Relationship between clinical performance measures and outcomes among patients receiving long-term hemodialysis.
BACKGROUND
Patients receiving long-term hemodialysis have a yearly mortality rate of 15% to 20%.


OBJECTIVE
To determine whether attaining clinical performance measures for hemodialysis care is associated with favorable 12-month mortality and hospitalization rates.


METHODS
Cohort study.


METHODS
Outpatient hemodialysis centers in the United States.


METHODS
15 287 patients who were selected from a 5% random sample of patients receiving long-term hemodialysis.


METHODS
The authors used data from the Centers for Medicare & Medicaid Services End-Stage Renal Disease Clinical Performance Measures Project from 1999 and 2000. The clinical performance measure targets were hemoglobin value of 110 g/L or greater; serum albumin value of 40 g/L or greater or 37 g/L or greater (bromcresol green and bromcresol purple laboratory methods, respectively); use of a fistula for vascular access; and measured single-pool Kt/V urea value of 1.2 or greater. The outcome measures were death or hospitalization during 1-year follow-up.


RESULTS
8364 patients (54.7%) were hospitalized and 3062 (20.0%) died during the 12-month follow-up period. Six percent of patients did not meet any clinical measure targets, 24% met 1 target, 39% met 2 targets, 24% met 3 targets, and 7% met all 4 targets. The unadjusted 12-month hospitalization and mortality rates for these 5 groups were 60%, 60%, 56%, 49%, and 43% (P < 0.001) and 29%, 25%, 21%, 14%, and 7% (P < 0.001), respectively. The risk for death increased for each additional guideline indicator that was not met: Adjusted hazard ratios were 4.6 (95% CI, 3.3 to 6.4), 3.5 (CI, 2.6 to 4.7), 2.6 (CI, 1.9 to 3.5), and 1.9 (CI, 1.4 to 2.6) for 0, 1, 2, or 3 targets met, respectively, compared with meeting 4 targets (referent). Similarly, the risk for hospitalization increased for each additional guideline indicator that was not met: Adjusted hazard ratios were 1.6 (CI, 1.4 to 1.9), 1.5 (CI, 1.3 to 1.7), 1.3 (CI, 1.1 to 1.5), and 1.1 (CI, 0.98 to 1.3), respectively.


CONCLUSIONS
It was not possible to determine the roles of severity of illness, other patient factors, or suboptimal care in failure to meet performance measures.


CONCLUSIONS
In patients receiving long-term hemodialysis, meeting multiple clinical measure targets is associated with a decrease in hospitalization and mortality rates.
Rocco
Michael V
MV
Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1053, USA. mrocco@wfubmc.edu
Frankenfield
Diane L
DL
Hopson
Sari D
SD
McClellan
William M
WM
D000740:Anemia / Q000175:diagnosis; D001166:Arteriovenous Shunt, Surgical; D015331:Cohort Studies; D006305:Health Status Indicators; D006454:Hemoglobins / Q000032:analysis; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007676:Kidney Failure, Chronic / Q000097:blood / Q000628:therapy; D017063:Outcome Assessment, Health Care; D016016:Proportional Hazards Models; D006435:Renal Dialysis / Q000401:mortality* / Q000592:standards*; D012307:Risk Factors; D012709:Serum Albumin / Q000032:analysis; D013997:Time Factors; D014481:United States; D014508:Urea / Q000032:analysis
D006454:Hemoglobins; D012709:Serum Albumin; D014508:Urea