Perceived barriers to guidelines in peritoneal dialysis.

BACKGROUND: Little is known regarding barriers to guideline adherence in the nephrology community. We set out to identify perceived barriers to evidence-based medicine (EBM) and measurement of continuous quality indicators (CQI) in an international cohort of peritoneal dialysis (PD) practitioners. METHODS: Subscribers to an online nephrology education site (Nephrology Now) were invited to participate in an online survey. Nephrology Now is a non-profit, monthly mailing list that highlights clinically relevant articles in nephrology. Four hundred and seventy-five physicians supplying PD care participated in an online survey assessing their use of EBM and CQI in their PD practice. Ordinal logistic regression was utilized to determine relationships between baseline characteristics and EBM and CQI practices. RESULTS: The majority of physicians were nephrologists (89.7%), and 50.4% worked in an academic centre. Respondents were from the following geographic regions: 13.5% Canadian, 24% American, 23.8% European, 4.4% Australian, 5.3% South American, 10.7% African and 12.2% Asian. Adherence to PD clinical practice guidelines were generally strong; however, lower adherence was associated with countries with lower healthcare expenditure, not using personal digital assistant (PDA), the longer the physician had been practising and smaller (< 20 patients per centre) PD practice. CONCLUSIONS: International variation in guideline adherence may be influenced by a country's healthcare expenditure, physician's PDA use and experience, and size of PD practice which may impact future guideline development and implementation.

International practice patterns and factors associated with non-conventional hemodialysis utilization.

BACKGROUND: The purpose of our study was to determine characteristics that influence the utilization of non-conventional hemodialysis (NCHD) therapies and its subtypes (nocturnal (NHD), short daily (SDHD), long conventional (LCHD) and conventional hemodialysis (CHD) as well as provider attitudes regarding the evidence for NCHD use. METHODS: An international cohort of subscribers of a nephrology education website http://www.nephrologynow.com was invited to participate in an online survey. Non-conventional hemodialysis was defined as any forms of hemodialysis delivered > 3 treatments per week and/or > 4 hours per session. NHD and SDHD included both home and in-centre. Respondents were categorized as CHD if their centre only offered conventional thrice weekly hemodialysis. Variables associated with NCHD and its subtypes were determined using multivariate logistic regression analysis. The survey assessed multiple domains regarding NCHD including reasons for initiating and discontinuing, for not offering and attitudes regarding evidence. RESULTS: 544 surveys were completed leading to a 15.6% response rate. The final cohort was limited to 311 physicians. Dialysis modalities utilized among the respondents were as follows: NCHD194 (62.4%), NHD 83 (26.7%), SDHD 107 (34.4%), LCHD 81 (26%) and CHD 117 (37.6%). The geographic regions of participants were as follows: 11.9% Canada, 26.7% USA, 21.5% Europe, 6.1% Australia/New Zealand, 10% Africa/Middle East, 10.9% Asia and 12.9% South America. Variables associated with NCHD utilization included NCHD training (OR 2.47 CI 1.25-4.16), government physician reimbursement (OR 2.66, CI 1.11-6.40), practicing at an academic centre (OR 2.28 CI 1.25-4.16), higher national health care expenditure and number of ESRD patients per centre. Hemodialysis providers with patients on NCHD were significantly more likely to agree with the statements that NCHD improves quality of life, improves nutritional status, reduces EPO requirements and is cost effective. The most common reasons to initiate NCHD were driven by patient preference and the desire to improve volume control and global health outcomes. CONCLUSION: Physician attitudes toward the evidence for NCHD differ significantly between NCHD providers and conventional HD providers. Interventions and health policy targeting these areas along with increased physician education and training in NCHD modalities may be effective in increasing its utilization.

Do e-mail alerts of new research increase knowledge translation? A "Nephrology Now" randomized control trial.

PURPOSE: As the volume of medical literature increases exponentially, maintaining current clinical practice is becoming more difficult. Multiple, Internet-based journal clubs and alert services have recently emerged. The purpose of this study is to determine whether the use of the e-mail alert service, Nephrology Now, increases knowledge translation regarding current nephrology literature. METHOD: Nephrology Now is a nonprofit, monthly e-mail alert service that highlights clinically relevant articles in nephrology. In 2007-2008, the authors randomized 1,683 subscribers into two different groups receiving select intervention articles, and then they used an online survey to assess both groups on their familiarity with the articles and their acquisition of knowledge. RESULTS: Of the randomized subscribers, 803 (47.7%) completed surveys, and the two groups had a similar number of responses (401 and 402, respectively). The authors noted no differences in baseline characteristics between the two groups. Familiarity increased as a result of the Nephrology Now alerts (0.23 ± 0.087 units on a familiarity scale; 95% confidence interval [CI]: 0.06-0.41; P = .007) especially in physicians (multivariate odds ratio 1.83; P = .0002). No detectable improvement in knowledge occurred (0.03 ± 0.083 units on a knowledge scale; 95% CI: -0.13 to 0.20; P = .687). CONCLUSIONS: An e-mail alert service of new literature improved a component of knowledge translation--familiarity--but not knowledge acquisition in a large, randomized, international population.

Vitamin C prevents hyperoxia-mediated vasoconstriction and impairment of endothelium-dependent vasodilation.

High arterial blood oxygen tension increases vascular resistance, possibly related to an interaction between reactive oxygen species and endothelium-derived vasoactive factors. Vitamin C is a potent antioxidant capable of reversing endothelial dysfunction due to increased oxidant stress. We tested the hypotheses that hyperoxic vasoconstriction would be prevented by vitamin C, and that acetylcholine-mediated vasodilation would be blunted by hyperoxia and restored by vitamin C. Venous occlusion strain gauge plethysmography was used to measure forearm blood flow (FBF) in 11 healthy subjects and 15 congestive heart failure (CHF) patients, a population characterized by endothelial dysfunction and oxidative stress. The effect of hyperoxia on FBF and derived forearm vascular resistance (FVR) at rest and in response to intra-arterial acetylcholine was recorded. In both healthy subjects and CHF patients, hyperoxia-mediated increases in basal FVR were prevented by the coinfusion of vitamin C. In healthy subjects, hyperoxia impaired the acetylcholine-mediated increase in FBF, an effect also prevented by vitamin C. In contrast, hyperoxia had no effect on verapamil-mediated increases in FBF. In CHF patients, hyperoxia did not affect FBF responses to acetylcholine or verapamil. The addition of vitamin C during hyperoxia augmented FBF responses to acetylcholine. These results suggest that hyperoxic vasoconstriction is mediated by oxidative stress. Moreover, hyperoxia impairs acetylcholine-mediated vasodilation in the setting of intact endothelial function. These effects of hyperoxia are prevented by vitamin C, providing evidence that hyperoxia-derived free radicals impair the activity of endothelium-derived vasoactive factors.