In her work and research, Mallika Mendu, MD, MBA, transforms care delivery at the Brigham, constantly seeking to improve inpatient operations, care continuum management, equitable care delivery and population health. Mendu is a nephrologist in the Department of Medicine, Renal Division, and serves as the associate chief medical officer at Brigham and Women’s Hospital. Many of her initiatives have been adopted by hospitals nation-wide. One of the areas she’s been focused on is identifying and addressing barriers to care for patients with kidney disease — particularly for disadvantaged patient groups — who already face difficulties obtaining information about their diagnosis.
In a recent editorial published in Kidney Medicine, Mendu explains why U.S. News and World Report’s decision to remove nephrology as a ranked specialty from its 2021-2022 “Best Hospitals” and specialties rankings negatively impacts patients and calls for U.S. News to reinstate nephrology’s former status. CRN spoke with Mendu about her work at the Brigham to facilitate access to care for patients with kidney disease.
Q: Can you tell us more about your research, as a nephrologist and hospital administrator?
MM: As a nephrologist, I take care of patients who have chronic kidney disease and who are on dialysis, specifically a type of home dialysis called peritoneal dialysis. As an administrator, I’m focused on how we can make our inpatient, care continuum management, and value-based operations efficient and effective. In all those areas, my colleagues and I collect data, identify opportunities for improving care, implement initiatives, and then, ideally, disseminate best practices.
We were one of the first hospitals, nationally to look at the impact of using race to calculate a common metric of kidney function called estimated glomerular filtration rate (eGFR), showing that the typical method, which used race, was disadvantaging Black patients. Based on our findings, we eliminated the use of race-based eGFR calculation at Mass General Brigham and have advocated for eliminating race-based kidney care nationally, which ultimately has become the standard for the rest of the country. Within Nephrology, we need to be focused on ensuring that the most disadvantaged patients are not further disadvantaged by existing care delivery practices, and on closing the gaps in health outcomes that have existed for far too long.
Q: U.S. News and World Report recently removed nephrology as a ranked specialty. What was your reaction when you heard this news?
MM: I was really stunned, to be honest. I have conducted research on U.S. News’s ranking system for hospitals, so I am very familiar with their methodology and appreciate that U.S. News often adjusts their methodology. However, dropping a specialty has never happened before. It’s particularly striking and concerning because, historically, patients with kidney diseases have had limited access to data to guide their clinical decision making. It was also very disappointing to see the sudden change without a clear explanation. The explanation that they did provide was that they had challenges in terms of their existing methodology in identifying patients, but those challenges aren’t specific to patients with kidney disease. There are patients attributed to other specialties such as rheumatology and endocrinology that result in similar methodologic challenges.
To rank hospitals, U.S. News organizes and analyzes publicly available information. There are reputation-only specialties, like rheumatology, which are ranked based on criteria such as physician rating surveys, and data-driven specialties, ranked based on Medicare claims-based outcomes. U.S. News has received criticism for its methodology and there are many issues, particularly when it comes to how the company uses mortality data to rank hospitals, which is flawed.
Hospitals use U.S. News’ rankings to market to patients and families, and patients use this information to make care decisions. Our paper, which included a patient advocate as first author, makes specific suggestions for adjustments that U.S. News could use to improve their methodology related to nephrology specialty ranking. However, we concluded that if that takes considerable time to implement those suggestions, U.S. News should at least restore nephrology as a reputation-only specialty like rheumatology, because patients with kidney disease want and deserve to know that information.
Q: Why does this action add a barrier to care for millions of Americans, especially disadvantaged populations?
MM: There are major disparities in kidney treatment outcomes based on race, ethnicity, and socioeconomic status. Black, Indigenous and Latine patients tend to have worse outcomes during treatment. There are many contributors, but part of the challenge is patient engagement, which is contingent on access to information. The data show there are lower levels of patient engagement and information sharing among patients with kidney disease. By eliminating access to U.S. News information, it is more challenging for patients with kidney disease to identify where to receive high quality nephrology care and disadvantages them compared to patients with other conditions.
Q: What research-based administrative initiatives are you most excited about now?
MM: Recently, our care continuum management team implemented a tool at our community hospital, Brigham and Women’s Faulkner Hospital, to screen patients when they are admitted based on likelihood of needing inpatient case manager services, an early screening for discharge planning (ESDP) tool. By implementing this tool, we were able to screen out about 50 percent of patients who didn’t need a case manager following them on a day-to-day basis. That allowed our case managers to focus on our highest-risk patients, allowing them to have additional conversations with the patients and their families and get them to where they needed to be. We saw a 0.5-day reduction in the length of stay in the unit we piloted the initiative on, compared to a control unit with similar patients, which is meaningful. Jim Grafton, RN, MSN, MHA, interim director of case management at BWH, was lead author on the study that was recently accepted for publication in Professional Case Management and is working on disseminating the findings nationally.
Q: What are your favorite aspects of your work?
MM: I love what I do because I partner with others to examine opportunities to deliver care better, and I’m in a position where I can try to implement solutions in a team-based, multidisciplinary way. I work with nursing colleagues, physician colleagues and administrators to implement solutions, measure the impact and disseminate those findings. As a clinician, I get to see the impacts of these initiatives at the patient level, and that’s really rewarding.