Early intervention improves mortality and hospitalization rates in incident hemodialysis patients: RightStart program

Assessing the impact of transitional care units on dialysis patient outcomes: A multicenter, propensity score-matched analysis

INTRODUCTION

Inadequate predialysis care and education impacts the selection of a dialysis modality and is associated with adverse clinical outcomes. Transitional care units (TCUs) aim to meet the unmet educational needs of incident dialysis patients, but their impact beyond increasing home dialysis utilization has been incompletely characterized.

METHODS

This retrospective study included adults initiating in-center hemodialysis at a TCU, matched to controls (1:4) with no TCU history initiating in-center hemodialysis. Patients were followed for up to 14 months. TCUs are dedicated spaces where staff provide personalized education and as-needed adjustments to dialysis prescriptions. For many patients, therapy was initiated with four to five weekly dialysis sessions, with at least some sessions delivered by home dialysis machines. Outcomes included survival, first hospitalization, transplant waiting-list status, post-TCU dialysis modality, and vascular access type.

FINDINGS

The study included 724 patients initiating dialysis across 48 TCUs, with 2892 well-matched controls. At the end of 14 months, patients initiating dialysis in a TCU were significantly more likely to be referred and/or wait-listed for a kidney transplant than controls (57% vs. 42%; p < 0.0001). Initiation of dialysis at a TCU was also associated with significantly lower rates of receiving in-center hemodialysis at 14 months (74% vs. 90%; p < 0.0001) and higher rates of arteriovenous access (70% vs. 63%; p = 0.003). Although not statistically significant, TCU patients were more likely to survive and less likely to be hospitalized during follow-up than controls.

DISCUSSION

Although TCUs are sometimes viewed as only a means for enhancing utilization of home dialysis, patients attending TCUs exhibited more favorable outcomes across all endpoints. In addition to being 2.5-fold more likely to receive home dialysis, TCU patients were 42% more likely to be referred for transplantation. Our results support expanding utilization of TCUs for patients with inadequate predialysis support.

Patient Navigators for CKD and Kidney Failure: A Systematic Review

Rationale & Objective

To what degree and how patient navigators improve clinical outcomes for patients with chronic kidney disease (CKD) and kidney failure is uncertain. We performed a systematic review to summarize patient navigator program design, evidence, and implementation in kidney disease.

Study Design

A search strategy was developed for randomized controlled trials and observational studies that evaluated the impact of navigators on outcomes in the setting of CKD and kidney failure. Articles were identified from various databases. Two reviewers independently screened the articles and identified those meeting the inclusion criteria.

Setting & Participants

Patients with CKD or kidney failure (in-center hemodialysis, peritoneal dialysis, home hemodialysis, or kidney transplantation).

Selection Criteria for Studies

Studies that compared patient navigators with a control, without limits on size, duration, setting, or language. Studies focusing solely on patient education were excluded.

Data Extraction

Data were abstracted from full texts and risk of bias was assessed.

Analytical Approach

No meta-analysis was performed.

Results

Of 3,371 citations, 17 articles met the inclusion criteria including 14 original studies. Navigators came from various healthcare backgrounds including nursing (n=6), social worker (n=2), medical interpreter (n=1), research (n=1), and also included kidney transplant recipients (n=2) and non-medical individuals (n=2). Navigators focused mostly on education (n=9) and support (n = 6). Navigators were used for patients with CKD (n=5), peritoneal dialysis (n=2), in-center hemodialysis (n=4), kidney transplantation (n=2), but not home hemodialysis. Navigators improved transplant workup and listing, peritoneal dialysis utilization, and patient knowledge.

Limitations

Many studies did not show benefits across other outcomes, were at a high risk of bias, and none reported cost-effectiveness or patient-reported experience measures.

Conclusions

Navigators improve some health outcomes for CKD but there was heterogeneity in their structure and function. High-quality randomized controlled trials are needed to evaluate navigator program efficacy and cost-effectiveness.

Lack or insufficient predialysis nephrology care worsens the outcomes in dialyzed patients - call for action

The phenomenon of patients with advanced renal failure accepted for dialysis at a late stage in the disease process (late referral [LR]) is known almost from the beginning of dialysis therapy. It may also be associated with worse outcomes. The aim of the study was to assess the effect of referral time on the outcomes, such as number of hospitalizations, length of stay, kidney transplantation, and mortality. A study of 1303 patients with end-stage renal failure admitted for dialysis in the same period in Fresenius Nephrocare Poland dialysis centers was initiated. The type of vascular access during the first dialysis was accepted as the criterion differentiating LR (n = 457 with acute catheter) from early referral (ER; n = 846). The primary endpoint was the occurrence of death during the 13-month observation. By the end of observation, 341 (26.2%) of patients died. The frequency of death was 18.1 for ER and 37.9 for LR per 1000 patient-months. It can be estimated that 52.1% (95% CI: 40.5–61.5%) of the 341 deaths were caused by belonging to the LR group. Patients from LR group had longer hospitalizations, more malignancies, lower rate of vascular access in the form of a–v fistula, higher comorbidity index. It seems that establishing a nephrological registry would help to improve the organization of care for patients with kidney disease, particularly in the pandemic era.

Quality assuring early dialysis care: evaluating rates of death and recovery within 90 days of first dialysis using the UK Renal Registry

Background

Kidney disease registries typically report populations incident to kidney replacement therapy (KRT) after excluding reversible disease. Registry-based audit and quality assurance is thus based on populations depleted of those with the highest early mortality. It is now mandatory for UK kidney units to report all recipients of dialysis, both acute and chronic. This work presents 90-day survival and recovery outcomes for all reported adults.

Methods

Seventy adult centres reporting to the UK Renal Registry were included. Those assessed as underreporting death and recovery were excluded. Survival was evaluated using a Kaplan–Meier estimator. Cox regression was used to describe hazard ratios (HRs) for age, sex and acute/chronic dialysis coding on day 1. Analysis of all-cause 90-day mortality with recovery as a competing risk is presented.

Results

Twenty-four centres were assessed as underreporting, with rates of death/recovery below the 99.7th centile. Of 5784 dialysis starters in the remaining 46 centres, 2163 (37.4%) were coded as receiving acute dialysis on day 1. Ninety days after starting, 3860 (66.7%) of all starters were receiving KRT, 1157 (20.0%) were alive having stopped, 716 (12.4%) were dead and 51 (0.9%) were lost to follow-up. Mortality was higher among those coded as receiving acute dialysis on day 1 (HR 4.88, P &lt; 0.001). The sub-HR for recovery among those coded as receiving acute compared with chronic dialysis was 56.14 (P &lt; 0.001).

Conclusions

Death and recovery rates are substantially higher than reported in conventional incident populations. This work highlights a vulnerable subgroup of patients largely overlooked by most national quality assurance systems.

Malnutrition and Sarcopenia Combined Increases the Risk for Mortality in Older Adults on Hemodialysis

Aim: Sarcopenia and malnutrition are highly prevalent in older adults undergoing hemodialysis (HD) and are associated with negative outcomes. This study aimed to evaluate the role of sarcopenia and malnutrition combined on the nutritional markers, quality of life, and survival in a cohort of older adults on chronic HD. Methods: This was an observational, longitudinal, and multicenter study including 170 patients on HD aged >60 years. Nutritional status was assessed by 7-point-subjective global assessment (7p-SGA), body composition (anthropometry and bioelectrical impedance), and appendicular skeletal muscle mass (Baumgartner's prediction equation). Quality of life was assessed by KDQoL-SF. The cutoffs for low muscle mass and low muscle strength established by the 2019 European Working group on sarcopenia for Older People (EWGSOP) were used for the diagnosis of sarcopenia. Individuals with a 7p-SGA score ≤5 were considered malnourished, individuals with low strength or low muscle mass were pre-sarcopenic, and those with low muscle mass and low muscle strength combined as sarcopenic. The sample was divided into four groups: sarcopenia and malnutrition; sarcopenia and no-malnutrition; no-sarcopenia with malnutrition; and no-sarcopenia and no-malnutrition. Follow-up for survival lasted 23.5 (12.2; 34.4) months. Results: Pre-sarcopenia, sarcopenia, and malnutrition were present in 35.3, 14.1, and 58.8% of the patients, respectively. The frequency of malnutrition in the group of patients with sarcopenia was not significantly higher than in the patients without sarcopenia (66.7 vs. 51.2%; p = 0.12). When comparing groups according to the occurrence of sarcopenia and malnutrition, the sarcopenia and malnutrition group were older and presented significantly lower BMI, calf circumference, body fat, phase angle, body cell mass, and mid-arm muscle circumference. In the survival analysis, the group with sarcopenia and malnutrition showed a higher hazard ratio 2.99 (95% CI: 1.23: 7.25) for mortality when compared to a group with no-sarcopenia and no-malnutrition. Conclusion: Older adults on HD with sarcopenia and malnutrition combined showed worse nutritional parameters, quality of life, and higher mortality risk. In addition, malnutrition can be present even in patients without sarcopenia. These findings highlight the importance of complete nutritional assessment in patients on dialysis.

Characteristics and Effectiveness of Dedicated Care Programs for Patients Starting Dialysis: A Systematic Review

BACKGROUND

Dedicated care programs that provide increased support to patients starting dialysis are increasingly being used to reduce the risk of complications. The objectives of this systematic review were to determine the characteristics of existing programs and their effect on patient outcomes.

METHODS

We searched Embase, MEDLINE, Web of Science, Cochrane CENTRAL, and CINAHL from database inception to November 20, 2019 for English-language studies that evaluated dedicated care programs for adults starting maintenance dialysis in the inpatient or outpatient setting. Any study design was eligible, but we required the presence of a control group and prespecified patient outcomes. We extracted data describing the nature of the interventions, their components, and the reported benefits.

RESULTS

The literature search yielded 12,681 studies. We evaluated 66 full texts and included 11 studies (n=6812 intervention patients); eight of the studies evaluated hemodialysis programs. All studies were observational, and there were no randomized controlled trials. The most common interventions included patient education (n=11) and case management (n=5), with nurses involved in nine programs. The most common outcomes were mortality (n=8) and vascular access (n=4), with only three studies reporting on the uptake of home dialysis and none on transplantation. We identified four high-quality studies that combined patient education and case management; in these programs, the relative reduction in 90-day mortality ranged from 22% (95% CI, -3% to 41%) to 49% (95% CI, 33% to 61%). Pooled analysis was not possible due to study heterogeneity.

CONCLUSIONS

Few studies have evaluated dedicated care programs for patients starting dialysis, especially their effect on home dialysis and transplantation. Whereas multidisciplinary care models that combine patient education with case management appear to be promising, additional prospective studies that involve patients in their design and execution are needed before widespread implementation of these resource-intensive programs.

Can incremental haemodialysis reduce early mortality rates in patients starting maintenance haemodialysis?

PURPOSE OF REVIEW

Early mortality rates after the start of maintenance haemodialysis therapy are high. Compared with three-times weekly haemodialysis, incremental haemodialysis is associated with better preservation of residual renal function (RRF) and at least equivalent mid-term to long-term survival. However, there is paucity of data in relation to its use as a means of helping patients through the transitional period, when they first become dialysis dependent.

RECENT FINDINGS

Studies of incremental haemodialysis have overlooked early mortality as an outcome measure. This is primarily due to their retrospective design which makes it difficult to link early deaths to the frequency of haemodialysis. New data confirm previous observations associating incremental haemodialysis with favourable outcomes. They also raise the possibility that in selected groups and for short periods, the pursuit of set clearance targets during the early days of dialysis may not necessarily bring additional short-term gains.

SUMMARY

We argue that, while simpler ways of estimating RRF are being explored, future trials must consider implementing incremental haemodialysis focusing on practical aspects of care in the transitional period; safety monitoring in such regimes should be undertaken using conventional methods. Such an approach is likely to benefit a larger subset of haemodialysis population.

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Estimating the Fraction of First-Year Hemodialysis Deaths Attributable to Potentially Modifiable Risk Factors: Results from the DOPPS

PURPOSE

Mortality among first-year hemodialysis (HD) patients remains unacceptably high. To address this problem, we estimate the proportions of early HD deaths that are potentially preventable by modifying known risk factors.

METHODS

We included 15,891 HD patients (within 60 days of starting HD) from 21 countries in the Dialysis Outcomes and Practice Patterns Study (1996-2015), a prospective cohort study. Using Cox regression adjusted for potential confounders, we estimated the fraction of first-year deaths attributable to one or more of twelve modifiable risk factors (the population attributable fraction, AF) identified from the published literature by comparing predicted survival based on risk factors observed vs counterfactually set to reference levels.

RESULTS

The highest AFs were for catheter use (22%), albumin <3.5 g/dL (19%), and creatinine <6 mg/dL (12%). AFs were 5%-9% for no pre-HD nephrology care, no residual urine volume, systolic blood pressure <130 or ≥160 mm Hg, phosphorus <3.5 or ≥5.5 mg/dL, hemoglobin <10 or ≥12 g/dL, and white blood cell count >10,000/μL. AFs for ferritin, calcium, and PTH were <3%. Overall, 65% (95% CI: 59%-71%) of deaths were attributable to these 12 risk factors. Additionally, the AF for C-reactive protein >10 mg/L was 21% in facilities where it was routinely measured.

CONCLUSION

A substantial proportion of first-year HD deaths could be prevented by successfully modifying a few risk factors. Highest priorities should be decreasing catheter use and limiting malnutrition/inflammation whenever possible.

Integrating a Medical Home in an Outpatient Dialysis Setting: Effects on Health-Related Quality of Life

BACKGROUND

Integrating primary care has been proposed to reduce fragmented care delivery for patients with complex medical needs. Because of their high rates of morbidity, healthcare use, and mortality, patients with end-stage kidney disease (ESKD) may benefit from increased access to a primary care medical home.

OBJECTIVE

To evaluate the effect of integrating a primary care medical home on health-related quality of life (HRQOL) for patients with ESKD receiving chronic hemodialysis.

DESIGN

Before-after intervention trial with repeated measures at two Chicago dialysis centers.

PARTICIPANTS

Patients receiving hemodialysis at either of the two centers.

INTERVENTION

To the standard hemodialysis team (nephrologist, nurse, social worker, dietitian), we added a primary care physician, a pharmacist, a nurse coordinator, and a community health worker. The intervention took place from January 2015 through August 2016.

MAIN MEASURES

Health-related quality of life, using the Kidney Disease Quality of Life (KDQOL) measures.

KEY RESULTS

Of 247 eligible patients, 175 (71%) consented and participated; mean age was 54 years; 55% were men and 97% were African American or Hispanic. In regression analysis adjusted for individual visits with the medical home providers and other factors, there were significant improvements in four of five KDQOL domains: at 12 and 18 months, the Mental Component Score improved from baseline (adjusted mean 49.0) by 2.64 (p = 0.01) and 2.96 (p = 0.007) points, respectively. At 6 and 12 months, the Symptoms domain improved from baseline (adjusted mean = 77.0) by 2.61 (p = 0.02) and 2.35 points (p = 0.05) respectively. The Kidney Disease Effects domain improved from baseline (adjusted mean = 72.7), to 6, 12, and 18 months by 4.36 (p = 0.003), 6.95 (p < 0.0001), and 4.14 (p = 0.02) points respectively. The Physical Component Score improved at 6 months only.

CONCLUSIONS

Integrating primary care and enhancing care coordination in two dialysis facilities was associated with improvements in HRQOL among patients with ESKD who required chronic hemodialysis.

Assessment of dialysis initiation by a fuzzy mathematics equation (ADIFE): a study protocol for a randomised controlled trial

INTRODUCTION

Starting dialysis early or late both result in a low quality of life and a poor prognosis in patients undergoing haemodialysis. However, there remains no consensus on the optimal timing of dialysis initiation, mainly because of a lack of suitable methods to assess variations in dialysis initiation time. We have established a novel equation named DIFE (Dialysis Initiation based on Fuzzy-mathematics Equation) through a retrospective, multicentre clinical cohort study in China to determine the most suitable timing of dialysis initiation. The predictors of the DIFE include nine biochemical markers and clinical variables that together influence dialysis initiation. To externally validate the clinical accuracy of DIFE, we designed the assessment of DIFE (ADIFE) study as a prospective, open-label, multicentre, randomised controlled trial to assess the clinical outcomes among patients who initiate dialysis in an optimal start dialysis group and a late-start dialysis group, based on DIFE.

METHODS AND ANALYSIS

A total of 388 enrolled patients with end-stage renal disease will be randomised 1:1 to the optimal start dialysis group, with a DIFE value between 30 and 35, or the late-start dialysis group, with a DIFE value less than 30, using the Randomization and Trial Supply Management system. Participants will be assessed for changes in signs and symptoms, dialysis mode and parameters, biochemical and inflammatory markers, Subjective Global Assessment, Kidney Disease Quality of Life Short Form, Cognitive Assessment, medical costs, adverse events and concomitant medication at baseline, predialysis visiting stage and postdialysis visiting stage, every 12-24 weeks. The following data will be recorded on standardised online electronic case report forms. The primary endpoint is 3-year all-cause mortality. The secondary endpoints include non-fatal cerebrocardiovascular events, annual hospitalisation rate, quality of life, medical costs and haemodialysis related complications.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ethics Committee of the First Affiliated Hospital of Dalian Medical University China (registration no: YJ-KY-2017-119) and the ethics committees of all participating centres. The final results of the ADIFE trial will be presented to the study sponsor, clinical researchers and the patient and public involvement reference group. Findings will be disseminated through peer-reviewed journals, Clinical Practice Guidelines and at scientific meetings.

TRIAL REGISTRATION NUMBER

ClinicalTrial.gov. Registry (NCT03385902); pre-results.

Development and effect of a rational-emotive-behaviour-therapy-based self-management programme for early renal dialysis patients

AIMS AND OBJECTIVES

This study attempts to develop and determine the effect a rational-emotive-behaviour-therapy-based self-management programme can have on the self-efficacy, self-care, depression and dyssomnia of patients undergoing early renal dialysis.

BACKGROUND

When renal dialysis is initiated, changes in everyday life are inevitable, and patients can suffer from both psychological and physical symptoms. Hence, to obtain the best results from renal dialysis, active self-management is required.

DESIGN

Quasi-experimental and longitudinal.

METHODS

Forty-eight early-stage renal dialysis patients registered for and undergoing renal dialysis at a hospital located in S city participated in this study. These individuals were divided into an experimental and control group. The former group engaged in a self-management programme consisting of eight weekly sessions of 50 min in duration, while the latter received traditional nursing care. Data were collected from June 2012-May 2014 through the use of a preliminary survey, a postsurvey that was distributed after the eight sessions of the self-management programme had been completed, and a follow-up survey allocated 4 weeks after the postsurvey. Data collection was conducted using the Self-efficacy Scale, Self-care Practice Scale, Beck Depression Inventory, and Korean Sleep Scale, and a repeated-measures ANOVA was used to perform analysis.

RESULTS

The experimental group significantly differed from the control group in regard to self-efficacy (p = 0.006) and self-care (p = 0.031), but differences in terms of depression (p = 0.492) and dyssomnia (p = 0.141) were nonsignificant. In the experimental group, the depression decreased but then increased again, while the dyssomnia gradually decreased.

CONCLUSIONS

The provision of a rational-emotive-behaviour-therapy-based self-management programme that involves lectures, discussions, teach-backs, demonstrations and posters explaining diet choices improves the self-efficacy and self-care of patients receiving renal dialysis.

RELEVANCE TO CLINICAL PRACTICE

Rational-emotive-behaviour-therapy-based self-management programmes can be used in clinical nursing sites to improve the self-efficacy and self-care of early renal dialysis patients.

End-stage renal disease treatment options education: What matters most to patients and families

Treatment modality education can offer many important benefits to patients and their families. Evidence suggests such education can increase use of home dialysis, reduce catheter use, decrease 90-day mortality, and increase transplantation. While these benefits are encouraging, not all patients are offered options education and when they are, it may not be presented in a way that is immediately applicable to them and their lives. Furthermore, little is known regarding specific characteristics (e.g. format such as group or individual or in-person or online, duration, teaching methods, location, content) of educational programs that are most successful. No single approach has emerged as a best practice. In the absence of such evidence, adult learning principles, such as involving patients and families in the development programs and materials, can serve as a guide for educational development. Adult learning principles can enhance options education, evolving them from information delivery to a person-centered, values-based endeavor that helps match treatment to values and lifestyle.

Dialysis Access as an Area of Improvement in Elderly Incident Hemodialysis Patients: Results from a Cohort Study from the International Monitoring Dialysis Outcomes Initiative

BACKGROUND

Commencing hemodialysis (HD) using a catheter is associated with a higher risk of adverse outcomes, and early conversion from central-venous catheter (CVC) to arteriovenous fistula/graft (non-CVC) improves outcomes. We investigated CVC prevalence and conversion, and their effects on outcomes during the first year of HD in a multinational cohort of elderly patients.

METHODS

Patients ≥70 years from the MONDO Initiative who commenced HD between 2000 and 2010 in Asia-Pacific, Europe, North-, and South-America and survived at least 6 months were included in this investigation. We stratified by age (70-79 years [younger] vs. ≥80 years [older]) and compared access types (at first and last available date) and their changes. We studied the association between access at initiation and conversion, respectively, and all-cause mortality using Kaplan-Meier curve and Cox regression, and predicted the absence of conversion from catheter to non-CVC using adjusted logistic regression.

RESULTS

In 14,966 elderly, incident HD patients, survival was significantly worse when using a CVC at all times. In Europe, the conversion frequency from CVC to non-CVC was higher in the younger fraction. Conversion from non-CVC to CVC was associated with worsened outcomes only in the older fraction.

CONCLUSION

These results corroborate the need for early HD preparation in the elderly HD population. Treatment of elderly patients who commence HD with a CVC should be planned considering aspects of individual clinical risk assessment. Differences in treatment practices in predialysis care specific to the elderly as a population may influence access care and conversion rate.

Effects of Different Models of Dialysis Care on Patient-Important Outcomes: A Systematic Review and Meta-Analysis

Ongoing payment reform in dialysis necessitates better patient outcomes and lower costs. Suggested improvements to processes of care for maintenance dialysis patients are abundant; however, their impact on patient-important outcomes is unclear. This systematic review included comparative randomized controlled trials or observational studies with no restriction on language, published from 2000 to 2014, involving at least 5 adult dialysis patients who received a minimum of 6 months of follow-up. The effect size was pooled and stratified by intervention strategy (multidisciplinary care [MDC], home dialysis, alternate dialysis settings, and electronic health record implementation). Heterogeneity (I²) was used to assess the variability in study effects related to study differences rather than chance. Of the 1988 articles screened, 25 international studies with 74,833 maintenance dialysis patients were included. Interventions with MDC or home dialysis were associated with a lower mortality (hazard ratio [HR] = 0.72, 95% confidence interval [CI] 0.61, 0.84, I² = 41.6%; HR = 0.57, 95% CI 0.41, 0.81, I² = 89.0%; respectively) and hospitalizations (incidence rate ratio [IRR] = 0.68, 95% CI 0.51, 0.91, I² = NA; IRR = 0.88, 95% CI 0.64, 1.20, I² = 79.6%; respectively). Alternate dialysis settings also were associated with a reduction in hospitalizations (IRR = 0.41, 95% CI 0.25, 0.69, I² = 0.0%). This systematic review underscores the importance of multidisciplinary care, and also the value of telemedicine as a means to increase access to providers and enhance outcomes for those dialyzing at home or in alternate settings, including those with limited access to nephrology expertise because of travel distance.

Facility Practice Variation to Help Understand the Effects of Public Policy: Insights from the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Recent Centers for Medicare & Medicaid Services policies have used dialysis facility practice variation to develop public ratings and adjust payments. In the Dialysis Facility Compare star rating system (DFC SRS), facility-relative rates of performance-based clinical measures varied nearly two-fold for mortality (standardized mortality ratio; 10th/90th percentiles: 0.71, 1.34) and hospitalization (standardized hospitalization ratio; 10th/90th percentiles: 0.64, 1.37), and nearly four-fold for transfusion (standardized transfusion ratio; 10th/90th percentiles: 0.43, 1.65). Medicare claims data (from July of 2014) demonstrate that facility variation for the proportions of patients on hemodialysis hospitalized (10th/90th percentiles: 27%, 50%) and transfused (10th/90th percentiles: 3%, 17%) within 6 months that far exceeds relatively modest recent overall longitudinal trends. DFC SRS-rated facility variation is also substantial for fistula (10th/90th percentiles: 50%, 78%) and catheter use >90 days (10th/90th percentiles: 3%, 19%). By contrast, DFC SRS-rated facility distributions for adult hemodialysis Kt/V>1.2 (10th/90th percentiles: 84%, 97%) and total serum calcium >10.2 mg/dl (median, 1%; 75th/90th percentiles: 3%, 5%) are quite narrow and may be of questionable value. Likewise, variation in the US Dialysis Outcomes and Practice Patterns Study is over two-fold for facility median serum parathyroid hormone (10th/90th percentiles: 290 pg/ml, 629 pg/ml) and ferritin (10th/90th percentiles: 469 ng/ml, 1143 ng/ml) levels, and facility mean treatment time varies by 30 minutes (10th/90th percentiles: 204 minutes, 234 minutes). Rising serum parathyroid hormone and ferritin levels, and generally short dialysis treatment time, represent areas unchecked by existing policy; both overall trends and facility variation in these values may reflect unintended consequences of policy or reimbursement pressures and therefore raise concern. Additionally, outcomes in the transition period from advanced CKD to dialysis remain poor, and policy initiatives and performance accountability in this area remain insufficient. Innovative models of comprehensive care in advanced CKD and the early dialysis period which are more amenable to policy oversight are needed. In summary, facility variation is typically larger than prevailing longitudinal trends, and should not be overlooked. The combination of nationally representative observational databases (e.g., the Dialysis Outcomes and Practice Patterns Study) and ESRD registries can provide policy makers with additional tools to evaluate facility variation, develop policies, and monitor unintended effects.

Effect of behavioral stage-based nutrition education on management of osteodystrophy among hemodialysis patients, Lebanon

OBJECTIVE

Assess the effect of intensive nutrition education by trained dedicated dietitians on osteodystrophy management among hemodialysis patients.

METHODS

Randomized controlled trial in 12 hospital-based hemodialysis units equally distributed over clusters 1 and 2. Cluster 1 patients were either assigned to usual care (n=96) or to individualized intensive staged-based nutrition education by a dedicated renal dietitian (n=88). Cluster 2 patients (n=210) received nutrition education from general hospital dietitians, educating their patients at their spare time from hospital duties. Main outcomes were: (1) dietary knowledge(%), (2) behavioral change, (3) serum phosphorus (mmol/L), each measured at T0 (baseline), T1 (post 6 month intervention) and T2 (post 6 month follow up).

RESULTS

Significant improvement was found only among patients receiving intensive education from a dedicated dietitian at T1; the change regressed at T2 without statistical significance: knowledge (T0: 40.3; T1: 64; T2: 63) and serum phosphorus (T0: 1.79; T1: 1.65; T2: 1.70); behavioral stages changed significantly throughout the study (T0: Preparation, T1: Action, T2: Preparation).

CONCLUSION

The intensive protocol showed to be the most effective.

PRACTICE IMPLICATIONS

Integrating dedicated dietitians and stage-based education in hemodialysis units may improve the nutritional management of patients in Lebanon and countries with similar health care systems.

Systems to cultivate suitable patients for home dialysis

The key to developing, initiating, and maintaining a strong home dialysis program is a fundamental commitment by the entire team to identify and cultivate patients who are suitable candidates to perform home dialysis. This process must start as early as possible in the disease trajectory, and must include a passionate and daily focus by physicians, nurses, social workers, and other members of the multidisciplinary team. This effort must be constant and sustained over months, with active promotion of home dialysis for suitable patients at every opportunity. Cultivation of suitable patients must become a defining and overarching mission for the entire program. This article reviews some of the components involved in this worthwhile effort and provides practical tips and links to resources.

The first year on haemodialysis: a critical transition

The first year following the start of haemodialysis (HD) is associated with increased mortality, especially during the first 90–120 days after the start of dialysis. Whereas the start of dialysis has important effects on the internal environment of the patient, there are relatively few studies assessing changes in phenotype and underlying mechanisms during the transition period following pre-dialysis to dialysis care, although more insight into these parameters is of importance in unravelling the causes of this increased early mortality. In this review, changes in cardiovascular, nutritional and inflammatory parameters during the first year of HD, as well as changes in physical and functional performance are discussed. Treatment-related factors that might contribute to these changes include vascular access and pre-dialysis care, dialysate prescription and the insufficient correction of the internal environment by current dialysis techniques. Patient-related factors include the ongoing loss of residual renal function and the progression of comorbid disease. Identifying phenotypic changes and targeting risk patterns might improve outcome during the transition period. Given the scarcity of data on this subject, more research is needed.

A nurse-led case management program on home exercise training for hemodialysis patients: A randomized controlled trial

BACKGROUND

Patients on maintenance hemodialysis suffer from diminished physical health. Directly supervised exercise programs have been shown to be effective at improving physical function and optimizing well-being. However, nurses seldom include an exercise intervention in the care plan for hemodialysis patients.

OBJECTIVES

The purpose of this study was to examine the effects of a 12-week nurse-led case management program on home exercise training for hemodialysis patients.

DESIGN

The study was a randomized, two-parallel group trial.

SETTINGS

Hemodialysis units in two tertiary hospitals in Nanjing, mainland China.

PARTICIPANTS

One hundred and thirteen adult patients who have been in stable condition while on dialysis treatment for more than 3 months were recruited and randomly assigned to either the study group (n=57) or the control group (n=56).

METHODS

Both groups underwent a brief weekly in-center exercise training session before their dialysis sessions for the first 6 weeks. The study group received additional nurse case management weekly for the first 6 weeks and biweekly for the following 6 weeks. The intervention was to facilitate patients in performing regular exercise at home. Outcome measures, including gait speed, 10-repetition sit-to-stand performance, and quality of life were collected at baseline, and at 6 and 12 weeks into the program.

RESULTS

The results revealed that patients in the study group demonstrated greater increases in normal gait speed [F(1,111)=4.42, p=0.038] than the control group. For the study group, a mean increase of 12.02 (±3.03)centimeters/second from baseline to week 12 was found. With regard to the fast gait speed, there was a marginally significant between-group effect [F(1,111)=3.93, p=0.050]. The study group showed a mean improvement of 11.08 (±3.32)cm/s, from baseline to week 12. Patients from both groups showed improvements in their 10-repetition sit-to-stand performance. The between-group differences approached significance [F(1,111)=3.92, p=0.050], with the study group showed greater improvement than the control group. The time taken by the patients in the study group to complete the 10-STS test increased by 5.75 (±3.88)s from baseline to week 12. Significant improvements in quality of life across three time points were found only in the study group.

CONCLUSIONS

Home exercise using a nurse-led case management approach is practical and effective in improving the physical function and self-perceived health of stable hemodialysis patients.

Rationale and design of a patient-centered medical home intervention for patients with end-stage renal disease on hemodialysis

In the U.S., more than 400,000 individuals with end-stage renal disease (ESRD) require hemodialysis (HD) for renal replacement therapy. ESRD patients experience a high burden of morbidity, mortality, resource utilization, and poor quality of life (QOL). Under current care models, ESRD patients receive fragmented care from multiple providers at multiple locations. The Patient-Centered Medical Home (PCMH) is a team approach, providing coordinated care across the healthcare continuum. While this model has shown some early benefits for complex chronic diseases such as diabetes, it has not been applied to HD patients. This study is a non-randomized quasi-experimental intervention trial implementing a Patient-Centered Medical Home for Kidney Disease (PCMH-KD). The PCMH-KD extends the existing dialysis care team (comprised of a nephrologist, dialysis nurse, dialysis technician, social worker, and dietitian) by adding a general internist, pharmacist, nurse coordinator, and a community health worker, all of whom will see the patients together, and separately, as needed. The primary goal is to implement a comprehensive, multidisciplinary care team to improve care coordination, quality of life, and healthcare use for HD patients. Approximately 240 patients will be recruited from two sites; a non-profit university-affiliated dialysis center and an independent for-profit dialysis center. Outcomes include (i) patient-reported outcomes, including QOL and satisfaction; (ii) clinical outcomes, including blood pressure and diet; (iii) healthcare use, including emergency room visits and hospitalizations; and (iv) staff perceptions. Given the significant burden that patients with ESRD on HD experience, enhanced care coordination provides an opportunity to reduce this burden and improve QOL.

Health policy, disparities, and the kidney

Kidney care and public policy have been linked for 40 years, with various consequences to outcomes. The 1972 Social Security Amendment, Section 2991, expanded Medicare coverage for all modalities of dialysis and transplant services and non-kidney-related care to those with end-stage renal disease (ESRD) regardless of age. This first and only disease-specific entitlement program was a step toward decreasing disparities in access to care. Despite this, disparities in kidney disease outcomes continue as they are based on many factors. Over the last 4 decades, policies have been enacted to understand and improve the delivery of ESRD care. More recent policies include novel shared-risk payment models to ensure quality and decrease costs. This article discusses the impact or potential impact of selected policies on health disparities in advanced chronic kidney disease and ESRD. Although it is too early to know the consequences of newer policies (Affordable Care Act, ESRD Prospective Payment System, Quality Incentive Program, Accountable Care Organizations), their goal of improving access to timely patient-centered appropriate affordable and quality care should lessen the disparity gap. The Nephrology community must leverage this dynamic state of care-delivery model redesign to decrease kidney-related health disparities.

Confounders of mortality and hospitalization rate calculations for profit and nonprofit dialysis facilities: analytic augmentation

BACKGROUND

Patient outcomes have been compared on the basis of the profit status of the dialysis provider (for-profit [FP] and not-for-profit [NFP]). In its annual report, United States Renal Data System (USRDS) provides dialysis provider level death and hospitalization rates adjusted by age, race, sex, and dialysis vintage; however, recent analyses have suggested that other variables impact these outcomes. Our current analysis of hospitalization and mortality rates of hemodialysis patients included adjustments for those used by the USRDS plus other potential confounders: facility geography (end-stage renal disease network), length of facility ownership, vascular access at first dialysis session, and pre-dialysis nephrology care.

METHODS

We performed a provider level, retrospective analysis of 2010 hospitalization and mortality rates among US hemodialysis patients exclusively using USRDS sources. Crude and adjusted incidence rate ratios (IRRs) were calculated using the 4 standard USRDS patient factors plus the 4 potential confounders noted above.

RESULTS

The analysis included 366,011 and 34,029 patients treated at FP and NFP facilities, respectively. There were statistical differences between the cohorts in geography, facility length of ownership, vascular access, and pre-dialysis nephrology care (p < 0.001), as well as age (p < 0.01), race (p < 0.001), and vintage (p < 0.001), but not sex (p = 0.12). When using standard USRDS adjustments, hospitalization and mortality rates for FP and NFP facilities were most disparate, favoring the NFP facilities. Rates were most similar between providers when adjustments were made for each of the 8 factors. With the FP IRR as the referent (1.0), the hospitalization IRR for NFP facilities was 1.00 (95% confidence interval [CI] 0.97-1.02; p = 0.69), while the NFP mortality IRR was 1.01 (95% CI 0.97-1.05; p = 0.64).

CONCLUSIONS

These data suggest there is no difference in mortality and hospitalization rates between FP and NFP dialysis clinics when appropriate statistical adjustments are made.

Improving outcomes for ESRD patients: shifting the quality paradigm

The availability of life-saving dialysis therapy has been one of the great successes of medicine in the past four decades. Over this time period, despite treatment of hundreds of thousands of patients, the overall quality of life for patients with ESRD has not substantially improved. A narrow focus by clinicians and regulators on basic indicators of care, like dialysis adequacy and anemia, has consumed time and resources but not resulted in significantly improved survival; also, frequent hospitalizations and dissatisfaction with the care experience continue to be seen. A new quality paradigm is needed to help guide clinicians, providers, and regulators to ensure that patients' lives are improved by the technically complex and costly therapy that they are receiving. This paradigm can be envisioned as a quality pyramid: the foundation is the basic indicators (outstanding performance on these indicators is necessary but not sufficient to drive the primary outcomes). Overall, these basics are being well managed currently, but there remains an excessive focus on them, largely because of publically reported data and regulatory requirements. With a strong foundation, it is now time to focus on the more complex intermediate clinical outcomes-fluid management, infection control, diabetes management, medication management, and end-of-life care among others. Successfully addressing these intermediate outcomes will drive improvements in the primary outcomes, better survival, fewer hospitalizations, better patient experience with the treatment, and ultimately, improved quality of life. By articulating this view of quality in the ESRD program (pushing up the quality pyramid), the discussion about quality is reframed, and also, clinicians can better target their facilities in the direction of regulatory oversight and requirements about quality. Clinicians owe it to their patients, as the ESRD program celebrates its 40th anniversary, to rekindle the aspirations of the creators of the program, whose primary goal was to improve the lives of the patients afflicted with this devastating condition.

Medication reconciliation and therapy management in dialysis-dependent patients: need for a systematic approach

Patients with ESRD undergoing dialysis have highly complex medication regimens and disproportionately higher total cost of care compared with the general Medicare population. As shown by several studies, dialysis-dependent patients are at especially high risk for medication-related problems. Providing medication reconciliation and therapy management services is critically important to avoid costs associated with medication-related problems, such as adverse drug events and hospitalizations in the ESRD population. The Medicare Modernization Act of 2003 included an unfunded mandate stipulating that medication therapy management be offered to high-risk patients enrolled in Medicare Part D. Medication management services are distinct from the dispensing of medications and involve a complete medication review for all disease states. The dialysis facility is a logical coordination center for medication management services, like medication therapy management, and it is likely the first health care facility that a patient will present to after a care transition. A dedicated and adequately trained clinician, such as a pharmacist, is needed to provide consistent, high-quality medication management services. Medication reconciliation and medication management services that could consistently and systematically identify and resolve medication-related problems would be likely to improve ESRD patient outcomes and reduce total cost of care. Herein, this work provides a review of available evidence and recommendations for optimal delivery of medication management services to ESRD patients in a dialysis facility-centered model.

Worldwide, mortality risk is high soon after initiation of hemodialysis

Mortality rates for maintenance hemodialysis patients are much higher than the general population and are even greater soon after starting dialysis. Here we analyzed mortality patterns in 86,886 patients in 11 countries focusing on the early dialysis period using data from the Dialysis Outcomes and Practice Patterns Study, a prospective cohort study of in-center hemodialysis. The primary outcome was all-cause mortality, using time-dependent Cox regression, stratified by study phase adjusted for age, sex, race, and diabetes. The main predictor was time since dialysis start as divided into early (up to 120 days), intermediate (121-365 days), and late (over 365 days) periods. Mortality rates (deaths/100 patient-years) were 26.7 (95% confidence intervals 25.6-27.9), 16.9 (16.2-17.6), and 13.7 (13.5-14.0) in the early, intermediate, and late periods, respectively. In each country, mortality was higher in the early compared to the intermediate period, with a range of adjusted mortality ratios from 3.10 (2.22-4.32) in Japan to 1.15 (0.87-1.53) in the United Kingdom. Adjusted mortality rates were similar for intermediate and late periods. The ratio of elevated mortality rates in the early to the intermediate period increased with age. Within each period, mortality was higher in the United States than in most other countries. Thus, internationally, the early hemodialysis period is a high-risk time for all countries studied, with substantial differences in mortality between countries. Efforts to improve outcomes should focus on the transition period and the first few months of dialysis.

Hemodialysis patient preference for type of vascular access: variation and predictors across countries in the DOPPS

PURPOSE

Catheters are associated with worse clinical outcomes than fistulas and grafts in hemodialysis (HD) patients. One potential modifier of patient vascular access (VA) use is patient preference for a particular VA type. The purpose of this study is to identify predictors of patient VA preference that could be used to improve patient care.

METHODS

This study uses a cross-sectional sample of data from the Dialysis Outcomes and Practice Patterns Study (DOPPS 3, 2005-09), that includes 3815 HD patients from 224 facilities in 12 countries. Using multivariable models we measured associations between patient demographic and clinical characteristics, previous catheter use and patient preference for a catheter.

RESULTS

Patient preference for a catheter varied across countries, ranging from 1% of HD patients in Japan and 18% in the United States, to 42% to 44% in Belgium and Canada. Preference for a catheter was positively associated with age (adjusted odds ratio per 10 years=1.14; 95% CI=1.02-1.26), female sex (OR 1.49; 95% CI=1.15-1.93), and former (OR=2.61; 95% CI=1.66-4.12) or current catheter use (OR=60.3; 95% CI=36.5-99.8); catheter preference was inversely associated with time on dialysis (OR per three years=0.90; 95% CI=0.82-0.97).

CONCLUSIONS

Considerable variation in patient VA preference was observed across countries, suggesting that patient VA preference may be influenced by sociocultural factors and thus could be modifiable. Catheter preference was greatest among current and former catheter users, suggesting that one way to influence patient VA preference may be to avoid catheter use whenever possible.

Clinical profile and post-transplant anaemia in renal transplant recipients restarting dialysis after a failed graft: changing trends between 2001 and 2009

BACKGROUND

The aim of this study was to compare the clinical profile, outcome and the prevalence and management of anaemia between two cohorts of renal transplant patients with graft failure restarting dialysis in 2001 and 2009.

METHODS

Cross-sectional, observational, retrospective and multicentre study of 397 patients in the 2001 cohort and 222 in the 2009 cohort. Data were recorded at 0, 3, 6, 9 and 12 months before the onset of dialysis resumption and during the first 90 days after restarting dialysis (mortality and hospital admission).

RESULTS

Patients in the 2009 cohort were older at the time of inclusion in the study and transplantation, and restarted dialysis therapy with a significantly better glomerular filtration rate. In both cohorts, there was a rapid deterioration of renal function with statistically significant differences in serum creatinine and glomerular filtration rate between the monthly intervals -12 and 0. The mean haemoglobin value at -12 months was 11.6 g/dL [7.2 mmol/L] in the 2001 cohort when compared with 12.3 g/dL [7.6 mmol/L] in the 2009 cohort, and at the time of restarting dialysis 9.6 g/dL [6.0 mmol/L] versus 10.6 g/dL [6.6 mmol/L]. The percentage of patients treated with erythropoiesis-stimulating agents, at any time during the 12 months before readmission to dialysis, increased significantly from 61.5% in the 2001 cohort to 96% in the 2009 cohort. There were no significant differences between the 2001 and 2009 cohorts in mortality rate (8.8 versus 9.0%) or hospital admission (31.5 versus 31.1%) during the study time.

CONCLUSIONS

At restarting dialysis, the proportion of patients with anaemia (and its severity) due to progressive graft nephropathy decreased over the past 8 years, increasing significantly the percentage of patients treated with erythropoietin. Differences in morbimortality after dialysis resumption were not observed, this is probably due to an increase in the age of donors and recipients.

Quality-of-care indicators among remote-dwelling hemodialysis patients: a cohort study

BACKGROUND

We hypothesized that the higher mortality for hemodialysis patients who live farther from the closest attending nephrologist compared with patients living closer might be due to lower quality of care.

STUDY DESIGN

Population-based longitudinal study.

SETTING & PARTICIPANTS

All adult maintenance hemodialysis patients with measurements of quality-of-care indicators initiating hemodialysis therapy between January 2001 and June 2010 in Northern Alberta, Canada.

PREDICTORS

Hemodialysis patients were classified into categories based on the distance by road from their residence to the closest nephrologist: ≤50 (referent), 50.1-150, 150.1-300, and >300 km.

OUTCOMES

Quality-of-care indicators were based on published guidelines.

MEASUREMENTS

Quality-of-care indicators at 90 days following initiation of hemodialysis therapy and, in a secondary analysis, at 1 year.

RESULTS

Measurements were available for 1,784 patients. At baseline, the proportions of patients residing in each category were 69% for ≤50 km to closest nephrologist; 17%, 50.1-150 km; 7%, 150.1-300 km; and 7%, >300 km. Those who lived farther away from the closest nephrologist were less likely to have seen a nephrologist 90 days prior to the initiation of hemodialysis therapy (P for trend = 0.008) and were less likely to receive Kt/V of 1.2 (adjusted OR, 0.50; 95% CI, 0.30-0.84; P for trend = 0.01). Remote location also was associated with suboptimal levels of phosphate control (P for trend = 0.005). There were no differences in the prevalence of arteriovenous fistulas or grafts or hemoglobin levels across distance categories.

LIMITATIONS

Registry data with limited data for non-guideline-based quality indicators.

CONCLUSIONS

Although several quality-of-care indicators were less common in remote-dwelling hemodialysis patients, these differences do not appear sufficient to explain the previously noted disparities in clinical outcomes by residence location.

Comprehensive and personalized care of the hemodialysis patient in tassin, france: a model for the patient-centered medical home for subspecialty patients

The Centre de Rein Artificiel in Tassin, France, provides comprehensive care to patients with chronic renal disease similar to the model proposed for Patient Center Medical Homes; patients with end-stage renal disease in the Tassin Hemodialysis Center appear to have better outcomes than patients in the United States. These differences likely reflect this center's approach to patient-centered care, the use of longer dialysis times, and focused vascular access care. Longer dialysis times provide better clearance of small and middle toxic molecules, salt, and water; 85% of patients at the Tassin center have a normal blood pressure without the use of antihypertensive medications. The observed mortality rate in patients at the Tassin Center is approximately 50% of that predicted based on the United States Renal Data system standard mortality tables. Patient outcomes at the Tassin center suggest that longer dialysis times and the use of multidiscipline teams led by nephrologists directing all health care needs probably explain the outcomes in these patients. These approaches can be imported into the U.S healthcare system and form the framework for patient-centered medical practice for ESRD patients.

Effectiveness of multidisciplinary care for chronic kidney disease in Taiwan: a 3-year prospective cohort study

BACKGROUND

Previous studies have demonstrated that multidisciplinary pre-dialysis education and team care may slow the decline in renal function for chronic kidney disease (CKD). Our study compared clinical outcomes of CKD patients between multidisciplinary care (MDC) and usual care in Taiwan.

METHODS

In this 3-year prospective cohort study from 2008 to 2010, we recruited 1056 CKD subjects, aged 20-80 years, from five hospitals, who received either MDC or usual care, had an estimated glomerular filtration rate (eGFR) <60 mL/min, were matched one to one with the propensity score including gender, age, eGFR and co-morbidity diseases. The MDC team was under-cared based on NKF K/DOQI clinical practice guidelines and the Taiwanese pre-end-stage renal disease (ESRD) care program. The incidence of progression to ESRD (initiation of dialysis) and mortality was compared between two groups. We also monitored blood pressure control, the rate of renal function decline, lipid profile, hematocrit and mineral bone disease control.

RESULTS

Participants were prone to be male (64.8%) with a mean age of 65.1 years and 33.1 months of mean follow-up. The MDC group had higher prescription rates of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), phosphate binder, vitamin D3, uric acid lower agents and erythropoietin-stimulating therapy and better control in secondary hyperparathyroidism. The decline of renal function in advanced stage CKD IV and V was also slower in the MDC group (-5.1 versus -7.3 mL/min, P = 0.01). The use of temporary dialysis catheter was higher in the usual care group, and CKD patients under MDC intervention exhibited a greater willingness to choose peritoneal dialysis modality. A Cox regression revealed that the MDC group was associated with a 40% reduction in the risk of hospitalization due to infection, and a 51% reduction in patient mortality, but a 68% increase in the risk of initiation dialysis when compared with the usual care group.

CONCLUSIONS

MDC patients were found to have more effective medication prescription according to K/DOQI guidelines and slower renal function declines in advanced/late-stage CKD. After MDC intervention, CKD patients had a better survival rate and were more likely to initiate renal replacement therapy (RRT) instead of mortality.

Factors associated with suboptimal initiation of dialysis despite early nephrologist referral

BACKGROUND

STARRT recently demonstrated that many patients experience suboptimal dialysis starts (defined as initiation as an inpatient and/or with a central venous catheter), even when followed by a nephrologist for >12 months (NDT 2011). However, STARRT did not identify the factors associated with suboptimal initiation of dialysis. The objectives of this study were to extend the results of STARRT by ascertaining the factors leading to suboptimal initiation of dialysis in patients who were referred at least 12 months prior to commencement of dialysis.

METHODS

At each of the three Toronto centers, charts of consecutive incident RRT patients were identified from 1 January 2009 to 31 December 2010, with predetermined data extracted.

RESULTS

A total of 436 incident RRT patients were studied; 52.4% were followed by a nephrologist for >12 months prior to the initiation of dialysis. Suboptimal starts occurred in 56.4% of these patients. No attempt at arteriovenous fistula (AVF) or arteriovenous graft (AVG) prior to initiation was made in 65% of these starts. Factors contributing to suboptimal starts despite early referral included patient-related delays (31.25%), acute-on-chronic kidney disease (31.25%), surgical delays (16.41%), late decision-making (8.59%) and others (12.50%). The percentage of optimal starts with early referral among 14 nephrologists ranged from 33 to 72%.

CONCLUSIONS

Most patients started dialysis in a suboptimal manner, despite an extended period of pre-dialysis care. Nephrologists should take responsibility for suboptimal initiation of dialysis despite early referral and test methods that attempt to prevent this.

Intensive hemodialysis in the (nursing) home: the bright side of geriatric ESRD care?

Elderly ESRD patients often lose functionality when they start dialysis, which may be due to a variety of clinical problems. We recently postulated that intensive (longer and/or more frequent) hemodialysis (HD) may be the ideal strategy to try to prevent these ESRD- and dialysis-related complications, including dialysis-induced hypotension, cardiac and cerebral events, malnutrition, infections, sleep problems, and psychological issues. The feasibility of home dialysis therapies has been demonstrated in observational studies. As self-care dialysis is often a challenge in the elderly patient, assisted intensive home HD may facilitate the long-term continuation of this modality. Intensive nursing home HD seems to be an attractive goal for the future because many elderly ESRD patients reside in an extended care facility. Combination with rehabilitation and support by social worker and psychologist remains crucial in the holistic approach toward the elderly ESRD patient. Further studies are required to test the potential protective effects of intensive HD on functionality and quality of life in elderly ESRD patients, and to elucidate the mechanisms underlying frailty and other geriatric syndromes in this highly vulnerable patient population.

Intensity of care and better outcomes among hemodialysis patients: a role for the Medical Director

The Medical Director is responsible for all levels of quality patient care in the facility as mandated by the 2008 revision of the Medicare Conditions for Coverage of dialysis facilities. He/she is the leader and primary individual tasked with ensuring that facility processes are in place to meet or exceed key quality goals or adopt new ones and prioritize them appropriately-all to drive improved facility performance, particularly the ultimate outcomes of morbidity and mortality rates. Management of vascular access, dialysis dose, mineral metabolism, acid-base balance, sodium and fluid management, anemia, among other aspects of care, have representative intermediate clinical outcomes that are often called "surrogate" or "process" measures-because they may reflect the quality of care delivery while impacting "primary" outcomes such as death and hospitalization. The proportion of dialysis patients within a dialysis facility meeting a selected group among these goals has become the standard "care process" metric since the 1990s. Evidence supports its use, in that graded improvements in the facility patients' primary outcomes have been documented as more patients in a facility achieved a greater number of these "process" goals. A caveat: these process measures do not represent overall quality by themselves because nonclinical processes also influence primary outcomes. Nevertheless, process improvement in meeting facility goals should be led by the Medical Director, particularly those with the strongest links to primary outcomes such as reduction of hemodialysis catheter exposure, forming the cornerstone of quality improvement efforts. Specific recommendations on how to effectively lead a care team to achieve these goals are discussed.

The IMPACT (Incident Management of Patients, Actions Centered on Treatment) program: a quality improvement approach for caring for patients initiating long-term hemodialysis

BACKGROUND

Patients beginning dialysis therapy are at risk of death and illness. The IMPACT (Incident Management of Patients, Actions Centered on Treatment) quality improvement program was developed to improve incident hemodialysis patient outcomes through standardized care.

STUDY DESIGN

Quality improvement report.

SETTING & PARTICIPANTS

Patients who started hemodialysis therapy between September 2007 and December 2008 at DaVita facilities using the IMPACT program (n = 1,212) constituted the intervention group. Propensity score-matched patients who initiated hemodialysis therapy in the same interval at DaVita facilities not using the IMPACT program (n = 2,424) made up the control group.

QUALITY IMPROVEMENT PLAN

IMPACT intervention included a structured intake process and monitoring reports; patient enrollment in a 90-day patient education program and 90-day patient management pathway.

OUTCOMES

Mean dialysis adequacy (Kt/V), hemoglobin and albumin levels, percentage of patients using preferred vascular access (arteriovenous fistula or graft), and mortality at each quarter.

RESULTS

Compared with the non-IMPACT group, the IMPACT group was associated with a higher proportion of patients dialyzing with a preferred access at 90 days (0.50 [95% CI, 0.47-0.53] vs 0.47 [95% CI, 0.45-0.49]; P = 0.1) and 360 days (0.63 [95% CI, 0.61-0.66] vs 0.48 [95% CI, 0.46-0.50]; P < 0.001) and a lower mortality rate at 90 days (24.8 [95% CI, 19.0-30.7] vs 31.9 [95% CI, 27.1-36.6] deaths/100 patient-years; P = 0.08) and 360 days (17.8 [95% CI, 15.2-20.4] vs 25.1 [95% CI, 20.7-25.2] deaths/100 patient-years; P = 0.01).

LIMITATIONS

The study does not determine the care processes responsible for the improved outcomes.

CONCLUSIONS

Intense management of incident dialysis patients with the IMPACT quality improvement program was associated with significantly decreased first-year mortality. Focused attention to the care of incident patients is an important part of a dialysis program.

Association of early versus late initiation of dialysis with mortality: systematic review and meta-analysis

BACKGROUND/AIMS

The association of the timing of dialysis initiation with mortality is controversial. We conducted a meta-analysis to determine the relationship between the risk of death and early initiation of dialysis, when the patient has a greater estimated glomerular filtration rate (eGFR).

METHODS

Prospective and retrospective cohort studies that independently measured the effect of early vs. late initiation of dialysis on risk of death were identified by review of several databases. Odds ratios (ORs) were estimated by comparison of the highest and lowest quartiles and combined by a random-effects model.

RESULTS

15 studies (1,285,747 patients) met the inclusion criteria. Summary estimates indicated that early start of dialysis was associated with increased risk of mortality (OR = 1.33, 95% confidence interval (CI): 1.18-1.49, p < 0.00001). Subgroup analysis indicated that early starters were 6.61 years older (p < 0.00001) and more likely to have diabetes (OR = 2.23, 95% CI: 1.83-2.71, p < 0.00001) than late starters. Analysis of pooled results of early and late starters indicated that older age (OR = 1.18, 95% CI: 1.05-1.33, p = 0.006), diabetes (OR = 1.61, 95% CI: 1.38-1.87, p < 0.00001), and high comorbidity index score (OR = 2.38, 95% CI: 1.75-3.25, p < 0.00001) were strongly associated with increased risk of death.

CONCLUSION

Our meta-analysis indicates that early initiation of dialysis (at higher eGFR) was associated with an increased risk of death. Older age, greater likelihood of diabetes, and the presence of severe comorbid disease(s) partly explain this effect.

Dialysis at a crossroads--Part II: A call for action

A previous commentary pointed out that the renal community has led American healthcare in the development and continuous improvement of quality outcomes. However, survival, hospitalization, and quality of life for US dialysis patients is still not optimal. This follow-up commentary examines the obstacles, gaps, and metrics that characterize this unfortunate state of affairs. It posits that current paradigms are essential contributors to quality outcomes but are no longer sufficient to improve quality. New strategies are needed that arise from a preponderance of evidence, in addition to beyond a reasonable doubt standard. This work offers an action plan that consists of new pathways of care that will lead to improved survival, fewer hospitalizations and rehospitalizations, and better quality of life for patients undergoing dialysis therapy. Nephrologists in collaboration with large and small dialysis organizations and other stakeholders, including the Centers for Medicare and Medicaid Services, can implement these proposed new pathways of care and closely monitor their effectiveness. We suggest that our patients deserve nothing less and must receive even more.

Accountable care organizations and ESRD: the time has come

Accountable care organizations (ACOs) are a newly proposed vehicle for improving or maintaining high-quality patient care while controlling costs. They are meant to achieve the goals of the Medicare Shared Savings Program mandated by the Patient Protection and Affordable Care Act (PPACA) of 2010. ACOs are voluntary groups of hospitals, physicians, and health care teams that provide care for a defined group of Medicare beneficiaries and assume responsibility for providing high-quality care through defined quality measures at a cost below what would have been expected. If an ACO succeeds in achieving both the quality measures and reduced costs, the ACO will share in Medicare's cost savings. Health care for patients with end-stage renal disease is complex due to multiple patient comorbid conditions, expensive, and often poorly coordinated. Due to the unique needs of patients with end-stage renal disease receiving dialysis, ACOs may be unable to provide the highly specialized quality care these patients require. We discuss the benefits and risks of a renal-focused ACO for dialysis patients, as well as the kidney community's prior experience with an ACO-like demonstration project.

Depressive symptoms associate with high mortality risk and dialysis withdrawal in incident hemodialysis patients

BACKGROUND

The relationship between severity of depressive symptoms reported by incident dialysis patients and first-year outcomes is not known.

METHODS

We evaluated the association between self-report of depressive symptoms in incident hemodialysis patients admitted at Fresenius Medical Care North America facilities between 1 January and 31 December 2006 and mortality or withdrawal from dialysis for up to 1 year after the initial survey. The impact of depression scores calculated from two Short Form-36 (SF-36) questionnaires was determined independently of the mental and physical component scores, case-mix and laboratory variables using stepwise Cox models.

RESULTS

We received 6415 SF-36 responses within 46±24 days of first dialysis from a cohort with a mean age of 62.3±15.2 years; 58% were diabetic, 45% were female and 69% were Caucasian. A 1-point increase in depression score was associated with unadjusted hazard ratio (HR) of 1.09 (1.03, 1.15) for mortality and 1.15 (1.05, 1.26) for withdrawal from dialysis. After adjustment, a 1-point increase in depression score had a mortality HR of 1.08 (1.01, 1.14) and for withdrawal 1.19 (1.08, 1.31).

CONCLUSIONS

Depressive symptoms reported within the first 90 days of dialysis were associated with greater dialysis withdrawal and mortality risk over the succeeding year. Whether further evaluation for and treatment of depression during this early vulnerable period may improve symptoms, increase survival and decrease premature withdrawal from dialysis requires confirmation in prospective clinical trials.

Ideal timing and predialysis nephrology care duration for dialysis initiation: from analysis of Japanese dialysis initiation survey

Previous studies have suggested that early initiation of dialysis therapy was not superior in terms of patient survival. In this study, we analyzed the effects of renal function at the start of renal replacement therapy (RRT), duration of nephrology care, and comorbidity on 12-month survival of end-stage renal disease (ESRD) patients. The subjects in this study were 9695 new ESRD patients who started RRT in 2007. The average age of the subjects was 67.5 years, 64.1% of the subjects were male, and 42.9% had diabetes. During the 12-month period after the start of RRT, 1546 patients died, and 35 patients received renal transplantation. Average estimated glomerular filtration rate (eGFR) at the initiation of dialysis was 6.52 ± 4.20 mL/min/1.73 m(2) . By unadjusted logistic analysis, one-year Odds Ratio (OR) of mortality in patients with eGFR more than 4-6 mL/min/1.73 m(2) was increased with increased eGFR at dialysis initiation, but the OR was identical among the groups with eGFR less than 4 mL/min/1.73 m(2) . After adjustment for age, gender, underlying renal diseases, and other clinical characteristics at dialysis initiation, OR was identical among the groups with eGFR less than 8 mL/min/1.73 m(2) . Furthermore, an OR increment was observed in eGFR less than 4 mL/min/1.73 m(2) group. In terms of the duration of nephrology care before dialysis initiation, 6 months or longer of nephrology care significantly decreased the OR of mortality after adjustment of covariance. Not only patients with sufficient residual renal function at the initiation of dialysis, but also patients with very low eGFR at the initiation of dialysis showed poor survival.

Early outcomes among those initiating chronic dialysis in the United States

BACKGROUND AND OBJECTIVES

Approximately one million Americans initiated chronic dialysis over the past decade; the first-year mortality rate reported by the U.S. Renal Data System was 19.6% in 2007. This estimate has historically excluded the first 90 days of chronic dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

To characterize the mortality and hospitalization risks for patients starting chronic renal replacement therapy, we followed all patients initiating dialysis in 1733 facilities throughout the United States (n = 303,289). Mortality and hospitalizations within the first 90 days were compared with outcomes after this period, and the results were analyzed. Standard time-series analyses were used to depict the weekly risk estimates for each outcome.

RESULTS

Between 1997 and 2009, >300,000 patients initiated chronic dialysis and were followed for >35 million dialysis treatments; the highest risk for morbidity and mortality occurred in the first 2 weeks of treatment. The initial 2-week risk of death for a typical dialysis patient was 2.72-fold higher, and the risk of hospitalization was 1.95-fold higher when compared to a patient who survived the first year of chronic dialysis (week 53 after initiation). Similarly, over the first 90 days, the risk of mortality and hospitalization remained elevated. Thereafter, between days 91 and 365, these risks decreased considerably by more than half. Surviving these first weeks of dialysis was most associated with the type of vascular access. Initiating dialysis with a fistula was associated with a decreased early death risk by 61%, whereas peritoneal dialysis decreased the risk by 87%.

CONCLUSIONS

The first 2 weeks of chronic dialysis are associated with heightened mortality and hospitalization risks, which remain elevated over the ensuing 90 days.

Translating knowledge on best practice into improving quality of RRT care: a systematic review of implementation strategies

Recent studies showed wide variation in the extent to which guidelines and other types of best practice have been implemented as part of routine health care. This is also true for the delivery of renal replacement therapy (RRT) for ESRD patients. Increasing uptake of best practice within such complex care systems requires an understanding of implementation strategies and specific quality improvement (QI) techniques. Therefore, we systematically reviewed over 5000 titles published since 1990 and included papers describing planned attempts to accelerate uptake of best RRT practice into daily care. This resulted in a list of 93 QI initiatives, categorized in order to expedite shared learning. The majority of the initiatives were executed within the domains of vascular access, nutrition, and anemia management. Strategies oriented at patients were most common and many initiatives pre-defined an improvement target before starting implementation. Of the 93 initiatives, 22 were sufficiently robust methodologically to be analyzed in more detail. Our results tend to support previous findings that multifaceted strategies are more effective than single strategies. Improving our understanding of how to successfully implement best practice can inform system-level change and is the only way to close the gap between knowledge on what works and the actual care delivered to ESRD patients. Research into implementation, using specific QI techniques, should therefore be given priority in future.

Suboptimal initiation of dialysis with and without early referral to a nephrologist

BACKGROUND

Our objective was to examine patients who initiate renal replacement therapy (RRT) at 10 representative Canadian centers, characterize their initiation as inpatient or outpatient and describe their initial type of dialysis access, duration of pre-dialysis care and clinical status at the time of dialysis initiation. We also examined the impact of an optimal dialysis start (i.e. initiated as an outpatient with an arteriovenous fistula, arteriovenous graft or peritoneal dialysis catheter) on subsequent health outcomes.

METHODS

Charts of consecutive incident RRT patients were identified from 1 July to 31 December 2006. Information was collected until 6 months after the initiation or until death, transplant or transfer.

RESULTS

Three hundred and thirty-nine incident RRT patients were studied: 39.6% initiated as an inpatient; 54% started hemodialysis (HD) with a central venous catheter; 15.3% had <1 month predialysis care, while 64.6% had >1 year. Optimal starts occurred in 39.5% of patients. For HD patients, optimal starts occurred in 19.8%. Suboptimal starts were noted in patients referred <12 months prior to end-stage renal disease (44%) and in patients referred earlier (56%). The composite end point of death, transfusion or subsequent hospitalization was significantly reduced with an optimal start [hazard ratio 0.47 (95% confidence interval 0.32-0.68), P = 0.0001].

CONCLUSIONS

Suboptimal initiation of dialysis is common in patients referred early or late. The benefits of early referral are lost if dialysis is initiated suboptimally. There is a need to identify factors that lead to suboptimal initiation despite early referral.

Low health literacy associates with increased mortality in ESRD

Limited health literacy is common in the United States and associates with poor clinical outcomes. Little is known about the effect of health literacy in patients with advanced kidney disease. In this prospective cohort study we describe the prevalence of limited health literacy and examine its association with the risk for mortality in hemodialysis patients. We enrolled 480 incident chronic hemodialysis patients from 77 dialysis clinics between 2005 and 2007 and followed them until April 2008. Measured using the Rapid Estimate of Adult Literacy in Medicine, 32% of patients had limited (<9th grade reading level) and 68% had adequate health literacy (≥9th grade reading level). Limited health literacy was more likely in patients who were male and non-white and who had fewer years of education. Compared with adequate literacy, limited health literacy associated with a higher risk for death (HR 1.54; 95% CI 1.01 to 2.36) even after adjustment for age, sex, race, and diabetes. In summary, limited health literacy is common and associates with higher mortality in chronic hemodialysis patients. Addressing health literacy may improve survival for these patients.