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Improving Patient Care |

Relationship between Clinical Performance Measures and Outcomes among Patients Receiving Long-Term Hemodialysis

Michael V. Rocco, MD, MS; Diane L. Frankenfield, DrPH; Sari D. Hopson, MSPH; and William M. McClellan, MD, MPH
[+] Article and Author Information

From Wake Forest University School of Medicine, Winston-Salem, North Carolina; Centers for Medicare & Medicaid Services, Baltimore, Maryland; and Emory University, Atlanta, Georgia.


Disclaimer: The views expressed in this manuscript are those of the authors and do not necessarily reflect official policy of the Centers for Medicare & Medicaid Services.

Acknowledgments: This report is dedicated to the more than 270 000 patients receiving dialysis in the United States who inspired the authors to improve their understanding of dialysis. The ESRD Clinical Performance Measures Project and the U.S. Renal Data System (USRDS) have supplied the data reported in this study. The authors thank the numerous ESRD facilities and ESRD Network personnel whose diligence and conscientious efforts resulted in the success of the ESRD Clinical Performance Measures Project. They also thank Greg Russell for his expertise with SAS graphics and Laura Furr for her secretarial assistance.

Grant Support: None.

Potential Financial Conflicts of Interest:Honoraria: M.V. Rocco (Amgen, NxStage), W.M. McClellan (Amgen, Ortho Biotech, Roche).

Requests for Single Reprints: Michael V. Rocco, MD, MS, Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1053; e-mail, mrocco@wfubmc.edu.

Current Author Addresses: Dr. Rocco: Section on Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1053.

Dr. Frankenfield: Centers for Medicare & Medicaid Services, Office of Clinical Standards and Quality, 7500 Security Boulevard, Mailstop S3-02-01, Baltimore, MD 21244.

Ms. Hopson and Dr. McClellan: Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322.


Ann Intern Med. 2006;145(7):512-519. doi:10.7326/0003-4819-145-7-200610030-00009
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A total of 15 287 patients from 2668 dialysis facilities was included in the sample for analysis. For the 4 clinical measure targets that we examined, 100% of patients had data available to calculate a mean serum albumin value for the 3-month study period. For 98.2% (15 006 of 15 287 patients), a mean hemoglobin value was reported; for 98.0% (14 975 of 15 287 patients), a mean single-pool Kt/V urea value was reported; and for 97.2% (14 853 of 15 287 patients), the type of vascular access was reported. For the Cox proportional hazards modeling analyses, 115 patients were censored because of a switch to peritoneal dialysis, and 553 were censored because of transplantation; another 437 were lost to follow-up.

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Grahic Jump Location
Figure 1.
One-year mortality rates and percentage of patients hospitalized during a 1-year period based on the number of guideline-based indicators that were met during the preceding year.
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Figure 2.
Kaplan–Meier survival curve based on the number of guideline-based indicators that were met in the preceding year (top) and Kaplan–Meier hospitalization curve based on the number of guideline-based indicators that were met in the preceding year (bottom).
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Type of vascular access and patients' mortality
Posted on October 17, 2006
Yujiro Kida
Tsurumi University, Tokyo Medical and Dental University
Conflict of Interest: None Declared

Rocco and coworkers provided four indexes in order to evaluate the association between the quality of care of patients receiving long-term hemodialysis and the risk for death (1). Four indexes were composed of hemoglobin level, serum albumin level, Kt/V urea value, and type of vascular access (1). According to the article by Rocco et al., the use of arteriovenous fistula meets the target in the point of vascular access, whereas the use of arteriovenous graft or catheter does not meet such target (1). We disagree with such their manner.

The adjusted odds ratio for death among patients dialyzed with synthetic graft was 1.1 (0.9 to 1.4) compared with arteriovenous fistula (2). On the other hand, the adjusted odds ratio for death among patients dialyzed with catheter was 1.4 (1.1 to 1.9) compared with arteriovenous fistula (2). These results indicate that the use of arteriovenous fistula or graft for vascular access is superior to catheter in the survival of patients receiving hemodialysis.

Actually, in the patients dialyzed with catheter, lower blood flow rate during hemodialysis led insufficient dialyzed-state (2). Venous catheter was associated with increased rates of infection including bacteremia or endocarditis (3). These factors would increase patients' mortality.

Therefore, in order to perform more precise analysis, we would like to propose that the use of arteriovenous fistula or graft meets the target in the point of vascular access and the use of catheter does not meet such target.

References

(1) Rocco MV, Frankenfield DL, Hopson SD, et al. Ann Intern Med 2006;145:512-9.

(2) Pastin S, Soucie JM, McClellan WM. Kidney Int 2002;62:620-6.

(3) Nassar GM, Ayus JC. Kidney Int 2001;60:1-13.

Conflict of Interest:

None declared

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Summary for Patients

Relationship of Quality-of-Care Measures and Outcomes for Patients Receiving Hemodialysis

The summary below is from the full report titled “Relationship between Clinical Performance Measures and Outcomes among Patients Receiving Long-Term Hemodialysis.” It is in the 3 October 2006 issue of Annals of Internal Medicine (volume 145, pages 512-519). The authors are M.V. Rocco, D.L. Frankenfield, S.D. Hopson, and W.M. McClellan.

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