Association between facility-level adherence to phosphorus management guidelines and mortality in haemodialysis patients: a prospective cohort study.

OBJECTIVES: To examine the association between facility-level adherence to phosphorus management guidelines and mortality among patients with haemodialysis, and to explore the facility-related factors associated with facility-level guideline adherence. DESIGN: Prospective cohort study. SETTING: The Dialysis Outcomes and Practice Pattern Study, which included 57 representative dialysis facilities in Japan between 2012 and 2015. PARTICIPANTS: A total of 2054 adult patients who received maintenance haemodialysis were included. We defined exposure according to the following four categories, depending on whether facility-level target ranges of serum phosphorus concentration adhered to the Japanese clinical practice guidelines: adherence group (lower limit ≥3.5 mg/dL and upper limit ≤6.0 mg/dL), low-target group (lower limit <3.5 and upper limit ≤6.0), wide-target group (lower limit <3.5 and upper limit >6.0) and high-target group (lower limit ≥3.5 and upper limit >6.0). PRIMARY OUTCOME MEASURE: The primary outcome was the patient all-cause mortality rate. RESULTS: The mortality rate among the patients was 7.3 per 100 person-years; 27 facilities (47%) set targets according to the guidelines. HRs for mortality with reference to the adherence group were 1.04 (95% CI 0.76 to 1.43) in the low-target group, 1.11 (95% CI 0.68 to 1.81) in the wide-target group and 1.95 (95% CI 1.12 to 3.38) in the high-target group. Involvement of dieticians in dialysis treatment was associated with facility-level guideline adherence (OR 4.51; 95% CI 1.15 to 17.7). CONCLUSIONS: A higher facility-level target range for phosphorus was associated with increased patient mortality. Among facilities that set the target according to the guidelines, dieticians tended to be involved in dialysis care. These findings suggest the importance of reviewing facilities' treatment policies in relation to updated guidelines and the need to work with relevant professionals.

Association between religious beliefs and discussions regarding advance care planning: A nationwide survey.

BACKGROUND: The relationship between advance care planning and religious beliefs, which are important for palliative care, is controversial in Western countries and has not been verified in Asian countries. AIM: To investigate the association between advance care planning discussions and religious beliefs in Japan. DESIGN: A nationwide survey conducted in 2016 using a quota sampling method to obtain a representative sample of Japan's general population. SETTING/PARTICIPANTS: We analyzed responses from 3167 adults aged 20-84 years (mean age ± standard deviation, 50.9 ± 16.8 years). The outcome was measured by asking whether the respondents had ever discussed advance care planning, and the main exposure by whether they had any religious beliefs or affiliations, and if so, their degree of devoutness. We analyzed religious beliefs, affiliations, and devoutness in relation to the occurrence of discussions using multivariable logistic regression models adjusted for possible sociodemographic covariates. RESULTS: Compared with respondents without, those with religious beliefs had significantly higher odds of having had discussions (adjusted odds ratio: 1.45, 95% confidence interval: 1.22-1.73). The devoutness of religious belief was proportional to the propensity of the occurrence of discussions (p for trend < 0.001). In addition, Buddhists and Christians had higher odds of having had discussions than did nonbelievers. CONCLUSION: The results suggest that holding religious beliefs, especially in Japanese Buddhism and Christianity, facilitates advance care planning discussions among Japanese adults, and thus, may help health-care providers identify those prioritized for facilitating engagement in advance care planning, especially in palliative and spiritual care settings.

Population-level associations of achievement of targets for bone-mineral markers with survival in haemodialysis patients with mildly elevated intact-PTH levels: a case-cohort study.

Achieving calcium, phosphorus, and intact parathyroid hormone (PTH) targets helps improve dialysis population outcomes. We aimed to assess the population-level associations of achievement of those targets with survival using population-attributable-fractions (PAFs). We conducted a case-cohort study using data from 8229 haemodialysis patients with mildly elevated intact PTH, treated at 86 dialysis facilities in Japan. We examined associations among calcium, phosphorus, intact PTH, and mortality over 3 years. We estimated PAFs for achieving the targets of calcium, phosphorus, and intact PTH from the adjusted hazard ratios by Cox regression models. Proportions within the recommended range were 55.8%, 63.3%, and 39.1% for calcium (8.4-10.0 mg/dL), phosphorus (3.5-6.0 mg/dL) and intact PTH (60-240 pg/mL), respectively. The mortality rate was 5.7 per 100 person-years. Mortality was independently associated with non-achievement of targets. Regarding the population-level impact, statistically significant PAFs were found for achieving the combination of calcium and phosphorus (8.8%; 95% CI, 1.1-16.0). Further, PAF for combined calcium, phosphorus, and intact PTH was the largest (16.8%; 95% CI, 5.6-30.4). In conclusion, there might be additive and substantial population-level associations between survival and the achievement of calcium, phosphorus, and intact-PTH targets in the haemodialysis population with mildly elevated intact PTH.

Effects of Higher Quality of Care on Initiation of Long-term Dialysis in Patients With CKD and Diabetes.

BACKGROUND: The burden of diabetes-related chronic kidney disease (CKD) on individuals and society is increasing, shifting attention toward improving the quality of care for patients with CKD and diabetes. We assessed the quality of CKD care and its association with long-term dialysis, acute kidney injury (AKI), and death. STUDY DESIGN: Retrospective cohort study (2004-2011). SETTING & PARTICIPANTS: Adults in Taiwan with incident CKD enrolled in the Longitudinal Cohort of Diabetes Patients. PREDICTORS: 3 CKD-care quality indicators based on medical and pharmacy claims data were studied: prescription of renin-angiotensin system inhibitors, testing for proteinuria, and nutritional guidance. Each was examined individually, and all were summed into an overall quality score. OUTCOMES: The primary outcome was initiation of long-term dialysis therapy. Secondary outcomes were hospitalization due to AKI and death from any cause. MEASUREMENTS: Using instrumental variables related to the quality indicators to minimize both unmeasured and measured confounding, we fit a 2-stage residual inclusion model to estimate HRs and 95% CIs for each outcome. RESULTS: Among the 63,260 patients enrolled, 43.9% were prescribed renin-angiotensin system inhibitors, 60.6% were tested for proteinuria, and 13.4% received nutritional guidance. During a median follow-up of 37.9 months, 1,471 patients started long-term dialysis therapy, 2,739 patients were hospitalized due to AKI, and 4,407 patients died. Higher overall quality scores were associated with lower hazards for long-term dialysis in instrumental variable analyses (HR of 0.62 [95% CI, 0.40-0.98] per 1-point greater score) and hospitalization due to AKI (HR of 0.69 [95% CI, 0.50-0.96] per 1-point greater score). The hazard for all-cause death was nonsignificantly lower (HR of 0.80 [95% CI, 0.62-1.03] per 1-point greater score). LIMITATIONS: Potential misclassification and uncontrolled confounding by indication. CONCLUSIONS: Our findings suggest potential opportunities to improve long-term outcomes among patients with diabetes and CKD by improving the quality of their CKD care.