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Veinot TC, Gillespie B, Argentina M, Bragg-Gresham J, Chatoth D, Collins Damron K, Heung M, Krein S, Wingard R, Zheng K, Saran R. Enhancing the Cardiovascular Safety of Hemodialysis Care Using Multimodal Provider Education and Patient Activation Interventions: Protocol for a Cluster Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e46187. [PMID: 37079365 PMCID: PMC10160944 DOI: 10.2196/46187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/19/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND End-stage kidney disease (ESKD) is treated with dialysis or kidney transplantation, with most patients with ESKD receiving in-center hemodialysis treatment. This life-saving treatment can result in cardiovascular and hemodynamic instability, with the most common form being low blood pressure during the dialysis treatment (intradialytic hypotension [IDH]). IDH is a complication of hemodialysis that can involve symptoms such as fatigue, nausea, cramping, and loss of consciousness. IDH increases risks of cardiovascular disease and ultimately hospitalizations and mortality. Provider-level and patient-level decisions influence the occurrence of IDH; thus, IDH may be preventable in routine hemodialysis care. OBJECTIVE This study aims to evaluate the independent and comparative effectiveness of 2 interventions-one directed at hemodialysis providers and another for patients-in reducing the rate of IDH at hemodialysis facilities. In addition, the study will assess the effects of interventions on secondary patient-centered clinical outcomes and examine factors associated with a successful implementation of the interventions. METHODS This study is a pragmatic, cluster randomized trial to be conducted in 20 hemodialysis facilities in the United States. Hemodialysis facilities will be randomized using a 2 × 2 factorial design, such that 5 sites will receive a multimodal provider education intervention, 5 sites will receive a patient activation intervention, 5 sites will receive both interventions, and 5 sites will receive none of the 2 interventions. The multimodal provider education intervention involved theory-informed team training and the use of a digital, tablet-based checklist to heighten attention to patient clinical factors associated with increased IDH risk. The patient activation intervention involves tablet-based, theory-informed patient education and peer mentoring. Patient outcomes will be monitored during a 12-week baseline period, followed by a 24-week intervention period and a 12-week postintervention follow-up period. The primary outcome of the study is the proportion of treatments with IDH, which will be aggregated at the facility level. Secondary outcomes include patient symptoms, fluid adherence, hemodialysis adherence, quality of life, hospitalizations, and mortality. RESULTS This study is funded by the Patient-Centered Outcomes Research Institute and approved by the University of Michigan Medical School's institutional review board. The study began enrolling patients in January 2023. Initial feasibility data will be available in May 2023. Data collection will conclude in November 2024. CONCLUSIONS The effects of provider and patient education on reducing the proportion of sessions with IDH and improving other patient-centered clinical outcomes will be evaluated, and the findings will be used to inform further improvements in patient care. Improving the stability of hemodialysis sessions is a critical concern for clinicians and patients with ESKD; the interventions targeted to providers and patients are predicted to lead to improvements in patient health and quality of life. TRIAL REGISTRATION ClinicalTrials.gov NCT03171545; https://clinicaltrials.gov/ct2/show/NCT03171545. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/46187.
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Affiliation(s)
- Tiffany Christine Veinot
- School of Information, University of Michigan, Ann Arbor, MI, United States
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, United States
- Department of Learning Health Sciences, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Brenda Gillespie
- Department of Biostatistics, Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, MI, United States
| | | | - Jennifer Bragg-Gresham
- Division of Nephrology, School of Medicine, Ann Arbor, MI, United States
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, United States
| | | | | | - Michael Heung
- Division of Nephrology, School of Medicine, Ann Arbor, MI, United States
| | - Sarah Krein
- Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, United States
- Veterans Affairs Center for Clinical Management Research, US Department of Veterans Affairs, Ann Arbor, MI, United States
| | | | - Kai Zheng
- School of Information and Computer Sciences, University of California Irvine, Irvine, CA, United States
| | - Rajiv Saran
- Division of Nephrology, School of Medicine, Ann Arbor, MI, United States
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, United States
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2
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Čižman B, Lindo S, Bilionis B, Davis I, Brown A, Miller J, Phillips G, Kriukov A, Sloand JA. The Occurrence of Increased Intraperitoneal Volume Events in Automated Peritoneal Dialysis in the US: Role of Programming, Patient/User Actions and Ultrafiltration. Perit Dial Int 2020; 34:434-42. [DOI: 10.1177/089686081403400401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background, objectives and methodsIncreased intraperitoneal volume (IIPV) can occur during automated peritoneal dialysis (APD). The contribution of factors such as cycler programming and patient/user actions to IIPV has not been previously explored. The relationship between IIPV and cycler programming, patient/user actions, and ultra-filtration over a two-year period was investigated using US data from Baxter cyclers. Drain/fill volume ratios of > 1.6 to ≤ 2.0 and > 2.0 were defined as Level I and Level II IIPV events, respectively.ResultsLevel I IIPV events occurred in 2.39% of standard and 4.73% of small fill volume therapies, while Level II IIPV events occurred in 0.26% and 1.33% of therapies, respectively. IIPV events occurred significantly more often in association with tidal peritoneal dialysis (PD) compared to non-tidal PD therapies. In tidal therapies, IIPV events were primarily related to suboptimal programming of total ultrafiltration volume. Factors that increased the odds of IIPV events during standard therapies included programming the initial drain volume target to < 70% of the last fill, and setting minimum drain volumes to < 85% of the fill volume. Bypass of initial drain by patients/users was also associated with a significant increase in the odds of IIPV events in non-tidal, but not tidal PD. An increase in the odds for IIPV was also seen for standard therapies within the highest (> 1,245 mL) versus the lowest (< 427 mL) quartile of ultrafiltration. Similar trends were seen in small fill volume therapies. Clinical presentations associated with IIPV events were not assessed.ConclusionsIIPV events are more frequent in tidal and small fill volume therapies. The greatest potential for IIPV occurred when the total ultrafiltration was set too low for the patient's UF requirements during tidal therapy. Patient/user bypass of drains without reaching the target drain volume contributes significantly to IIPV events in non-tidal PD therapies. Poorly functioning PD catheters may be central to the cycler programming and patient/user actions that lead to IIPV.
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Affiliation(s)
- Borut Čižman
- Baxter Healthcare Corporation, Deerfield, IL 60015, USA
| | | | | | - Ira Davis
- Baxter Healthcare Corporation, Deerfield, IL 60015, USA
| | - Aaron Brown
- Baxter Healthcare Corporation, Deerfield, IL 60015, USA
| | | | | | - Alex Kriukov
- Baxter Healthcare Corporation, Deerfield, IL 60015, USA
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3
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Port FK, Morgenstern H, Bieber BA, Karaboyas A, McCullough KP, Tentori F, Pisoni RL, Robinson BM. Understanding associations of hemodialysis practices with clinical and patient-reported outcomes: examples from the DOPPS. Nephrol Dial Transplant 2018; 32:ii106-ii112. [PMID: 28201556 PMCID: PMC5837538 DOI: 10.1093/ndt/gfw287] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 06/18/2016] [Indexed: 11/14/2022] Open
Affiliation(s)
- Friedrich K Port
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Hal Morgenstern
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Department of Urology, Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Brian A Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | | | - Francesca Tentori
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA.,Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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4
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Wong LP. Systems Thinking and Leadership: How Nephrologists Can Transform Dialysis Safety to Prevent Infections. Clin J Am Soc Nephrol 2018; 13:655-662. [PMID: 29567864 PMCID: PMC5968907 DOI: 10.2215/cjn.09740917] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Infections are the second leading cause of death for patients with ESKD. Despite multiple efforts, nephrologists have been unable to prevent infections in dialysis facilities. The American Society of Nephrology and the Centers for Disease Control and Prevention have partnered to create Nephrologists Transforming Dialysis Safety to promote nephrologist leadership and engagement in efforts to "Target Zero" preventable dialysis infections. Because traditional approaches to infection control and prevention in dialysis facilities have had limited success, Nephrologists Transforming Dialysis Safety is reconceptualizing the problem in the context of the complexity of health care systems and organizational behavior. By identifying different parts of a problem and attempting to understand how these parts interact and produce a result, systems thinking has effectively tackled difficult problems in dynamic settings. The dialysis facility is composed of different physical and human elements that are interconnected and affect not only behavior but also, the existence of a culture of safety that promotes infection prevention. Because dialysis infections result from a complex system of interactions between caregivers, patients, dialysis organizations, and the environment, attempts to address infections by focusing on one element in isolation often fail. Creating a sense of urgency and commitment to eradicating dialysis infections requires leadership and motivational skills. These skills are not taught in the standard nephrology or medical director curriculum. Effective leadership by medical directors and engagement in infection prevention by nephrologists are required to create a culture of safety. It is imperative that nephrologists commit to leadership training and embrace their potential as change agents to prevent infections in dialysis facilities. This paper explores the systemic factors contributing to the ongoing dialysis infection crisis in the United States and the role of nephrologists in instilling a culture of safety in which infections can be anticipated and prevented.
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Affiliation(s)
- Leslie P Wong
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
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5
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Nissenson AR. Delivering Better Quality of Care: Relentless Focus and Starting with the End in Mind at DaVita. Semin Dial 2016; 29:111-8. [DOI: 10.1111/sdi.12462] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Allen R. Nissenson
- Office of the Chief Medical Officer; DaVita Healthcare Partners Inc.; El Segundo California
- Department of Medicine; David Geffen School of Medicine at UCLA; Los Angeles California
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6
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Abstract
Four decades after the successful implementation of the ESRD program currently providing life-saving dialysis therapy to >430,000 patients, the definitions of and demands for a high-quality program have evolved and increased at the same time. Through substantial technological advances ESRD care improved, with a predominant focus on the technical aspects of care and the introduction of medications such as erythropoiesis-stimulating agents and active vitamin D for anemia and bone disease management. Despite many advances, the size of the program and the increasingly older and multimorbid patient population have contributed to continuing challenges for providing consistently high-quality care. Medicare's Final Rule of the Conditions for Coverage (April 2008) define the medical director of the dialysis center as the leader of the interdisciplinary team and the person ultimately accountable for quality, safety, and care provided in the center. Knowledge and active leadership with a hands-on approach in the quality assessment and performance improvement process (QAPI) is essential for the achievement of high-quality outcomes in dialysis centers. A collaborative approach between the dialysis provider and medical director is required to optimize outcomes and deliver evidence-based quality care. In 2011 the Centers for Medicare & Medicaid Services introduced a pay-for-performance program-the ESRD quality incentive program (QIP)- with yearly varying quality metrics that result in payment reductions in subsequent years when targets are not achieved during the performance period. Success with the QIP requires a clear understanding of the structure, metrics, and scoring methods. Information on achievement and nonachievement is publicly available, both in facilities (through the facility performance score card) and on public websites (including Medicare's Dialysis Facility Compare). By assuming the leadership role in the quality program of dialysis facilities, the medical director is given an important opportunity to improve patients' lives and effect true change in a patient population dealing with a very challenging chronic disease. This article in the series on the role of the medical director summarizes the medical director's specific role in the quality improvement process in the dialysis facility and the associated requirements and programs, including QAPI and QIP.
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Affiliation(s)
- Brigitte Schiller
- Satellite Healthcare, San Jose, California, and
- Department of Medicine, Division of Nephrology, Stanford University, Palo Alto, California
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7
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Balter P, Artemyev M, Zabetakis P. Methods and challenges for the practical application of Crit-Line™ monitor utilization in patients on hemodialysis. Blood Purif 2015; 39:21-4. [PMID: 25660221 DOI: 10.1159/000368936] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The Crit-Line™ monitor measures relative changes in intravascular blood volume during hemodialysis. The device is also used to monitor hematocrit and oxygen saturation. Using this device to decrease fluid volume has yielded inconsistent results on outcome measures such as hospitalization rates, erythropoietin utilization, and blood pressure reduction. Through a year-long deployment of the Crit-Line™ monitor, the Renal Research Institute (RRI) has shown that outcomes can be improved even in a busy dialysis clinic with attention to the details of how the device is utilized. In this paper, we are proposing areas of focus and methods that if properly implemented should yield improved clinical outcomes. Strong physician approval and enthusiasm coupled with clinical staff support have been shown to be vital to the success of this device in improving clinical outcomes. Even in this setting, inadequately and improperly trained staff have been identified as almost insurmountable impediments to adequate Crit-Line™ use. Our studies have shown that in facilities where staff turnover is high, procedures must be implemented to engage and train new staff immediately upon their arrival on the dialysis floor. Other issues that may lead to improper use of the Crit-Line™ monitor include incorrect target weight assessments, failure of staff to properly monitor patients during the treatment, and the over dependency of saline administration for cramps.
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Affiliation(s)
- Paul Balter
- Renal Research Institute, New York, N.Y., USA
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8
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Siskind E, Alex A, Alexander M, Akerman M, Mathew C, Fishbane L, Thomas J, Israel E, Fana M, Evans C, Godwin A, Agorastos S, Mellace B, Rosado J, Rajendran PP, Krishnan P, Ramadas P, Flecha A, Kiernan L, Morgan RM, Ali N, Sachdeva M, Calderon K, Hong S, Kaur J, Basu A, Nicastro J, Coppa G, Bhaskaran M, Molmenti E. Factors associated with completion of pre-kidney transplant evaluations. Int J Angiol 2014; 23:23-8. [PMID: 24627614 DOI: 10.1055/s-0033-1358661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
This study sought to examine various factors that may prevent transplant candidates from completing their transplant workup prior to listing. We reviewed the records of 170 subjects (cases = 100, controls 70) who were either on dialysis or had less than 20 mL/min creatinine clearance and were therefore candidates for preemptive transplantation. Approximately, 56% of preemptive patients completed their workup, while only 36% of patients on dialysis completed their workup. Our data revealed that factors contributing toward completion of workup included intrinsic motivation (four times more likely), lack of specific medical comorbidities (three times more likely), and preemptive status (two times more likely). Among patients on dialysis, intrinsic motivation (five times more likely) and absence of cardiovascular complications (four times more likely) were associated with completion. When comparing patients on dialysis to patients not on dialysis, there were significant differences between the two groups in distance from home to the transplant center, level of education, and presence of medical comorbidities. We believe that targeted interventions such as timely referral, providing appropriate educational resources, and development of adequate support systems, have the potential to improve workup compliance of patients with advanced chronic kidney disease, including those on dialysis.
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Affiliation(s)
- Eric Siskind
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Asha Alex
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Mohini Alexander
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Meredith Akerman
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Christine Mathew
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Lara Fishbane
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Jisha Thomas
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Ezra Israel
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Melissa Fana
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Cory Evans
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Andrew Godwin
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Stergiani Agorastos
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Barbara Mellace
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Jesus Rosado
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Prejith P Rajendran
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Prathik Krishnan
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Poornima Ramadas
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Antonette Flecha
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Lisa Kiernan
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Ruth M Morgan
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Nicole Ali
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Mala Sachdeva
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Kellie Calderon
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Susana Hong
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Jasmeet Kaur
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Amit Basu
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Jeffrey Nicastro
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Gene Coppa
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Madhu Bhaskaran
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
| | - Ernesto Molmenti
- Departments of Surgery and Medicine, Hofstra North Shore, Long Island Jewish School of Medicine, New York
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Mehrotra R, Agarwal A, Bargman JM, Himmelfarb J, Johansen KL, Watnick S, Work J, McBryde K, Flessner M, Kimmel PL. Dialysis therapies: a National Dialogue. Clin J Am Soc Nephrol 2014; 9:812-4. [PMID: 24458085 DOI: 10.2215/cjn.12601213] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The National Institute of Diabetes, Digestive, and Kidney Diseases-supported Kidney Research National Dialogue asked the scientific community to formulate and prioritize research objectives that would improve our understanding of kidney function and disease. Kidney Research National Dialogue participants identified the need to improve outcomes in ESRD by decreasing mortality and morbidity and enhancing quality of life as high priority areas in kidney research. To reach these goals, we must identify retained toxins in kidney disease, accelerate technologic advances in dialysate composition and devices to remove these toxins, advance vascular access, and identify measures that decrease the burden of disease in maintenance dialysis patients. Together, these research objectives provide a path forward for improving patient-centered outcomes in ESRD.
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Affiliation(s)
- Rajnish Mehrotra
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington;, †Ohio State University, Columbus, Ohio;, ‡University Health Network, Toronto, Ontario, Canada;, §University of California, San Francisco, California;, ‖Oregon Health and Science University, Portland, Oregon;, ¶Emory University, Atlanta, Georgia, *National Institute of Diabetes, Digestive, and Kidney Disease, National Institutes of Health, Bethesda, Maryland
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10
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Dalrymple LS, Johansen KL, Romano PS, Chertow GM, Mu Y, Ishida JH, Grimes B, Kaysen GA, Nguyen DV. Comparison of hospitalization rates among for-profit and nonprofit dialysis facilities. Clin J Am Soc Nephrol 2013; 9:73-81. [PMID: 24370770 DOI: 10.2215/cjn.04200413] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The vast majority of US dialysis facilities are for-profit and profit status has been associated with processes of care and outcomes in patients on dialysis. This study examined whether dialysis facility profit status was associated with the rate of hospitalization in patients starting dialysis. DESIGN, SETTING, PARTICIPANTS, & METHODS This was a retrospective cohort study of Medicare beneficiaries starting dialysis between 2005 and 2008 using data from the US Renal Data System. All-cause hospitalization was examined and compared between for-profit and nonprofit dialysis facilities through 2009 using Poisson regression. Companion analyses of cause-specific hospitalization that are likely to be influenced by dialysis facility practices including hospitalizations for heart failure and volume overload, access complications, or hyperkalemia were conducted. RESULTS The cohort included 150,642 patients. Of these, 12,985 (9%) were receiving care in nonprofit dialysis facilities. In adjusted models, patients receiving hemodialysis in for-profit facilities had a 15% (95% confidence interval [95% CI], 13% to 18%) higher relative rate of hospitalization compared with those in nonprofit facilities. Among patients receiving peritoneal dialysis, the rate of hospitalization in for-profit versus nonprofit facilities was not significantly different (relative rate, 1.07; 95% CI, 0.97 to 1.17). Patients on hemodialysis receiving care in for-profit dialysis facilities had a 37% (95% CI, 31% to 44%) higher rate of hospitalization for heart failure or volume overload and a 15% (95% CI, 11% to 20%) higher rate of hospitalization for vascular access complications. CONCLUSIONS Hospitalization rates were significantly higher for patients receiving hemodialysis in for-profit compared with nonprofit dialysis facilities.
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Affiliation(s)
- Lorien S Dalrymple
- Departments of Medicine,, *Public Health Sciences, and, ††Biochemistry and Molecular Medicine, University of California, Davis, California;, †San Francisco Department of Veterans Affairs Medical Center, San Francisco, California;, Departments of ‡Medicine and, ‖Epidemiology, and Biostatistics, University of California, San Francisco, California;, §United States Renal Data System Special Studies Center, Stanford, California;, ¶Department of Medicine, Stanford University School of Medicine, Palo Alto, California, ‡‡Department of Medicine, University of California Irvine, California
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11
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Nissenson AR. Improving outcomes for ESRD patients: shifting the quality paradigm. Clin J Am Soc Nephrol 2013; 9:430-4. [PMID: 24202130 DOI: 10.2215/cjn.05980613] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Allen R Nissenson
- David Geffen School of Medicine, University of California, Los Angeles, California
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12
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Abstract
BACKGROUND Dialysis and its complications were debated recently. There was lack of an adjuvant renal replacement method to reduce the complications of patients with chronic renal failure and dialysis itself. MATERIALS AND METHODS In this article, we reviewed the role of thermal sweating in treating of the patients with chronic renal failure, and the role of traditional Chinese medicine in the therapy of chronic kidney diseases. RESULTS Thermal sweating can reduce interdialytic weight gain and improve the patients' blood pressure; Chinese herbal medicine can promote the excretion of uremic toxicities and relieve the skin disorders of these patients. CONCLUSIONS Traditional Chinese medicine-mediated hot bath could be one of the adjuvant renal replacement methods.
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Affiliation(s)
- Ting Ye
- Department of Nephrology, Second Affiliated Hospital, Nanchang University , Nanchang , PR China and
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13
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Coelho AP, Sá HO, Diniz JA, Dussault G. The integrated management for renal replacement therapy in Portugal. Hemodial Int 2013; 18:175-84. [DOI: 10.1111/hdi.12064] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Anabela P. Coelho
- Department of Quality in Health; Directorate-General of Health; Lisbon Portugal
| | - Helena O. Sá
- Dialysis Unit; Coimbra University and Hospital Centre; Coimbra Portugal
| | - José A. Diniz
- Department of Quality in Health; Directorate-General of Health; Lisbon Portugal
| | - Gilles Dussault
- Health Systems Unit; Institute of Tropical Medicine and Hygiene; Lisbon Portugal
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14
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Bansal N, He C, Murphy DP, Johansen KL, Hsu CY. Timing of preemptive vascular access placement: do we understand the natural history of advanced CKD?: an observational study. BMC Nephrol 2013; 14:115. [PMID: 23714195 PMCID: PMC3671964 DOI: 10.1186/1471-2369-14-115] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 05/21/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Little is known about the targets and expectations of practicing nephrologists with regard to timing of preemptive AV access surgery and how these relate to actual observed practice patterns in clinical care. METHODS We administered a 8-question survey to assess nephrologists' expectations for preemptive vascular access placement to 53 practicing nephrologists in California. We performed a retrospective chart review of 116 patients who underwent preemptive vascular access placement at a large academic medical center and examined progression to ESRD. RESULTS According to our survey of nephrologists, most aimed to have preemptive vascular access created about 6 months prior to start of ESRD or when the chances of ESRD within the next year is two-thirds or greater. The estimated GFR level at which they believe match these conditions is approximately 18 ml/min/1.73 m2. Among the 116 patients with CKD who underwent preemptive vascular access creation, the mean estimated GFR at the time of access creation was 16.1 (6.8) ml/min/1.73 m2. Only 57 out of the 116 patients (49.1%) patients initiated maintenance HD within 1 year after surgery. CONCLUSIONS In our study, most nephrologists aim for preemptive vascular access surgery approximately 6 months prior to the start of HD. However in fact, only approximately 50% of patients who underwent preemptive vascular access surgery started HD within 1 year. Better tools are needed to predict the natural history of advanced CKD.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, University of California, San Francisco, 521 Parnassus Ave, Box 0532, San Francisco, CA, 94143, USA
| | - Chenyin He
- Division of Nephrology, University of California, San Francisco, 521 Parnassus Ave, Box 0532, San Francisco, CA, 94143, USA
| | - Daniel P Murphy
- Division of Nephrology, University of California, San Francisco, 521 Parnassus Ave, Box 0532, San Francisco, CA, 94143, USA
| | - Kirsten L Johansen
- Division of Nephrology, University of California, San Francisco, 521 Parnassus Ave, Box 0532, San Francisco, CA, 94143, USA
| | - Chi-yuan Hsu
- Division of Nephrology, University of California, San Francisco, 521 Parnassus Ave, Box 0532, San Francisco, CA, 94143, USA
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15
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Stivelman JC. Monitoring quality of care at dialysis facilities: a case for regulatory parsimony--and beyond. Clin J Am Soc Nephrol 2012; 7:1673-81. [PMID: 22822012 DOI: 10.2215/cjn.01750212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
With the issuance of the new Conditions for Coverage in 2008 and the implementation of the Prospective Payment System in 2011, the Centers for Medicare & Medicaid Services has fundamentally altered the regulatory landscape of quality in the ESRD program. Although these changes-largely through use of tools comparing individual facility performance to regional and national quality expectations-have increased facility accountability for the quality of patient care in many quarters, they have also complicated both substance and process of facility adherence to quality rules in that component of the program. This editorial critically assesses the main quality tools now in use for dialysis facilities and reviews the issues arising from their conjoint use. A scheme for improving the effectiveness of each quality tool is proposed, and an assessment of their future value and effectiveness in quality improvement is offered.
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Affiliation(s)
- John C Stivelman
- Northwest Kidney Centers; Division of Nephrology, University of Washington School of Medicine, Seattle, WA 98122, USA.
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