Improving hepatitis B vaccination rates for advanced chronic kidney disease patients: a quality improvement initiative.

INTRODUCTION: Chronic kidney disease (CKD) patients are vulnerable to hepatitis B, and immunization prior to end stage kidney disease is recommended to optimize seroconversion. Our institution undertook a process improvement approach to increase hepatitis B vaccination in stage 4 and 5 CKD patients. METHODS: Four strategies were utilized such as: (1) Electronic health record (EHR)-based CKD registry to identify patients, (2) EHR-based physician/nurse reminders, (3) a co-located nurse appointment for vaccine administration, and (4) information sharing and provider awareness effort. The CKD registry was utilized to identify patients with stage 4 or 5 CKD, with at least two clinic visits in the prior 2 years, who had not received the hepatitis B vaccine or did not have serologic evidence of immunity. Target monthly vaccination rate was set at 75%, based on clinic leadership, nephrologist, and nurse consensus. RESULTS: A total of 239 patients were included in the study period, from November 2018 to January 2019 (observation period) and from February 2019 to September 2019 (intervention period). Monthly vaccination rate improved from 48% in November 2018 to the target rate of 75% by the end of the intervention (August and September 2019). There was a statistically significant increase from the rate of vaccination at a unique patient level in the first month of the baseline period, compared to the last month of the intervention period (51 vs. 75% p = 0.03). CONCLUSIONS: Utilizing a nurse-led approach to hepatitis B vaccination, coupled with EHR-based tools, along with continuous monitoring of performance, helped to improve hepatitis B vaccination among CKD stage 4 and 5 patients.

The Effect of Predialysis Fistula Attempt on Risk of All-Cause and Access-Related Death.

Whether the lower risk of mortality associated with arteriovenous fistula use in hemodialysis patients is due to the avoidance of catheters or if healthier patients are simply more likely to have fistulas placed is unknown. To provide clarification, we determined the proportion of access-related deaths in a retrospective cohort study of patients aged ≥18 years who initiated hemodialysis between 2004 and 2012 at five Canadian dialysis programs. A total of 3168 patients initiated dialysis at the participating centers; 2300 met our inclusion criteria. Two investigators independently adjudicated cause of death using explicit criteria and determined whether a death was access-related. We observed significantly lower mortality in individuals who underwent a predialysis fistula attempt than in those without a predialysis fistula attempt in patients aged <65 years (hazard ratio [HR], 0.49; 95% confidence interval [95% CI], 0.29 to 0.82) and in the first 2 years of follow-up in those aged ≥65 years (HR0-24 months, 0.60; 95% CI, 0.43 to 0.84; HR24+ months, 1.83; 95% CI, 1.25 to 2.67). Sudden deaths that occurred out of hospital accounted for most of the deaths, followed by deaths due to cardiovascular disease and infectious complications. We found only 2.3% of deaths to be access-related. In conclusion, predialysis fistula attempt may associate with a lower risk of mortality. However, the excess mortality observed in patients treated with catheters does not appear to be due to direct, access-related complications but is likely the result of residual confounding, unmeasured comorbidity, or treatment selection bias.

Patient Navigators for CKD and Kidney Failure: A Systematic Review.

Rationale & Objective: To what degree and how patient navigators improve clinical outcomes for patients with chronic kidney disease (CKD) and kidney failure is uncertain. We performed a systematic review to summarize patient navigator program design, evidence, and implementation in kidney disease. Study Design: A search strategy was developed for randomized controlled trials and observational studies that evaluated the impact of navigators on outcomes in the setting of CKD and kidney failure. Articles were identified from various databases. Two reviewers independently screened the articles and identified those meeting the inclusion criteria. Setting & Participants: Patients with CKD or kidney failure (in-center hemodialysis, peritoneal dialysis, home hemodialysis, or kidney transplantation). Selection Criteria for Studies: Studies that compared patient navigators with a control, without limits on size, duration, setting, or language. Studies focusing solely on patient education were excluded. Data Extraction: Data were abstracted from full texts and risk of bias was assessed. Analytical Approach: No meta-analysis was performed. Results: Of 3,371 citations, 17 articles met the inclusion criteria including 14 original studies. Navigators came from various healthcare backgrounds including nursing (n=6), social worker (n=2), medical interpreter (n=1), research (n=1), and also included kidney transplant recipients (n=2) and non-medical individuals (n=2). Navigators focused mostly on education (n=9) and support (n = 6). Navigators were used for patients with CKD (n=5), peritoneal dialysis (n=2), in-center hemodialysis (n=4), kidney transplantation (n=2), but not home hemodialysis. Navigators improved transplant workup and listing, peritoneal dialysis utilization, and patient knowledge. Limitations: Many studies did not show benefits across other outcomes, were at a high risk of bias, and none reported cost-effectiveness or patient-reported experience measures. Conclusions: Navigators improve some health outcomes for CKD but there was heterogeneity in their structure and function. High-quality randomized controlled trials are needed to evaluate navigator program efficacy and cost-effectiveness.

An Environmental Scan of Ambulatory Care Quality Indicators for Patients With Advanced Kidney Disease Currently Used in Canada.

BACKGROUND: Quality indicators can be used to identify gaps in care and drive frontline improvement activities. These efforts are important to prevent adverse events in the increasing number of ambulatory patients with advanced kidney disease in Canada, but it is unclear what indicators exist and the components of health care quality they measure. OBJECTIVE: We sought to identify, categorize, and evaluate quality indicators currently in use across Canada for ambulatory patients with advanced kidney disease. DESIGN: Environmental scan of quality indicators currently being collected by various organizations. SETTING: We assembled a 16-member group from across Canada with expertise in nephrology and quality improvement. PATIENTS: Our scan included indicators relevant to patients with chronic kidney disease in ambulatory care clinics. MEASUREMENTS: We categorized the identified quality indicators using the Institute of Medicine and Donabedian frameworks. METHODS: A 4-member panel used a modified Delphi process to evaluate the indicators found during the environmental scan using the American College of Physicians/Agency for Healthcare Research and Quality criteria. The ratings were then shared with the full panel for further comments and approval. RESULTS: The environmental scan found 28 quality indicators across 7 provinces, with 8 (29%) rated as "necessary" to distinguish high-quality from poor-quality care. Of these 8 indicators, 3 were measured by more than 1 province (% of patients on a statin, number of patients receiving a preemptive transplant, and estimated glomerular filtration rate at dialysis start); no indicator was used by more than 2 provinces. None of the indicators rated as necessary measured timely or equitable care, nor did we identify any measures that assessed the setting in which care occurs (ie, structure measures). LIMITATIONS: Our list cannot be considered as an exhaustive list of available quality indicators at hand in Canada. Our work focused on quality indicators for nephrology providers and programs, and not indicators that can be applied across primary and specialty providers. We also focused on indicator constructs and not the detailed definitions or their application. Last, our panel does not represent the views of other important stakeholders. CONCLUSIONS: Our environmental scan provides a snapshot of the scope of quality indicators for ambulatory patients with advanced kidney disease in Canada. This catalog should inform indicator selection and the development of new indicators based on the identified gaps, as well as motivate increased pan-Canadian collaboration on quality measurement and improvement. TRIAL REGISTRATION: Not applicable as this article is not a systematic review, nor does it report results of a health intervention on human participants.

CONTEXTE: Les indicateurs de la qualité peuvent être utilisés pour révéler des lacunes dans les soins et orienter les activités de première ligne visant leur amélioration. Ces efforts sont importants pour prévenir les événements indésirables chez le nombre croissant de patients ambulatoires aux prises avec des néphropathies de stades avancés au Canada. On connaît toutefois peu les indicateurs existants et les composants de la qualité des soins qu'ils mesurent. OBJECTIF: Nous souhaitions répertorier, catégoriser et évaluer les indicateurs de la qualité des soins actuellement en usage au Canada pour les patients ambulatoires atteints de néphropathies de stade avancé. TYPE D'ÉTUDE: Une analyse contextuelle des indicateurs de la qualité colligés en ce moment par différents organismes. CADRE: Nous avons constitué un groupe de seize personnes provenant de partout au Canada et détenant une expérience pertinente en néphrologie et en amélioration de la qualité des soins. SUJETS: Notre étude a inclus les indicateurs pertinents pour les patients atteints d'insuffisance rénale chronique fréquentant les cliniques de soins ambulatoires. MESURES: Nous avons catégorisé les indicateurs de la qualité à l'aide des cadres de l'Institute of Medicine (IOM) et du modèle de Donabedian. MÉTHODOLOGIE: Un comité constitué de quatre personnes a employé une version modifiée de la méthode de Delphi pour évaluer les indicateurs colligés durant l'analyse contextuelle à l'aide des critères de l'American College of Physicians/Agency for Healthcare Research and Quality. Les scores ont ensuite été partagés avec l'ensemble du groupe pour recueillir leurs commentaires et leur approbation. RÉSULTATS: L'analyse contextuelle a permis de répertorier 28 indicateurs de la qualité dans sept provinces, parmi lesquels huit (29 %) étaient jugés « nécessaires ¼ pour distinguer les soins de grande qualité des soins de faible qualité. De ces huit indicateurs, trois ont été mesurés dans plus d'une province (pourcentage de patients prenant au moins une statine; nombre de patients recevant une greffe préemptive; DFGe à l'amorce de la dialyse). Aucun indicateur n'était en usage dans plus de deux provinces. Aucun des indicateurs jugés nécessaires ne mesurait les soins équitables ou les soins en temps opportun. Nous n'avons pas non plus constaté de mesures permettant d'évaluer le cadre dans lequel les soins sont prodigués (mesures structurelles). LIMITES: Cette liste ne constitue pas une liste exhaustive des indicateurs de la qualité en usage au Canada. Notre travail s'est concentré sur les indicateurs pertinents pour les programmes et les fournisseurs de soins en néphrologie, et non sur ceux pouvant s'appliquer à l'ensemble des prestataires de soins primaires et spécialisés. Nous sommes également attardés au cadre des indicateurs et non à leurs définitions détaillées ou à leur application. Enfin, notre comité évaluateur ne représente pas les points de vue des autres principaux intervenants. CONCLUSION: Cette analyse contextuelle donne un aperçu de l'ensemble des indicateurs pertinents pour les patients ambulatoires atteints de néphropathies de stade avancé au Canada. Ce catalogue pourra orienter le choix des indicateurs et le développement de nouveaux indicateurs fondés sur les lacunes révélées. Il servira également à encourager une collaboration pancanadienne accrue en matière de mesure et d'amélioration de la qualité des soins.

Multi-Disciplinary Vascular Access Care and Access Outcomes in People Starting Hemodialysis Therapy.

BACKGROUND AND OBJECTIVES: Fistulas, the preferred form of hemodialysis access, are difficult to establish and maintain. We examined the effect of a multidisciplinary vascular access team, including nurses, surgeons, and radiologists, on the probability of using a fistula catheter-free, and rates of access-related procedures in incident patients receiving hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We examined vascular access outcomes in the first year of hemodialysis treatment before (2004-2005, preteam period) and after the implementation of an access team (2006-2008, early-team period; 2009-2011, late-team period) in the Calgary Health Region, Canada. We used logistic regression to study the probability of fistula creation and the probability of catheter-free fistula use, and negative binomial regression to study access-related procedure rates. RESULTS: We included 609 adults (mean age, 65 [±15] years; 61% men; 54% with diabetes). By the end of the first year of hemodialysis, 102 participants received a fistula in the preteam period (70%), 196 (78%) in the early-team period (odds ratios versus preteam, 1.47; 95% confidence interval, 0.92 to 2.35), and 139 (66%) in the late-team period (0.85; 0.54 to 1.35). Access team implementation did not affect the probability of catheter-free use of the fistula (odds ratio, 0.87; 95% confidence interval, 0.52 to 1.43, for the early; and 0.89; 0.52 to 1.53, for the late team versus preteam period). Participants underwent an average of 4-5 total access-related procedures during the first year of hemodialysis, with higher rates in women and in people with comorbidities. Catheter-related procedure rates were similar before and after team implementation; relative to the preteam period, fistula-related procedure rates were 40% (20%-60%) and 30% (10%-50%) higher in the early-team and late-team periods, respectively. CONCLUSION: Introduction of a multidisciplinary access team did not increase the probability of catheter-free fistula use, but resulted in higher rates of fistula-related procedures.