Roadmaps to green nephrology: a mediterranean point of view.

PURPOSE OF REVIEW: Green nephrology is a movement whose aim is to find ways to reduce the environmental impact of kidney care. The question is of particular concern in this field since haemodialysis is one of the major contributors to waste generation, energy use and water consumption in healthcare. Although several ways for improving sustainability have been advocated, they are all context sensitive. This review aims to analyse the interventions that have been proposed to improve the ecologic sustainability and reduce the carbon footprint of nephrology care adapting to specific settings, and taking advantage of local expertise. RECENT FINDINGS: Green hospitals are becoming a reality in several high-income settings, thanks to new building guidelines, with greater awareness of climate change and users' demands. Water saving is feasible, and is increasingly done, in different ways (improving hardware, reducing and adapting dialysate flows). Recycling noncontaminated plastic waste is feasible, but is still rarely performed. However, ecological transition has been slow even in high-income countries, while in low and middle-income countries lack of resources limit the ability to cope with the planet's urgent needs. Conversely, where man-power cost is low, some time-consuming tasks, such as separation of various components for recycling may be affordable. Theoretically, implementation of all clinical tasks aiming to avoid or retard dialysis, should be a priority. SUMMARY: There is no single roadmap for achieving green nephrology. Each setting should start from those feasible interventions most in line with its specific needs and priorities.

Safety and efficacy of COVID-19 vaccines in patients on dialysis: a multicentre cohort study in Italy.

BACKGROUND: The aim of this study was to evaluate the efficacy and safety of COVID-19 vaccines in patients undergoing haemodialysis in Italy compared to the general population. METHODS: In this cohort study, 118 dialysis centres from 18 Italian Regions participated. Individuals older than 16 years on dialysis treatment for at least 3 months, who provided informed consent were included. We collected demographic and clinical information, as well as data on vaccination status, hospitalisations, access to intensive care units and adverse events. We calculated the incidence, hospitalisation, mortality, and fatality rates in the vaccinated dialysis cohort, adjusted for several covariates. The incidence rates of infection in the dialysis cohort and the general population were compared through Standardised Incidence Rate Ratio. RESULTS: The study included 6555 patients vaccinated against SARS-CoV-2 infection according to the schedule recommended in Italy. Between March 2021 and May 2022, there were 1096 cases of SARS-CoV-2 infection, with an incidence rate after completion of the three-dose vaccination cycle of 37.7 cases per 100 person-years. Compared to the general population, we observed a 14% reduction in the risk of infection for patients who received three vaccine doses (Standardised Incidence Rate Ratio: 0.86; 95% Confidence Interval: 0.81-0.91), whereas no statistically significant differences were found for COVID-19-related hospitalisations, intensive care unit admissions or death. No safety signals emerged from the reported adverse events. CONCLUSIONS: The vaccination program against SARS-CoV-2 in the haemodialysis population showed an effectiveness and safety profile comparable to that seen in the general population.

Increase of continuous treatments and regional citrate anticoagulation during renal replacement therapy in the ICUs of the North-West of Italy from 2007 to 2015.

BACKGROUND: Few reports have addressed the change in renal replacement therapy (RRT) management in the Intensive care Units (ICUs) over the years in western countries. This study aims to assess the trend of dialytic practice in a 4.5-million population-based study of the northwest of Italy. METHODS: A nine-year survey covering all the RRT provided in the ICUs. Consultant nephrologists of the 26 Nephrology and Dialysis centers reported their activities in the years 2007, 2009, 2012, and 2015. RESULTS: From 2007 to 2015 the patients treated increased from 1042 to 1139, and the incidence of RRT from 254 to 263 cases/10^6 inhabitants. The workload for dialysis center was higher in the larger hub hospitals. RRT for acute kidney injury (AKI), continuation of treatment in chronically dialyzed patients, or extrarenal indications accounted for about the stable rate of 70, 25 and 5% of all RRT sessions, respectively. Continuous modality days increased from 2731 days (39.5%) in 2007 to 5076 (70.6%) in 2015, when the continuous+prolonged treatment days were 6880/7196 (95.6% of total days). As to RRT timing, in 2015 only the classical clinical criteria, and no K-DIGO stage were adopted by most Centers. As to RRT interruption, in 2015 urine volume was the first criterion. Implementation of citrate anticoagulation (RCA) for RRT patients significantly increased from 2.8% in 2007 to 30.9% in 2015, when it was applied in all 26 Centers. CONCLUSIONS: From 2007 to 2015, current practice has changed towards shared protocols, with increasing continuous modality and RCA implementation.

Estimating hospital inpatient cost-savings with sucroferric oxyhydroxide in patients on chronic hemodialysis in five European countries: a cost analysis.

AIMS: Hyperphosphatemia is common among patients with advanced chronic kidney disease (CKD) undergoing dialysis. The iron-based phosphate binder (PB), sucroferric oxyhydroxide (SO), has a low daily pill burden and is indicated for the control of serum phosphorus in these patients. In a retrospective database study, hemodialysis patients switched to long-term SO therapy had fewer hospitalizations compared with patients switched to other PB therapies. This economic analysis aimed to quantify potential cost-savings of reduced hospitalizations associated with SO for healthcare systems in five European countries. MATERIALS AND METHODS: All-cause hospital admissions incidence data were sourced from a real-world retrospective database study comparing adult, in-center hemodialysis patients maintained on 2 years of SO therapy (mSO) versus patients who discontinued SO (dSO) within 90 days of their first prescription and switched to other PBs. A literature search was conducted to determine the cost per hospital admission for dialysis patients in the healthcare setting of each European country. A cost-model combined the incidence rate of all-cause hospital admissions and the cost per admission to estimate the country-specific inpatient costs for the mSO and dSO groups. RESULTS: Annual inpatient cost-savings per patient in the mSO group versus the dSO group were €1,201, €2,097, €2,059, €1,512, and €3,068 in France, Germany, Italy, Spain, and the UK, respectively. When annual PB drug costs per patient were considered, the net annual economic cost-savings per patient were €327, €1,585, €1,022, €1,100, and €2,204, respectively. LIMITATIONS: Hospital admissions data used in the analysis were observational in nature and derived from a US hemodialysis patient population; the effect of SO therapy on hospitalization rates for US and European hemodialysis patients may differ. The analysis did not consider indirect healthcare costs associated with hospitalizations. CONCLUSION: SO therapy may offer substantial inpatient cost-savings by reducing all-cause hospital admissions attributable to uncontrolled hyperphosphatemia.

Case series of six kidney transplanted patients with COVID-19 pneumonia treated with tocilizumab.

Few reports described the outcome of kidney transplanted patients (KTs) affected by COVID-19 treated with interleukin-6 receptor inhibitor tocilizumab (TCZ). We report our case series of 6 KTs with COVID-19 pneumonia who received TCZ: All were of male gender, with a mean age of 55.5 ± 8.4 years, a median time from transplantation of 3611 days (1465-5757); 5/6 had cardiovascular comorbidities, 1/6 had diabetes, and 3/6 have one or more previous KTs. Four out of six patients died, at an average time of 9.75 ± 2.4 days after tocilizumab administration, 3/6 due to a coexistent septic shock. Two patients improved after TCZ and were discharged at 20 and 21 days, respectively; in both patient, a significant increase of total lymphocyte count was observed. In conclusion, KTs, where the role of peculiar factors such as chronic immunosuppression is still undetermined, represent a high-risk group with significant COVID-19-associated mortality. The evaluation of the TCZ effect in COVID-19 pneumonia requires controlled studies (ideally RCTs) in this specific population.

[Nutritional diet therapy in the management of the patient with Chronic Kidney Disease in advanced phase to delay the beginning and reduce the frequency of dialysis. An option also in the pre-emptive transplant program].

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and / or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis. The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty (20) essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

Nutritional treatment of advanced CKD: twenty consensus statements.

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and/or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis. The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

Ten-year comparative analysis of incidence, prognosis, and associated factors for dialysis and renal transplantation in type 1 and type 2 diabetes versus non-diabetes.

AIMS: To study the incidence of and the factors associated with renal dialysis and transplantation in type 1 (T1DM) and type 2 diabetes (T2DM). METHODS: Data on individuals who had received dialysis treatment or renal transplant between 1 January 2004 and 31 December 2013 were extracted from the regional administrative database (Piedmont, Italy), and the crude (cumulative) incidence of dialysis was calculated. Overall cumulative survival was estimated using the Kaplan-Meier method and compared using the log-rank test. Poisson regression was used to estimate adjusted rate ratios for potential predictors of renal transplant or death. RESULTS: A total of 7401 persons started dialysis treatment during the decade, with a 10-year cumulative crude incidence of 16.8/100,000. Incidence was stable and consistently eightfold higher in persons with T2DM (tenfold higher in T1DM) compared to those without diabetes. The risk of dialysis in T1DM was about double that of T2DM. The mortality rate was significantly higher in diabetics than in non-diabetes (241.4/1000 vs. 153.99/1000 person-years). During the decade 2004-2013, 893 patients underwent a kidney transplant. Transplantation rates were significantly lower for diabetics than non-diabetics (16.5/1000 vs. 42.9/1000 person-years). CONCLUSIONS: In the past decade, the incidence of dialysis has stabilized in both the general population and in diabetics in whom it remains far higher by comparison. Also mortality rates are higher, with a worse prognosis for T1DM. Diabetes poses a barrier to allotransplantation, and efforts should be made to overcome this limitation.

Low versus high dose erythropoiesis-stimulating agents in hemodialysis patients with anemia: A randomized clinical trial.

The increased risks of death and adverse events with erythropoiesis-stimulating agent (ESA) therapy targeting a higher hemoglobin level are established. It is uncertain whether the adverse effects of ESA therapy are related to dose and are mitigated when a fixed low ESA dose is used. We conducted a multicenter, prospective randomized open-label, blinded-endpoint (PROBE) trial to evaluate fixed low versus high dose ESA therapy on patient outcomes. We intended to recruit 2104 hemodialysis patients >18 years with anemia or receiving ESA treated at dialysis clinics in Italy. The intervention was fixed low (4000 IU epoetin alfa equivalent weekly) or high (18,000 IU epoetin alfa equivalent weekly) dose ESA for 12 months. Primary outcomes were serum transferrin, ferritin, albumin, C-reactive protein and ESA dose. Secondary outcomes were the composite of death or cardiovascular event, all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, cardiovascular hospitalization, and quality of life. Study recruitment was terminated after inclusion of 656 participants with convergence of ESA dose between groups during follow up. Fixed low dose ESA had uncertain effects on serum ferritin (delta of delta (DD) 3.9 ng/ml, 95% CI -85.0 to 92.8), transferrin (9.2 mg/dl, -6.3 to 24.8), transferrin saturation (3.7%, -5.0 to 12.3), serum albumin (-0.03 g/dl, -0.2 to 0.1), or C-reactive protein (-0.6 mg/l, -3.3 to 2.1). In addition, fixed dose therapy had inconclusive effects on the composite endpoint of mortality and cardiovascular events (hazard ratio [HR] 0.95, 95% CI 0.66 to 1.37), death (0.98, 0.64 to 1.52), nonfatal myocardial infarction (0.52, 0.18 to 1.52), nonfatal stroke (no events), hospital admission for cardiovascular causes (0.93, 0.50 to 1.72) or health-related quality of life. A fixed low ESA dose in hemodialysis patients has uncertain effects on serum parameters, mortality, cardiovascular events, and quality of life. Hemoglobin targets may be so entrenched in nephrology practice that a trial of ESA dose is no longer possible.

[Renal biopsy practice in Piedmont and Valle d'Aosta]. / Indagine sulle modalità di esecuzione delle biopsia renale in Piemonte e Valle d'Aosta.

In 2010 a questionnaire was administered to the renal units of Piedmont and Valle d'Aosta to analyze their procedures for renal biopsy (RB). Seventy-eight percent of units performed RBs, 57% for more than 20 years, but only 43% performed at least 20 BRs per year. 20/21 units performed RB in an inpatient setting and 1/21 in day hospital with the patient remaining under observation the night after. Thirty-two percent did not consider a single kidney as a contraindication to RB, 59% considered it a relative contraindication and 9% considered it an absolute contraindication. In 90.5% of units there was a specific protocol for patient preparation for RB and 86% used a specific informed consent form. Ninety-five percent of units performed ultrasound-guided RB, 60% of them using needle guides attached to the probe. In 81% of units the left side was preferred; 71% put a pillow under the patient's abdomen. All units used disposable, automated or semi-automated needles. Needle size was 16G in 29%, 18G in 58%, and both 16G and 18G in 14% of units; 1 to 3 samples were drawn. One third of units had a microscope available for immediate evaluation of specimen adequacy. After RB, 86% of units kept patients in the prone position for 2-6 hours and all prescribed a period of bed rest (at least 24 hours in 90.5%). 90.5% of units followed a specific postbiopsy observation protocol consisting of blood pressure, heart rate and red blood cell measurements at different times, and urine monitoring and ultrasound control within 12-24 hours (only half of them also employing color Doppler). One third of all units discharged patients after 1 day and two thirds after 2-3 days; all prescribed abstention from effort and from antiplatelet drugs for 7-15 days. In 9 units both RB and tissue processing and examination were done in the same hospital, while 12 units sent the samples elsewhere. 76% obtained results in 2-4 days, 19% in 6-7 days, and 5% in 10-15 days. Less than 20% of the interviewed operators were fully familiar with the clauses of hospital insurance securing their activity. Use of RB is widespread in Piedmont and Valle d'Aosta but its practice shows variation between centers.

[SIN census 2008: the management model]. / Censimento SIN 2008: il modello organizzativo.

This paper reports the analysis of the second part of the data obtained from the second SIN census and illustrates the management model of the Italian dialysis centers, highlighting its strengths but also its limits. The census was carried out between March and December 2008 with a webbased survey using fillable PDF forms. The survey was validated by comparing the data with those sent to the Italian Dialysis and Transplant Register (Registro Italiano di Dialisi e Trapianti, RIDT) and hence it refers to December 31, 2008, the date of the last RIDT report. Forty-two percent of dialysis centers, which altogether take care of 50% of Italian dialysis patients, participated in the census. The participation percentage was very variable among Italian regions (from 5% to 100% of dialysis centers). By excluding the three regions with a participation rate below 10%, the survey reached a participation rate of 68% of all Italian dialysis centers and is therefore sufficient to give an estimate of the Italian dialysis situation. However, because of this variability it was not possible to compare regional situations, and the data were evaluated only by analyzing the ''complex'' and ''simple'' dialysis centers separately. The state of affairs of dialysis in Italy on the whole proved to be complicated. It is striking, for example, that 15% of the ''complex'' dialysis centers do not have their own hospital beds and some of them lack traceability programs. Noteworthy are also the increasing use of central venous catheters and the number of patients that need an ambulance to get to the dialysis center. Despite its limits due to the reduced participation in the census, this work offers a fair description of the state of affairs of dialysis in Italy, where there is certainly space for qualitative improvement. First of all, however, every effort should be made to implement and improve the use of the existing structures and to standardize protocols and behaviors in all Italian dialysis centers.

[SIN census 2008: the nephrologist's workload]. / Censimento SIN 2008: il lavoro del nefrologo.

This paper reports on a first analysis of data of the second survey promoted by the Italian Society of Nephrology (SIN), with particular regard to data referring to the nephrologist's workload. The survey was carried out through a Web-based questionnaire that participants could fill in online between March and December 2010. The data were validated against those of the Italian Dialysis and Transplant Registry (RIDT) and therefore refer to 31 December 2008, the date of the last RIDT report. Accurate completion of the questionnaires and reminders were monitored by the presidents of the regional sections of the SIN and the regional registries' chairpersons under the coordination of four area managers and a census committee. The response to the survey represented 42% of all nephrology centers, treating about 50% of all dialysis patients in Italy. The response percentage varied widely among regions (from 5% to 100% of the centers). After exclusion of the three regions with responses below 10%, it reached 68%, which was sufficient to give an idea of the state of nephrology in Italy. However, due to this wide variability, it was not possible to make an overall comparison of the regional situations, hence data for complex and simple structures were assessed separately. Despite the limits due to the incomplete participation in the survey, this article provides a clear description of the state of nephrology in Italy. The results confirm the hypothesis presented in the work of Bocconi Cergas, namely that the nephrology market is broader than nephrologists are able to control. The work of the nephrologist, which still seems to be focused mainly on dialysis in its various forms, should be directed more towards the development of methods for early detection of kidney disease and close follow-up. The ultimate aim is the early diagnosis of kidney disease and hence prevention of its complications, so that the focus no longer needs to be on ESKD treatment systems.

[Indications from the first audit on peritoneal dialysis in Piedmont and Aosta valley]. / Indicazioni dal primo audit sulla dialisi peritoneale in Piemonte e in Valle D'Aosta.

In March 2009 a clinical audit was held in Turin on peritoneal dialysis in order to analyze the problems that still hinder the effective deployment of the technique in Piedmont-Aosta Valley. Various data about epidemiological and clinical management were collected by means of a questionnaire that all 26 nephrology centers of the two regions responded to. The two major critical issues highlighted were the role of the outpatient facility dedicated to uremic patients and why the peritoneal technique was not chosen for new dialysis patients. With regard to the first issue, the presence of a well structured outpatient facility dedicated to chronic renal failure seems to direct more uremic patients to peritoneal dialysis, at the same time decreasing the rate of late referrals. Regarding the second issue, patient choice was the leading cause followed by problems related to the partner, while traditional clinical contraindications interfered to a lesser extent with the choice of dialysis technique. We therefore believe that it will be possible to increase the use of peritoneal dialysis by improving organizational aspects of the dialysis center and trying to remedy the lack of social support. Accurate information and early care of uremic patients by dedicated outpatient facilities are in fact able to lead more patients to choose peritoneal dialysis. The implementation of measures of support, such as financial incentives to dialysis patients following a recent decision of the Piedmont region, could help to overcome problems related to the lack or unhelpfulness of a partner.

Level of renal function in patients starting dialysis: an ERA-EDTA Registry study.

BACKGROUND: The aims of this European study were (i) to compare the level of renal function at the start of dialysis between age groups, gender, primary renal disease, comorbid conditions, treatment modality, time periods and countries, and (ii) to determine which baseline characteristics are associated with the level of renal function at the start of dialysis. METHODS: Renal registries participating in the European Renal Association-European Dialysis and Transplant Association Registry provided data on serum creatinine 0-4 weeks before the start of dialysis in incident dialysis patients in 1999 and 2003. Data were available in 11 472 patients from nine renal registries. Glomerular filtration rate (GFR) was estimated by the four-variable Modification of Diet in Renal Disease equation. RESULTS: The unadjusted median eGFR at the start of dialysis was 7.0 mL/min/1.73 m(2) in the 1999 data (median serum creatinine 7.5 mg/dL) and 7.7 mL/min/1.73 m(2) in the 2003 data (serum creatinine 7.0 mg/dL). Using linear regression with adjustment for the other covariates, older patients, males, patients with diabetes mellitus, hypertension/renal vascular disease (HT/RVD) as primary renal disease (vs glomerulonephritis), ischaemic heart disease or peripheral vascular disease and patients starting on peritoneal dialysis (PD) initiated dialysis at higher levels of eGFR (range Δ eGFR: 0.1-1.2 mL/min/1.73 m(2)). Using the same analyses, eGFR differed between countries (range: 6.5-8.6 mL/min/1.73 m(2)). CONCLUSIONS: During 2003, patients started dialysis at somewhat higher eGFR levels than those starting during 1999. There were also international differences in eGFR. Such differences may, at least in part, be explained by differences in creatinine measurement methods between countries and time periods. Finally, older patients, males, patients with HT/RVD or comorbidity and those starting on PD had slightly higher eGFR levels than younger patients, females, those with glomerulonephritis, without comorbidity and those starting on haemodialysis. Further research is needed into other, more clinically related factors affecting the decision to start dialysis.

Residual renal function at the start of dialysis and clinical outcomes.

BACKGROUND: This study evaluates the association between estimated GFR (eGFR) at the start of dialysis and mortality within Europe. METHODS: Renal registries participating in the ERA-EDTA Registry were asked to provide data on serum creatinine recorded 0-4 weeks before the start of dialysis in incident dialysis patients in 1999 and 2003. Within this cohort study, data were available in 11 472 patients from nine national or regional European renal registries. Cox regression analyses were performed to examine the association between GFR estimated by the four-variable MDRD equation (eGFR) and all-cause mortality, using a follow-up through 31 December 2005. RESULTS: In the 2003 data, the mean eGFR was 8.6 ml/min/1.73 m(2). The unadjusted survival analyses showed that an increase in eGFR of 1 ml/min/1.73 m(2) was associated with a higher mortality risk (HR = 1.03; 95% CI: 1.03-1.04) that remained similar after adjustment for age, gender, primary renal disease, treatment modality, country and comorbidity. The findings were consistent across gender, treatment modalities, geographical regions and time periods (2003 versus 1999), but the association between a higher eGFR at the start of dialysis and mortality was the strongest in the youngest age groups and in patients with glomerulonephritis. Analyses at centre level showed that a 10% increase in the percentage of patients starting dialysis at high eGFR levels (>or=10.5 ml/min) was associated with a 22% higher mortality risk (HR = 1.22; 95% CI: 1.18-1.26). CONCLUSIONS: This European study showed that a higher eGFR at the start of dialysis was associated with a higher mortality risk. However, an answer to the question when to start dialysis needs to come from randomized controlled trials.

Guidelines audit may overcome disparities in health care: experience of an Italian region.

BACKGROUND: A clinical audit is used to verify the application of evidence-based clinical guidelines. Our regional section of the Italian Society of Nephrology was the first to establish a region-based program of clinical audits of compliance with guidelines for treating osteodystrophy and anemia of patients on chronic dialysis. This study summarizes the main results of the 2 audits of the Piemonte region. METHODS: Structured questionnaires were sent twice to all of the 22 dialysis centers of Piemonte and to the Center of Valle D'Aosta for an Audit on Osteodystrophy (in 2000 and 2004) and for the Audit on Anemia (2003). The questionnaires were meant to evaluate the clinical schedule of treatment relative to calcium-phosphate balance and anemia in dialysis patients. RESULTS: All centers responded, showing low levels of agreement with the targets of Italian guidelines. In sum, in 2000 only 27% of centers had more than 70% of patients with serum phosphate <5.5 mg/dL, but that rate had increased to 33% in 2004. Only 35% (in 2000) and 40% (in 2004) of the centers had more than 90% of patients with Kt/V >1.2. The Audit on Anemia showed a median of 42% of patients with hemoglobin between 11 and 12 g/dL, and only 2 centers had more than 70% of patients above this target. CONCLUSIONS: The first result of our pioneering experience was that we found that compliance with minimal levels of care was still inadequate, with regard to hyperphosphatemia, dialysis adequacy and anemia. Nevertheless, the 2nd Audit on Osteodystrophy showed a relative improvement in the results. But, most importantly, this open regional report has encouraged comparisons, and motivated centers to adopt a strategy of understanding, addressing and correcting inadequate levels of care, and furthermore increased satisfaction with the care being offered.