Dialysis practices that distinguish facilities with below- versus above-expected mortality.

BACKGROUND AND OBJECTIVES: Mortality rates vary widely among dialysis facilities even after adjustment with standardized mortality ratios (SMRs). This variation may occur because top-performing facilities use practices not shared by others, because the SMR fails to capture key patient characteristics, or both. Practices were identified that distinguish top- from bottom-performing facilities by SMR. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A cross-sectional survey was performed of staff across three organizations. Staff members rated the perceived quality of their units' patient-, provider-, and facility-level practices using a six-point Likert scale. Facilities were divided into those with above- versus below-expected mortality on the basis of SMRs from U.S. Renal Data Service facility reports. Mean Likert scores were computed for each practice using t tests. Practices that were statistically significant (P ≤ 0.05) and achieved at least a medium effect size of ≥0.4 were reported. Significant predictors were entered into a linear regression model. RESULTS: Dialysis facilities with below-expected mortality reported that patients in their unit were more activated and engaged, physician communication and interpersonal relationships were stronger, dieticians were more resourceful and knowledgeable, and overall coordination and staff management were superior versus facilities with above-expected mortality. Staff ratings of these practices explained 31% of the variance in SMRs. CONCLUSIONS: Patient-, provider-, and facility-level practices partly explain SMR variation among facilities. Improving SMRs may require processes that reflect a coordinated, multidisciplinary environment (i.e., no one group, practice, or characteristic will drive facility-level SMRs). Understanding and improving SMRs will require a holistic view of the facility.

Dialysis practices that distinguish top- versus bottom-performing facilities by hemoglobin outcomes.

BACKGROUND: Because there is wide variation in outcomes across dialysis facilities, it is possible that top-performing units use practices not shared by others. The Identifying Best Practices in Dialysis (IBPiD) Study seeks to identify practices that distinguish top- from bottom-performing facilities by key outcomes, including achievement of recommended hemoglobin targets. STUDY DESIGN: Observational study with cross-sectional study ascertainment of predictors and outcomes. PREDICTORS: Facility dialysis practices ascertained using practice surveys of dialysis staff who indicated their level of agreement that each practice occurs in their facility (1-6 on a Likert scale). SETTING & PARTICIPANTS: 423 personnel in 90 dialysis facilities from 1 for-profit and 2 not-for-profit dialysis organizations. OUTCOMES: Percentage of patients per month per facility with hemoglobin levels of 11-12 g/dL. We divided facilities by median into top- versus bottom-performing groups and compared mean scores for each practice using t tests. We report practices that were statistically significant and achieved at least a medium effect size (ES) >or=0.4. RESULTS: 17 of 155 tested predictors were significant. Achievement of hemoglobin level targets was related most strongly to the use of chairside computers (ES, 0.8 [95% CI, 0.4-1.4]), extent/quality of educational videos (ES, 0.6 [95% CI, 0.2-1.1]), frequency of calling per diem staff if short staffed (ES, 0.6 [95% CI, 0.21-1.1]), policy that nurses pass written competency examinations before hire (ES, 0.6 [95% CI, 0.2-1.0]), and technician cannulation mastery (ES, 0.6 [95% CI, 0.2-1.1]). LIMITATIONS: This is a cross-sectional study that can address only associations, not causations. Future research should measure the longitudinal predictive value of these practices. CONCLUSIONS: High-performing facilities report more effective education programs, better staff management, higher staff competency, and higher use of chairside computers, a potential marker of information technology proficiency. This suggests that hemoglobin level management is enhanced by processes reflecting a coordinated multidisciplinary environment.

The relationship between laboratory-based outcome measures and mortality in end-stage renal disease: a systematic review.

Despite data that traditional laboratory-based outcome measures in dialysis are improving over time, population-based data indicate that mortality rates are not improving in parallel. With increased focus on performance measures based on laboratory-based outcomes (e.g., hematocrit, albumin, and parathyroid hormone), less emphasis has been placed on other markers, some of which may be stronger predictors of mortality. We performed a systematic review to interpret the predictive value of laboratory-based outcome measures in dialysis. We identified studies with data regarding the predictive value of laboratory-based outcomes for mortality in dialysis. We calculated the sample size-weighted pooled relative risk of death with dichotomized "high" vs. "low" levels of each measure. We rank-ordered predictors by scaling the pooled relative risk of each measure by its pooled standard deviation. There were 5171 titles, of which 128 (representing 44 laboratory-based outcomes) were selected. Nine were significantly associated with mortality, in order of decreasing scaled effect size: (1) tumor necrosis factor-alpha, (2) hematocrit, (3) interleukin-6, (4) troponin T, (5) Kt/V(urea), (6) prealbumin, (7) urea reduction ratio, (8) serum albumin, and (9) C-reactive protein. Other oft-cited measures such as calcium phosphate product and parathyroid hormone were not significantly associated with mortality in pooled analysis. Quality improvement efforts to improve traditional laboratory-based outcomes in end-stage renal disease are necessary, but likely insufficient, to improve overall mortality in dialysis. Renewed consideration of cardiovascular, inflammatory, and nutritional markers that are especially strong predictors of mortality may have important implications for risk stratification and targeted therapeutic interventions.

Is there "cherry picking" in the ESRD Program? Perceptions from a Dialysis Provider Survey.

BACKGROUND AND OBJECTIVES: Changes in ESRD reimbursement policy, including proposed bundled payment, have raised concern that dialysis facilities may use "cherry picking" practices to attract a healthier, better insured, or more adherent patient population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: As part of a national survey to measure beliefs about drivers of quality in dialysis, respondents were asked about their perceptions of cherry picking, including the frequency and effect of various cherry picking strategies on dialysis outcomes. We surveyed a random sample of 250 nurse members of the American Nephrology Nurses Association, 250 nephrologist members of the American Medical Association, 50 key opinion leaders, and 2000 physician members of the Renal Physicians Association. We tested hypothesized predictors of perception, including provider group, region, age, experience, and the main practice facility features. RESULTS: Three-quarters of respondents reported that cherry picking occurred "sometimes" or "frequently." There were no differences in perceptions by provider or facility characteristics, insurance status, or health status. In multivariable regression, perceived cherry picking was 2.8- and 3.5-fold higher in the northeast and Midwest, respectively, versus the west. Among various cherry picking strategies, having a "low threshold to 'fire' chronic no-shows/late arrivers," and having a "low threshold to 'fire' for noncompliance with diet and meds" had the largest perceived association with outcomes. CONCLUSIONS: Under current reimbursement practices, dialysis caregivers perceive that cherry picking is common and important. An improved understanding of cherry picking practices, if evident, may help to protect vulnerable patients if reimbursement practices were to change.

The microeconomics of personalized medicine: today's challenge and tomorrow's promise.

'Personalized medicine' promises to increase the quality of clinical care and, in some cases, decrease health-care costs. Despite this, only a handful of diagnostic tests have made it to market, with mixed success. Historically, the challenges in this field were scientific. However, as discussed in this article, with the maturation of the '-omics' sciences, it now seems that the major barriers are increasingly related to economics. Overcoming the poor microeconomic alignment of incentives among key stakeholders is therefore crucial to catalysing the further development and adoption of personalized medicine, and we propose several actions that could help achieve this goal.

Management of acute kidney injury in the intensive care unit: a cost-effectiveness analysis of daily vs alternate-day hemodialysis.

BACKGROUND: Although evidence suggests that a higher hemodialysis dose and/or frequency may be associated with improved outcomes, the cost-effectiveness of a daily hemodialysis strategy for critically ill patients with acute kidney injury (AKI) is unknown. METHODS: We developed a Markov model of the cost, quality of life, survival, and incremental cost-effectiveness of daily hemodialysis, compared with alternate-day hemodialysis, for patients with AKI in the intensive care unit (ICU). We employed a societal perspective with a lifetime analytic time horizon. We modeled the efficacy of daily hemodialysis as a reduction in the relative risk of death on the basis of data reported in the 2004 clinical trial published by Schiffl et al. We performed 1- and 2-way sensitivity analyses across cost, efficacy, and utility input variables. The main outcome measure was cost per quality-adjusted life-year (QALY). RESULTS: In the base case for a 60-year-old man, daily hemodialysis was projected to add 2.14 QALYs and $10,924 in cost. We found that the cost-effectiveness of daily hemodialysis compared with alternate-day hemodialysis was $5084 per QALY gained. The incremental cost-effectiveness ratio became less favorable (>$50,000 per QALY gained) when the maintenance hemodialysis rate of the daily hemodialysis group was varied to more than 27% and when the difference in 14-day postdischarge mortality between the alternatives was varied to less than 0.5%. CONCLUSION: Daily hemodialysis is a cost-effective strategy compared with alternate-day hemodialysis for patients with severe AKI in the ICU.

Identifying best practices in dialysis care: results of cognitive interviews and a national survey of dialysis providers.

BACKGROUND AND OBJECTIVES: Because there is wide variation in case-mix adjusted outcomes across dialysis facilities, it is possible that top-performing facilities use practices not shared by others. We sought to catalogue "best practices" that may account for interfacility variations in outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This multidisciplinary study identified candidate best practices in dialysis through a staged process, including systematic review, cognitive interviews, and a national "virtual focus group" of dialysis providers. The resulting candidate practices were rank-ordered by perceived importance as determined by mean RAND Appropriateness Scores from a national survey of nephrologists, nurses, and opinion leaders. RESULTS: A total of 155 candidate best practices were identified. Among these, respondents believed dialysis outcomes are most strongly related to 1) characteristics of multidisciplinary care conferences, 2) technician proficiency in protecting vascular access, 3) training of nurses to provide education in fluid management, vascular access, and nutrition, 4) use of random and blinded audits of staff performance, and 5) communication and teamwork among staff. In contrast, there was wide disagreement about the importance of facility-based health maintenance practices, optimal staffing ratios, frequency of dialysis-based physician visits, and optimal frequency of multidisciplinary care. CONCLUSIONS: This study provides a "conceptual map" of candidate dialysis best practices and highlights areas of general agreement and disagreement. These findings can help the dialysis community think critically about what may define "best practice" and provide targets for future research in quality improvement.

Rise of pay for performance: implications for care of people with chronic kidney disease.

Many health care providers and policy makers believe that health care financing systems fail to reward high-quality care. In recent years, federal and private payers have begun to promote pay for performance, or value-based purchasing, initiatives to raise the quality of care. This report describes conceptual issues in the design and implementation of pay for performance for chronic kidney disease and ESRD care. It also considers the implications of recent ESRD payment policy changes on the broader goals of pay for performance. Congressionally mandated bundle payment demonstration for dialysis, newly implemented case-mix adjustment of the composite rate, and G codes for the monthly capitation payment are important opportunities to understand facility and provider behavior with particular attention to patient selection and treatment practices. Well-designed payment systems will reward quality care for patients while maintaining appropriate accountability and fairness for health care providers.

Prion protein repeat expansion results in increased aggregation and reveals phenotypic variability.

Mammalian prion diseases are fatal neurodegenerative disorders dependent on the prion protein PrP. Expansion of the oligopeptide repeats (ORE) found in PrP is associated with inherited prion diseases. Patients with ORE frequently harbor PrP aggregates, but other factors may contribute to pathology, as they often present with unexplained phenotypic variability. We created chimeric yeast-mammalian prion proteins to examine the influence of the PrP ORE on prion properties in yeast. Remarkably, all chimeric proteins maintained prion characteristics. The largest repeat expansion chimera displayed a higher propensity to maintain a self-propagating aggregated state. Strikingly, the repeat expansion conferred increased conformational flexibility, as observed by enhanced phenotypic variation. Furthermore, the repeat expansion chimera displayed an increased rate of prion conversion, but only in the presence of another aggregate, the [RNQ+] prion. We suggest that the PrP ORE increases the conformational flexibility of the prion protein, thereby enhancing the formation of multiple distinct aggregate structures and allowing more frequent prion conversion. Both of these characteristics may contribute to the phenotypic variability associated with PrP repeat expansion diseases.

The importance of routine HIV testing in the incarcerated population: the Rhode Island experience.

Routine HIV testing in the correctional setting offered to all inmates at entry has played an important role in the diagnosis of HIV in Rhode Island. Diagnosis and treatment of HIV in prisons can further public health goals of HIV control, prevention, and education. Routine HIV testing can be incorporated into primary and secondary prevention programs in correctional facilities. In Rhode Island, where HIV testing is routine at entry into the correctional facility, approximately one third of all persons who test positive are identified in the correctional facility. The proportion of males and females testing positive in the correctional facility versus those testing positive in other facilities has shown a gradual decrease, with positive female HIV tests declining more substantially in recent years. Specific groups, such as males, African Americans, and injection drug users continue to be more likely diagnosed in the state correctional facility than in other testing sites. These differences may reflect barriers to health care access that other community initiatives have failed to address.