Reaching More Quality-of-Care Targets Predicts Better Dialysis Outcomes

Marlene Busko

October 13, 2006

October 13, 2006 — Patients on long-term hemodialysis who reached 4 or more of care-guideline targets — recommended levels of hemoglobin, albumin, and Kt/V urea and the presence of a fistula for venous access — were less likely to be hospitalized or die during a one-year follow-up. These findings are based on an analysis of data from a representative sample of all US patients receiving chronic hemodialysis.

"These intermediate outcomes do appear to be associated with hard outcomes — hospitalization or mortality rates," said lead author Michael V. Rocco, MD, from Wake Forest University School of Medicine, in Winston-Salem, North Carolina. "This study indicates that you really need to focus on more than 1 variable at a time."

The authors explain that yearly mortality rates among patients in the US who are receiving long-term hemodialysis have remained persistently high, around 15% to 20%, so it is important to identify potentially modifiable patient risk factors. On the other hand, they note that during the past decade there have been substantial improvements in individual variables of dialysis care, after the Centers for Medicare & Medicaid Services (CMS) started conducting a national program to improve dialysis care. Most studies have looked at outcomes using single measures of performance, however. The team sought to determine whether patients who attained 4 or more of intermediate clinical-performance measures for hemodialysis care were less likely to be hospitalized or die at 1 year than patients whose care did not meet those targets.

The article is published in the October 3 issue of Annals of Internal Medicine.

Random Sample of 5% of US Dialysis Patients

The study data came from the CMS ESRD Clinical Performance Measures Project, which collects data every year from a 5% random sample of all US patients receiving long-term hemodialysis. The team analyzed data from 1999 and 2000 from 15,287 patients treated at 2668 dialysis centers.

They examined whether patients met the following 4 intermediate-outcome targets:

  • Mean Kt/V urea value of 1.2 or greater.

  • Mean hemoglobin value of 110 g/L or greater.

  • Mean serum albumin level of 40 g/L or greater or 37 g/L or greater (by the bromcresol green or bromcresol purple laboratory methods, respectively).

  • Use of an arteriovenous fistula for venous access.

Most Patients Met Only 2 or Fewer Care Targets

During the 1-year follow-up period, more than half of the study patients (54.7%) were hospitalized and 20% died. A high proportion (69%) of this nationally representative sample of patients receiving chronic hemodialysis achieved recommended therapeutic targets for only 2 or fewer of the quality indicators.

Attainment of Intermediate Performance Targets
Targets Met*
% of Patients, n = 15,287
*Targets = hemoglobin > 110 g/L; albumin > 40g/L or 37 g/L (bromcresol green or purple test, respectively); Kt/V urea > 1.2; and presence of a fistula for venous access.

Increased Risk With Failure to Meet Multiple Targets

Compared with patients who met all 4 targets, those who met fewer targets were more likely to be hospitalized or die within the following year. For each additional guideline-based indicator that was not met, the increase in the hazard ratio for death was 70% to 90% and the increase in the hazard ratio for hospitalization was 10% to 30%.

Outcome Hazard Ratios (95% CI), Meeting 0 to 3 vs 4 Targets
Targets Met
4.6 (3.3 – 6.4)
1.6 (1.4 – 1.9)
3.5 (2.6 – 4.7)
1.5 (1.3 – 1.7)
2.6 (1.9 – 3.5)
1.3 (1.1 – 1.5)
1.9 (1.4 – 2.6)
1.1 (0.98 – 1.3)
*Targets = hemoglobin > 110 g/L; albumin > 40g/L or 37 g/L (bromcresol green or purple test, respectively); Kt/V urea > 1.2; and presence of a fistula for venous access.

Still Room for Improvement

The group writes that study limitations include the fact that only a median of 2 patients per center were examined. The study was unable to determine whether patient factors (comorbid medical conditions or socioeconomic factors) or poor care explained why the patients did not meet the quality-of-care measures.

They note that the high prevalence of patients who did not meet clinical targets is "surprising," given that over the past decade they and others have observed substantial improvements in individual variables, such as dialysis dose adequacy, control of anemia, and presence of a fistula for vascular access, although serum albumin levels have not changed much.

"Although 3 of the 4 clinical performance measures have improved in the past 10 years, there is still room for additional improvement individually in measures of care and in the quality improvement process used to remediate less-than-optimal outcomes," they conclude.

"This study suggests that if future trials are done in patients with end-stage renal disease, there should be efforts made to try to improve multiple outcome measures instead of just 1 measure," Dr. Rocco said.

Dr. Rocco has received honoraria from Amgen and NxStage. Coauthor Wiliam M. McLellan, MD, from Emory University, in Atlanta, Georgia, has received honoraria from Amgen, Ortho Biotech, and Roche.

Ann Intern Med. 2006;145:512-519.


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