Association of residual urine output with mortality, quality of life, and inflammation in incident hemodialysis patients: the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study.

BACKGROUND: Residual kidney function (RKF) is associated with improved survival in peritoneal dialysis patients, but its role in hemodialysis patients is less well known. Urine output may provide an estimate of RKF. The aim of our study is to determine the association of urine output with mortality, quality of life (QOL), and inflammation in incident hemodialysis patients. STUDY DESIGN: Nationally representative prospective cohort study. SETTING & PARTICIPANTS: 734 incident hemodialysis participants treated in 81 clinics; enrollment, 1995-1998; follow-up until December 2004. PREDICTOR: Urine output, defined as producing at least 250 mL (1 cup) of urine daily, ascertained using questionnaires at baseline and year 1. OUTCOMES & MEASUREMENTS: Primary outcomes were all-cause and cardiovascular mortality, analyzed using Cox regression adjusted for demographic, clinical, and treatment characteristics. Secondary outcomes were QOL, inflammation (C-reactive protein and interleukin 6 levels), and erythropoietin (EPO) requirements. RESULTS: 617 of 734 (84%) participants reported urine output at baseline, and 163 of 579 (28%), at year 1. Baseline urine output was not associated with survival. Urine output at year 1, indicating preserved RKF, was independently associated with lower all-cause mortality (HR, 0.70; 95% CI, 0.52-0.93; P = 0.02) and a trend toward lower cardiovascular mortality (HR, 0.69; 95% CI, 0.45-1.05; P = 0.09). Participants with urine output at baseline reported better QOL and had lower C-reactive protein (P = 0.02) and interleukin 6 (P = 0.03) levels. Importantly, EPO dose was 12,000 U/wk lower in those with urine output at year 1 compared with those without (P = 0.001). LIMITATIONS: Urine volume was measured in only a subset of patients (42%), but agreed with self-report (P < 0.001). CONCLUSIONS: RKF in hemodialysis patients is associated with better survival and QOL, lower inflammation, and significantly less EPO use. RKF should be monitored routinely in hemodialysis patients. The development of methods to assess and preserve RKF is important and may improve dialysis care.

Accuracy of patients' reports of comorbid disease and their association with mortality in ESRD.

BACKGROUND: Patient awareness of chronic diseases is low. Unawareness may represent poor understanding of chronic illness and may be associated with poor outcomes in patients with end-stage renal disease (ESRD). STUDY DESIGN: Concurrent prospective national cohort study. SETTING & PARTICIPANTS: Incident hemodialysis and peritoneal dialysis patients enrolled in the Choices for Healthy Outcomes in Caring for ESRD Study and followed up until 2004. PREDICTOR: Inaccurate patient self-report of 8 comorbid diseases compared with the medical record. OUTCOMES & MEASUREMENTS: All-cause mortality was the primary outcome. Cox proportional hazard models were used to assess the contribution of demographics and clinical measures in the relation of inaccurate self-report to mortality. RESULTS: In 965 patients, the proportion of inaccurate self-reporters ranged from 3% for diabetes mellitus to 35% for congestive heart failure. Generally, inaccurate self-reporters were older and had more chronic diseases. Greater risk of death was found for inaccurate self-reporters of ischemic heart disease (hazard ratio [HR], 1.34; 95% confidence interval, 1.12 to 1.59; P = 0.001), coronary intervention (HR, 1.46; 95% confidence interval, 1.08 to 1.97; P = 0.01), and chronic obstructive pulmonary disease (HR, 1.40; 95% confidence interval, 1.14 to 1.70; P = 0.001). The greater risk of death remained significant for chronic obstructive pulmonary disease (HR, 1.36; 95% confidence interval, 1.11 to 1.66; P = 0.003) after adjustment for age, sex, and race. In patients receiving peritoneal dialysis, greater risk of death (HR, 2.06; 95% confidence interval, 1.34 to 3.15; P = 0.001) was found for inaccurate self-reporters of ischemic heart disease. LIMITATIONS: Includes potential for residual confounding, medical record error, misclassification of patient accuracy of self-report, and low inaccurate self-report of some chronic diseases, reducing the power to measure associations. CONCLUSIONS: Accuracy of self-report depends on the specific comorbid disease. Patients with ESRD, especially those receiving peritoneal dialysis, who inaccurately report heart disease may be less aware of their chronic comorbid disease and may be at greater risk of mortality compared with those who accurately report their comorbid disease.

Attainment of clinical performance targets and improvement in clinical outcomes and resource use in hemodialysis care: a prospective cohort study.

BACKGROUND: Clinical performance targets are intended to improve patient outcomes in chronic disease through quality improvement, but evidence of an association between multiple target attainment and patient outcomes in routine clinical practice is often lacking. METHODS: In a national prospective cohort study (ESRD Quality, or EQUAL), we examined whether attainment of multiple targets in 668 incident hemodialysis patients from 74 U.S. not-for-profit dialysis clinics was associated with better outcomes. We measured whether the following accepted clinical performance targets were met at 6 months after study enrollment: albumin (> or =4.0 g/dl), hemoglobin (> or =11 g/dl), calcium-phosphate product (<55 mg2/dl2), dialysis dose (Kt/V> or =1.2), and vascular access type (fistula). Outcomes included mortality, hospital admissions, hospital days, and hospital costs. RESULTS: Attainment of each of the five targets was associated individually with better outcomes; e.g., patients who attained the albumin target had decreased mortality [relative hazard (RH) = 0.55, 95% confidence interval (CI), 0.41-0.75], hospital admissions [incidence rate ratio (IRR) = 0.67, 95% CI, 0.62-0.73], hospital days (IRR = 0.61, 95% CI, 0.58-0.63), and hospital costs (average annual cost reduction = 3,282 dollars, P = 0.002), relative to those who did not. Increasing numbers of targets attained were also associated, in a graded fashion, with decreased mortality (P = 0.030), fewer hospital admissions and days (P < 0.001 for both), and lower costs (P = 0.029); these trends remained statistically significant for all outcomes after adjustment (P < 0.001), except cost, which was marginally significant (P = 0.052). CONCLUSION: Attainment of more clinical performance targets, regardless of which targets, was strongly associated with decreased mortality, hospital admissions, and resource use in hemodialysis patients.

Comparing the risk for death with peritoneal dialysis and hemodialysis in a national cohort of patients with chronic kidney disease.

BACKGROUND: The influence of type of dialysis on survival of patients with end-stage renal disease (ESRD) is controversial. OBJECTIVE: To compare risk for death among patients with ESRD who receive peritoneal dialysis or hemodialysis. DESIGN: Prospective cohort study. SETTING: 81 dialysis clinics in 19 U.S. states. PATIENTS: 1041 patients starting dialysis (274 patients receiving peritoneal dialysis and 767 patients receiving hemodialysis) at baseline. MEASUREMENTS: Patients were followed for up to 7 years and censored at transplantation or loss to follow-up. Cox proportional hazards regression stratified by clinic was used to compare the risk for death with peritoneal dialysis versus hemodialysis. RESULTS: Twenty-five percent of patients undergoing peritoneal dialysis and 5% of hemodialysis patients switched type of dialysis. After adjustment, the risk for death did not differ between patients undergoing peritoneal dialysis and those undergoing hemodialysis during the first year (relative hazard, 1.39 [95% CI, 0.64 to 3.06]), but the risk became significantly higher among those undergoing peritoneal dialysis in the second year (relative hazard, 2.34 [CI, 1.19 to 4.59]). After stratification, the survival rate was no different for patients who had the highest propensity of being initially treated with peritoneal dialysis. Results were consistent with adjustment based on a propensity score model and in sensitivity analyses that used as-treated models and models in which switches in type of dialysis were treated as treatment failures. Results were similar but stronger in analyses that were restricted to patients who were treated only in clinics offering both types of dialysis. LIMITATIONS: Patients were not randomly assigned to their initial type of dialysis. Also, more patients undergoing peritoneal dialysis than hemodialysis switched type of dialysis over time, and the reason for switching was often a consequence of the technique. CONCLUSIONS: The risk for death in patients with ESRD undergoing dialysis depends on dialysis type. Further studies are needed to evaluate a possible survival benefit of a timely change from peritoneal dialysis to hemodialysis.

How strong are patients' preferences in choices between dialysis modalities and doses?

BACKGROUND: How dialysis patients feel about their treatment may influence how they respond to information suggesting that survival is better with a higher dose or different treatment modality. We assessed the strength of dialysis patients' preferences for their current treatment modality versus other modalities, how differences in survival between modalities and doses could influence preferences, and whether preferences differ by patient characteristics. METHODS: We measured preference values for current health on dialysis therapy and for standardized descriptions of dialysis modalities and doses by using a sample of dialysis patients in Maryland and Massachusetts and a time trade-off technique scaled between 0 (death) and 1 (perfect health). RESULTS: We interviewed 109 patients on hemodialysis therapy, 57 patients on continuous ambulatory peritoneal dialysis (CAPD), and 22 patients on continuous cycling peritoneal dialysis (CCPD). Hemodialysis, CAPD, and CCPD patients had similar preference values for current health (mean, 0.69, 0.74, and 0.70, respectively; P > 0.1) and lower preference values for alternative modalities (eg, mean of 0.55 assigned to CAPD by hemodialysis patients). More than 75% of patients would choose a high dose over a lower dose of dialysis if it increased length of survival by 20%, but more than 30% would not switch modality, even if it increased survival by 100%. The only characteristic associated with a difference in preference values was depression, with weaker preferences among those with mild to moderate depressive mood. CONCLUSION: Dialysis patients have strong preferences for their current modality and are more likely to accept a higher dose of dialysis than switch modality to increase survival. Physicians should talk with patients about the modality and dose they prefer because preferences cannot be predicted by patient characteristics.

Cost-quality trade-offs in dialysis care: a national survey of dialysis facility administrators.

Dialysis facilities face important trade-offs between cost and quality under constrained capitated reimbursement. How management at dialysis facilities makes decisions affecting cost and quality of care and views opportunities and threats is unknown. We conducted a national survey of dialysis facility administrators. We asked administrators what changes they would make in response to increases or decreases in reimbursement, their views on linking dialysis care payment to quality-of-care measures, and their views on providing patients with treatment options and outcomes information. One hundred fifty-seven of 280 dialysis facility administrators (56%) responded. If dialysis reimbursement were to increase by 20%, the five most common responses were to: improve patient education programs (62% of respondents), improve facility amenities (42%), purchase new equipment (30%), provide more money for staff salaries (28%), and increase number of nursing staff (21%). Conversely, if dialysis reimbursement were to decrease by 20%, the most common responses were to: limit staff salary (45% of respondents), decrease nursing staff (41%), not replace dialysis equipment (43%), increase dialyzer reuse (37%), and return less to investors (36%). Differences in rank order of responses were observed according to professional training of the administrator and profit status of the facility. Administrators uniformly believe that it is very acceptable to provide facility-specific outcomes data to the public, as well as information on modalities of treatment provided by facilities. However, administrators varied in their views regarding whether reimbursement should be based on quality by using a process-of-care measure, such as the average dose of dialysis, or an outcome-of-care measure, such as case-mix-adjusted mortality rates. We conclude that increases in facility reimbursement generally would be used by dialysis facility administrators for the benefit of patients, whereas decreases (or inflation erosion) in payment rates might compromise staffing. US dialysis administrators support sharing treatment options and outcomes information with patients, but appear to be ambivalent with regard to linking reimbursement to adequacy of dialysis or patient outcomes. These results have important implications regarding proposed changes in the US capitated dialysis payment rate and current efforts to empower consumers of dialysis care.

Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis.

CONTEXT: In light of conflicting evidence of differential effects of dialysis modality on survival, patient experience becomes a more important consideration in choosing between hemodialysis and peritoneal dialysis. OBJECTIVE: To compare patient satisfaction with hemodialysis and peritoneal dialysis in a cohort of patients who have recently begun dialysis. DESIGN AND SETTING: Cross-sectional survey at enrollment in a prospective inception cohort study of patients who recently started dialysis at 37 dialysis centers participating in the Choices for Healthy Outcomes in Caring for End-stage Renal Disease (CHOICE) study, a national multicenter study of dialysis outcomes, from October 1995 to June 1998. PATIENTS: Of 736 enrolled incident dialysis patients, 656 (89%) returned a satisfaction questionnaire after an average of 7 weeks of dialysis. MAIN OUTCOME MEASURE: Data collected from a patient-administered questionnaire including 3 overall ratings and 20 items rating specific aspects of dialysis care. RESULTS: Patients receiving peritoneal dialysis were much more likely than those receiving hemodialysis to give excellent ratings of dialysis care overall (85% vs 56%, respectively; relative probability, 1.46 [95% confidence interval, 1.31-1.57]) and significantly more likely to give excellent ratings for each specific aspect of care rated. The 3 items with the greatest differences were in the domain of information provided (average of information items: peritoneal dialysis [69% excellent] vs hemodialysis [30% excellent]). The smallest differences were in ratings of accuracy of information from the nephrologist, response to pain, amount of fluid removed, and staff availability in an emergency. Adjustment for patient age, race, education, health status, marital status, employment status, distance from the center, and time since starting dialysis did not reduce the differences between peritoneal dialysis and hemodialysis patients. CONCLUSIONS: After several weeks of initiating dialysis, patients receiving peritoneal dialysis rated their care higher than those receiving hemodialysis. These findings indicate that clinicians should give patients more information about the option of peritoneal dialysis.

MYH9 is associated with nondiabetic end-stage renal disease in African Americans.

As end-stage renal disease (ESRD) has a four times higher incidence in African Americans compared to European Americans, we hypothesized that susceptibility alleles for ESRD have a higher frequency in the West African than the European gene pool. We carried out a genome-wide admixture scan in 1,372 ESRD cases and 806 controls and found a highly significant association between excess African ancestry and nondiabetic ESRD (lod score = 5.70) but not diabetic ESRD (lod = 0.47) on chromosome 22q12. Each copy of the European ancestral allele conferred a relative risk of 0.50 (95% CI = 0.39-0.63) compared to African ancestry. Multiple common SNPs (allele frequencies ranging from 0.2 to 0.6) in the gene encoding nonmuscle myosin heavy chain type II isoform A (MYH9) were associated with two to four times greater risk of nondiabetic ESRD and accounted for a large proportion of the excess risk of ESRD observed in African compared to European Americans.

Frequency of patient-physician contact in chronic kidney disease care and achievement of clinical performance targets.

OBJECTIVE: To examine whether the frequency of physician contact is associated with accepted quality of care measures reflecting clinical performance in chronic kidney disease patients. DESIGN: Prospective cohort study of end-stage renal disease patients begun in 1995, followed for 2.5 years. SETTING: 76 not-for-profit US dialysis clinics. STUDY PARTICIPANTS: 678 incident hemodialysis patients for whom we had information on average frequency of patient-physician contact at each clinic (low, monthly or less frequent; intermediate, between monthly and weekly; high, more than weekly), determined by clinic survey. MAIN OUTCOME MEASURES: Achievement of accepted 6 month clinical performance targets of albumin (> or =3.5 g/dl), calcium-phosphate (Ca-P) product (<60 mg(2)/dl(2)), dialysis dose (Kt/V > or = 1.2), vascular access type (fistula), and hemoglobin (> or =11 g/dl). RESULTS: By logistic regression, patients treated at clinics reporting less frequent physician contact had lower odds of achieving most targets, statistically significantly for albumin [low, adjusted odds ratio (OR) = 0.83, 95% confidence interval (CI), 0.55-1.25; intermediate, adjusted OR = 0.62, 95% CI, 0.42-0.93; reference, high] and dialysis dose (low, adjusted OR = 0.26, 95% CI, 0.08-0.89; intermediate, adjusted OR = 0.67, 95% CI, 0.20-2.27); however, they had greater odds of achieving the hemoglobin target (low, adjusted OR = 1.94, 95% CI, 1.24-3.04; intermediate, adjusted OR = 1.89, 95% CI, 1.27-2.83). Additionally, the number of targets reached was statistically significantly lower in the monthly or less group (adjusted OR = 0.43, 95% CI, 0.20-0.94). CONCLUSIONS: More frequent patient-physician contact is positively associated with the achievement of clinical performance targets in chronic kidney disease care.

Frequency of sit-down patient care rounds, attainment of clinical performance targets, hospitalization, and mortality in hemodialysis patients.

Sit-down patient rounding in hemodialysis units allows providers to focus collectively on each patient's needs and may affect patient outcomes positively. The objective was to examine whether sit-down rounding practices improve patient outcomes in a cohort of 644 adult hemodialysis patients from 75 outpatient dialysis clinics in 17 states throughout the United States who survived at least 6 mo after enrollment (average follow-up, 3.2 yr). Achievement of well-accepted 6-mo clinical performance targets of albumin (> or =3.5 g/dl), hemoglobin (> or =11 g/dl), calcium-phosphate product (<60 mg(2)/dl(2)), dose (Kt/V > or =1.2), and vascular access type (fistula); hospitalization rates; and all-cause mortality served as outcomes. Monthly or more frequent sit-down rounds were conducted in 36 (48%) of 75 clinics, representing 287 (45%) of 644 patients. More frequent sit-down rounds were positively associated with an increased chance of achieving the 6-mo clinical performance target for albumin compared with less frequent rounds (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.12 to 3.15); patients who were treated at clinics with more frequent rounds also had nearly twice the odds of achieving more of the five performance targets (OR, 1.95; 95% CI, 1.11 to 3.42). After adjustment for potential confounders, patients who were treated at clinics with more frequent sit-down rounds were 32% less likely to be hospitalized (incidence rate ratio, 0.68; 95% CI, 0.51 to 0.91), had fewer hospital days per year (rate ratio, 0.50; 95% CI, 0.26 to 0.98), and were 29% less likely to die (relative hazard, 0.71; 95% CI, 0.53 to 0.95). Adjustment for some clinical performance targets attenuated the statistical significance of the association with hospitalization. More frequent sit-down rounds in hemodialysis units are associated with better patient outcomes, including an increased chance of meeting the albumin clinical performance target, decreased hospitalization, and decreased risk of mortality. This association may be due to the positive effect of collaborative discussion by the patient care team of short- and long-term care goals for individual patients.

Frequency of patient-physician contact and patient outcomes in hemodialysis care.

There is little evidence supporting the widespread belief that regular patient-physician contact in chronic disease management leads to better patient outcomes. The objective of this study was to examine the relationship of the frequency of patient-physician contact with several patient outcomes in a prospective cohort study begun in 1995 of incident hemodialysis patients treated at 75 US dialysis clinics. Average frequency of patient-physician contact at each clinic was determined by clinic survey (low, monthly or less frequent; intermediate, between monthly and weekly; high, more than weekly). The authors used logistic, Poisson, and Cox proportional hazards regression analyses to assess the relationship between contact and satisfaction, quality of life, patient adherence, hospitalizations, and mortality. Of 735 hemodialysis patients, 14.3% were treated at clinics with high frequency of contact, 65.2% intermediate, and 20.5% low. Patients treated at clinics reporting less frequent physician contact had lower odds of rating the frequency at which they saw a nephrologist excellent (low: adjusted OR = 0.39, 95% CI, 0.23-0.67; intermediate: adjusted OR = 0.57, 95% CI, 0.37-0.87; reference, high) and greater odds of nonadherence (low: adjusted OR = 2.89, 95% CI, 1.01-8.29; intermediate: adjusted OR = 1.58, 95% CI, 0.78-3.19). However, patient survival did not vary by frequency of physician contact (low: adjusted RH = 0.87, 95% CI, 0.53-1.44; intermediate: adjusted RH = 1.33, 95% CI, 0.82-2.13), nor did patients' overall ratings of care, hospitalization rates, or quality of life measures. Although less frequent patient-physician contact was associated with lower patient satisfaction with that contact and patient nonadherence, it was not associated with several other outcomes of care. Future studies are needed to assess the individual frequency and nature of physician contact over time, including total time spent with the patient and quality of the interaction, to guide the provision of patient-centered and cost-effective care.