to the QIP.
This year we are focusing on the following topics related to ESRD care and will be asking you about them
today:


Quality of dialysis care



Health Equity and access to ESRD care



Factors associated with access to home dialysis



Factors associated with access to transplant



Quality of life for individuals with ESRD

Informed Consent
Let me also take a minute to review the informed consent for the interview and how we’ll handle the
information you provide:


We will use the information you share with us for research purposes only.



All your responses will be kept confidential. No one except the Insight research team will have
access to the information you provide.

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

We will use your answers to produce summaries from our collective set of interviews.



We will not report information in any way that identifies you or the organization you are
affiliated with to anyone outside the research team, except with your permission or as required
by law. CMS will not see your name or your organization’s name connected to your individual
responses.



All information identifying you is stored securely and will be destroyed at the end of the study.



We’d also like to emphasize that your participation is completely voluntary:





Your participation or nonparticipation will not be reported to anyone.



You can stop the interview at any time for any reason, and you can decline to discuss any
topic we raise.

We expect that this call will take about 45 - 60 minutes.

You should have received an attachment to the email confirmation for the interview that covers this
information. That document also includes contact information for the project director if you have
questions about the study. Do you recall seeing that document?
[If no] We’ll send you that document again so you have a written copy of this information.
With your permission, we’d like to audio record the interview to ensure we capture and analyze your
remarks accurately. Only the research team will have access to the recording, and it will be destroyed at
the end of the project. Would it be okay to audio record the interview?
Do you have any questions before we begin?

Introduction of Interviewee(s)
[If there are several interviewees on the phone, call out each one individually and ask them the same
introductory question below.]
1. Before we start our discussion, would you please share with me about your practice and how you
typically work with dialysis facilities? Do you complete rounds at a specific facility? If not, do you
have a close relationship with the nephrologists that work with your patients at the dialysis facility?

Dialysis Quality
My first set of questions has to do with the quality of care dialysis patients receive.
1. From your perspective, what are the highest priorities for patients when selecting a dialysis provider
for treatment?
a. Probe: How clean the facility is? How often they see the nephrologist? How easy it is to reach
staff in an emergency?
2. How do you and your practice evaluate the quality of care provided to your patients? (i.e., which
survey or metrics do you use to measure quality)?

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3. How, if at all, does the QIP impact your care delivery for patients on dialysis?
a. Are there QIP measures you feel are closely aligned with patients’ priorities for their ESRD care?
If so, which ones and why?
b. Do you know of any QIP measures that don’t align with patients’ priorities for their ESRD care? If
so, which measures and how are they misaligned?

Access to Care
Next, I’m going shift gears a little and ask about patient access to ESRD care.
1. What do you see as the most significant barriers your patients face in accessing treatment for their
ESRD?
a. Probe: Access to financial resources, adequate facilities to choose from, transportation,
specialists, social support, distance to treatment.
2. Focusing on improving access to care for underserved populations, what are some effective
improvement strategies that you have implemented or seen implemented by dialysis facilities or
providers?
a. What are some challenges, if any, that affected implementation of these strategies?
b. What resources or incentives facilitated the implementation of these strategies?
3. Does your practice collect data on patients’ health-related social needs? If so, which needs are most
common?
a. Probe: Food insecurity, stable housing, mobility impairment, transportation barriers
4. [If yes to Q7] What does your practice do with the information collected related to those needs?
a. Probe: Make note in patient chart; referrals for social needs programs; additional screening
5. Can you tell me about supports or services that your practice offers, if any, to address the following
social determinants of health:
a. Safe housing
b. Transportation
c. Financial security to pay for health care
d. Language and health literacy

Access to Home Dialysis
As you may know, over the past several years there has been a push to get more dialysis patients access
to home dialysis as a strategy to improve quality of life.
1. When we think about someone who is just starting dialysis, what are the challenges associated with
starting them on home dialysis instead of in-center?
a. [Probe: Nephrologist recommendation; Crashing into dialysis vs managing CKD for a while; Cost;
Health literacy]
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b. What are the supports or factors that encourage them to start home dialysis before trying incenter?
i.

[Probe: Family support; Nephrologist support; Space in the home; Cost; COVID; their facility
does not offer home dialysis]

2. [If COVID-19 not mentioned in Q11] How, if at all, has the COVID-19 pandemic influenced patients’
decisions to receive home dialysis?
3. How do those social needs we discussed earlier (housing, transportation, food security, etc) affect
patients’ access to home dialysis?

Access to Transplant
Similar to the effort to get more patients on home dialysis, there has been a push to improve access to
kidney transplants for patients who are good candidates.
1. We know from research about multiple factors that reduce patients’ interest and access to
transplants, such as location of transplant centers, complexity of obtaining an assessment, cost,
availability of donor kidneys, and patient education about transplant. Have you noticed any other
challenges patients face in getting on the waitlist and ultimately receiving a kidney transplant?
2. What are some activities or policies that improve patients’ interest in, and access to, kidney
transplants?
a. Probe: Robust patient education, broad waitlist criteria, streamlined assessments, access to
several transplant centers, supplemental funding sources
3. How, if at all, has the COVID-19 pandemic influenced patients’ decisions to pursue a transplant?
4. Do you believe the geographic location of transplant centers in your area affects patients’ transplant
decisions? If so, how?
a. Probe: State/local requirements, distance to nearest transplant centers, number of transplant
centers available in the region
5. How do those social needs we discussed earlier (housing, transportation, food security, etc) affect
patients’ access to kidney transplants?
6. Please describe relationships that your practice has with the transplant center (or centers) that you
use for patient referrals or waitlists?
a. Does your practice have regular contact with local transplant centers, either with the
administrators or providers? If so, what is the frequency and focus of those communications?
b. Do you have an agreement with them that they are the go-to facility for your practice’s
referrals?
7. What approach does your practice take to patient engagement about transplantation as a treatment
option?
a. Probe: Patient education about finding a donor and referral for assessment for transplant
viability
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8. Has your approach to patient engagement about transplantation changed in the past five years? If
so, why and what was the change?

Quality of Life
As part of this research, we are trying to understand the quality of life that individuals with ESRD
experience and what can be done at the policy level to ensure the highest possible quality of life for this
patient population.
1. From your perspective, what are some aspects of everyday life that you would consider signs of a
higher quality of life for someone living with ESRD?
a. Probe: Feeling good; Having more energy; Feeling independent; Accessing healthy foods that are
enjoyable; Getting good sleep
2. Are there interventions that dialysis providers have implemented that improve the quality of life for
individuals living with ESRD? This could be an intervention implemented by a nephrologist or the
dialysis facility.
a. Probe: Social workers arranging transportation; Nephrologists helping them transition to home
dialysis; Improved coordination with transplant centers; Peer-to-peer support; Streamlining
screenings for depression
3. How, if at all, does your practice measure patient quality of life? Do you administer the KDQOL or
the HRQOL?
a. What does your practice do with quality of life data once it is collected?
4. In your experience, have you noticed the quality of life for individuals living with ESRD change over
time? What is the reason for the change?
a. Probe: Access to social services, screening of SDOH need, patient interest or eligibility for home
dialysis and/or transplant

Closing
Before we finish, is there anything you would like to share that I haven’t asked about or anything you
would like to elaborate on that you didn’t get a chance to discuss about providing care to dialysis
patients?
Thank you for taking the time to speak with me today. Your input is helpful, and we look forward to
summarizing all the information we hear from stakeholders. If you have questions after the call or wish
to offer additional feedback, please feel free to reach out to me.

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