Impact of facility size and profit status on intermediate outcomes in chronic dialysis patients

Effect of the ASCENT Intervention to Increase Knowledge of Kidney Allocation Policy Changes Among Dialysis Providers

INTRODUCTION

The Allocation System Changes for Equity in Kidney Transplantation (ASCENT) trial was a cluster-randomized pragmatic, effectiveness-implementation study designed to test whether a multicomponent educational intervention targeting leadership, clinic staff, and patients in dialysis facilities improved knowledge and awareness of the 2014 Kidney Allocation System (KAS) change.

METHODS

Participants included 690 dialysis facility medical directors, nephrologists, social workers, and other staff within 655 US dialysis facilities, with 51% (n = 334) in the intervention group and 49% (n = 321) in the control group. Intervention activities included a webinar targeting medical directors and facility staff, an approximately 10-minute educational video targeting dialysis staff, an approximately 10-minute educational video targeting patients, and a facility-specific audit and feedback report of transplant performance. The control group received a standard United Network for Organ Sharing brochure. Provider knowledge was a secondary outcome of the ASCENT trial and the primary outcome of this study; knowledge was assessed as a cumulative score on a 5-point Likert scale (higher score = greater knowledge). Intention-to-treat analysis was used.

RESULTS

At baseline, nonintervention providers had a higher mean knowledge score (mean ± SD, 2.45 ± 1.43) than intervention providers (mean ± SD, 2.31 ± 1.46). After 3 months, the average knowledge score was slightly higher in the intervention (mean ± SD, 3.14 ± 1.28) versus nonintervention providers (mean ± SD, 3.07 ± 1.24), and the estimated mean difference in knowledge scores between the groups at follow-up minus the mean difference at baseline was 0.25 (95% confidence interval [CI], 0.11-0.48; P = 0.039). The effect size (0.41) was low to moderate.

CONCLUSION

Dialysis facility provider education could help extend the impact of a national policy change in organ allocation.

Facility size, race and ethnicity, and mortality for in-center hemodialysis

The association between dialysis facility size and mortality for patients undergoing hemodialysis remains largely unclear, and whether the relationship differs by race and ethnicity or among high-risk subgroups is not known. Using data from the USRDS, we analyzed mortality rates in 385,074 incident patients ages ≥ 18 years who received in-center hemodialysis at 4633 dialysis facilities between 2003 and 2009. Facilities were categorized by the number of hemodialysis stations (1-5, 6-10, 11-15, 16-20, 21-25, 26-30, 31-35, 36-45, 46-60, and ≥ 61 stations). We found significantly higher mortality associated with facilities comprising ≤ 15 stations, and within this group, mortality increased as the number of stations decreased. The association with increased mortality was weaker for facilities with 16-30 stations, but >30 stations offered no additional survival benefit. The association between increased mortality and facilities with ≤ 15 stations was stronger for racial minorities and patients with diabetes or cardiovascular diseases. After adjustments, blacks had a 78% greater 1-year mortality risk in facilities with one to five stations, whereas whites had only a 26% greater risk. Notably, other patient-related events remained comparable across the categories assessed. In summary, these data suggest that hemodialysis care at small facilities associates with a significant increase in mortality that is only partially explained by measured patient case mix, other well defined facility characteristics, and geographic region. Future studies should investigate differences in processes of care and practices among hemodialysis facilities of different sizes.

Reexploring differences among for-profit and nonprofit dialysis providers

OBJECTIVE

To determine whether profit status is associated with differences in hospital days per patient, an outcome that may also be influenced by provider financial goals.

DATA SOURCES

United States Renal Data System Standard Analysis Files and Centers for Medicare and Medicaid Services cost reports.

DESIGN

We compared the number of hospital days per patient per year across for-profit and nonprofit dialysis facilities during 2003. To address possible referral bias in the assignment of patients to dialysis facilities, we used an instrumental variable regression method and adjusted for selected patient-specific factors, facility characteristics such as size and chain affiliation, as well as metrics of market competition.

DATA EXTRACTION METHODS

All patients who received in-center hemodialysis at any time in 2003 and for whom Medicare was the primary payer were included (N=170,130; roughly two-thirds of the U.S. hemodialysis population). Patients dialyzed at hospital-based facilities and patients with no dialysis facilities within 30 miles of their residence were excluded.

RESULTS

Overall, adjusted hospital days per patient were 17+/-5 percent lower in nonprofit facilities. The difference between nonprofit and for-profit facilities persisted with the correction for referral bias. There was no association between hospital days per patient per year and chain affiliation, but larger facilities had inferior outcomes (facilities with 73 or more patients had a 14+/-1.7 percent increase in hospital days relative to facilities with 35 or fewer patients). Differences in outcomes among for-profit and nonprofit facilities translated to 1,600 patient-years in hospital that could be averted each year if the hospital utilization rates in for-profit facilities were to decrease to the level of their nonprofit counterparts.

CONCLUSIONS

Hospital days per patient-year were statistically and clinically significantly lower among nonprofit dialysis providers. These findings suggest that the indirect incentives in Medicare's current payment system may provide insufficient incentive for for-profit providers to achieve optimal patient outcomes.

Association of standing-order policies with vaccination rates in dialysis clinics: a US-based cross-sectional study

BACKGROUND

Patients with end-stage renal disease are at increased risk of morbidity and mortality because of infection. Quality improvement efforts for this patient population include assessment of institutional policies and practices that may increase vaccination rates for influenza, hepatitis B, and pneumococcal disease.

STUDY DESIGN

A survey of vaccination practices, beliefs, and attitudes was sent to all dialysis centers in End-Stage Renal Disease Networks 6, 11, and 15.

SETTING & PARTICIPANTS

Of 1,052 dialysis facilities considered, 683 returned the survey, reported vaccination rates for 2005 to 2006, and had 20 or more patients.

PREDICTOR OR FACTOR

Standing-order policy of the dialysis facility, categorized as facility-wide orders, preprinted admission orders for each patient (chart orders), physician-specific orders, and individual orders.

OUTCOMES

Vaccination rates for influenza, hepatitis B (full or partial series), hepatitis B, and pneumococcal vaccine.

MEASUREMENTS

Patient vaccination, given at or outside the center.

RESULTS

Overall vaccination rates were 76% +/- 18% (SD) for influenza, 73% +/- 22% for hepatitis B full or partial series, 62% +/- 25% for hepatitis B full series, and 44% +/- 34% for pneumococcal vaccine. Compared with individual orders, facility-wide standing orders and chart orders were not associated with greater vaccination rates for influenza (0.4%; confidence interval, -4 to 5; and 1.27%; confidence interval, -3 to 5, respectively), but were associated with greater vaccination rates for hepatitis B full or partial series (9%; confidence interval, 3 to 15; and 11%; confidence interval, 5 to 17, respectively), hepatitis B full series (11%; confidence interval, 4 to 17; and 13%; confidence interval, 7 to 19, respectively), and pneumococcal disease (21%; confidence interval, 14 to 29; and 20%; confidence interval, 13 to 27, respectively).

LIMITATIONS

Data are cross-sectional, and vaccinations outside the center were self-reported.

CONCLUSIONS

Existing facility-wide or chart-based order programs may be effective in promoting vaccination against hepatitis B and pneumococcal disease.

Comparative mortality of hemodialysis patients at for-profit and not-for-profit dialysis facilities in the United States, 1998 to 2003: a retrospective analysis

BACKGROUND

Concern lingers that dialysis therapy at for-profit (versus not-for-profit) hemodialysis facilities in the United States may be associated with higher mortality, even though 4 of every 5 contemporary dialysis patients receive therapy in such a setting.

METHODS

Our primary objective was to compare the mortality hazards of patients initiating hemodialysis at for-profit and not-for-profit centers in the United States between 1998 and 2003. For-profit status of dialysis facilities was determined after subjects received 6 months of dialysis therapy, and mean follow-up was 1.7 years.

RESULTS

Of the study population (N = 205,076), 79.9% were dialyzed in for-profit facilities after 6 months of dialysis therapy. Dialysis at for-profit facilities was associated with higher urea reduction ratios, hemoglobin levels (including levels above 12 and 13 g/dL [120 and 130 g/L]), epoetin doses, and use of intravenous iron, and less use of blood transfusions and lower proportions of patients on the transplant waiting-list (P < 0.05). Patients dialyzed at for-profit and at not-for-profit facilities had similar mortality risks (adjusted hazards ratio 1.02, 95% CI 0.99-1.06, P = 0.143).

CONCLUSION

While hemodialysis treatment at for-profit and not-for-profit dialysis facilities is associated with different patterns of clinical benchmark achievement, mortality rates are similar.

Nonadherence in hemodialysis: associations with mortality, hospitalization, and practice patterns in the DOPPS

BACKGROUND

Nonadherence among hemodialysis patients compromises dialysis delivery, which could influence patient morbidity and mortality. The Dialysis Outcomes and Practice Patterns Study (DOPPS) provides a unique opportunity to review this problem and its determinants on a global level.

METHODS

Nonadherence was studied using data from the DOPPS, an international, observational, prospective hemodialysis study. Patients were considered nonadherent if they skipped one or more sessions per month, shortened one or more sessions by more than 10 minutes per month, had a serum potassium level openface>6.0 mEq/L, a serum phosphate level openface>7.5 mg/dL (>2.4 mmol/L), or interdialytic weight gain (IDWG)>5.7% of body weight. Predictors of nonadherence were identified using logistic regression. Survival analysis used the Cox proportional hazards model adjusting for case-mix.

RESULTS

Skipping treatment was associated with increased mortality [relative risk (RR) = 1.30, P = 0.01], as were excessive IDWG (RR = 1.12, P = 0.047) and high phosphate levels (RR = 1.17, P = 0.001). Skipping also was associated with increased hospitalization (RR = 1.13, P = 0.04), as were high phosphate levels (RR = 1.07, P = 0.05). Larger facility size (per 10 patients) was associated with higher odds ratios (OR) of skipping (OR = 1.03, P = 0.06), shortening (OR = 1.03, P = 0.05), and IDWG (OR = 1.02, P = 0.07). An increased percentage of highly trained staff hours was associated with lower OR of skipping (OR = 0.84 per 10%, P = 0.02); presence of a dietitian was associated with lower OR of excessive IDWG (OR = 0.75, P = 0.08).

CONCLUSION

Nonadherence was associated with increased mortality risk (skipping treatment, excessive IDWG, and high phosphate) and with hospitalization risk (skipping, high phosphate). Certain patient/facility characteristics also were associated with nonadherence.