Facility-level interpatient hemoglobin variability in hemodialysis centers participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS): Associations with mortality, patient characteristics, and facility practices.
BACKGROUND
Hemodialysis patients with larger hemoglobin level fluctuations have higher mortality rates. We describe facility-level interpatient hemoglobin variability, its relation to patient mortality, and factors associated with facility-level hemoglobin variability or achieving hemoglobin levels of 10.5-12.0 g/dL. Facility-level hemoglobin variability may reflect within-patient hemoglobin variability and facility-level anemia-control practices.


METHODS
Prospective cohort study.


METHODS
Data from the Dialysis Outcomes and Practice Patterns Study (DOPPS; 26,510 hemodialysis patients, 930 facilities, 12 countries, 1996-2008) and from the Centers for Medicare & Medicaid Services (CMS; 193,291 hemodialysis patients, 3,741 US facilities, 2002).


METHODS
Standard deviation (SD) in single-measurement hemoglobin levels in hemodialysis patients in facility cross-sections (facility-level hemoglobin SD); patient characteristics; facility practices.


RESULTS
Patient-level mortality; additionally, facility practices correlated with facility-level hemoglobin SD or patient hemoglobin levels of 10.5-12.0 g/dL.


RESULTS
Facility-level hemoglobin SD varied more than 5-fold across DOPPS facilities (range, 0.5-2.7 g/dL; mean, 1.3 g/dL) and by country (range, 1.1 in Japan-DOPPS [2005/2006] to 1.7 g/dL in Spain-DOPPS [1998/1999]), with substantial decreases seen in many countries from 1998 to 2007. Facility-level hemoglobin SD was related inversely to patient age, but was associated minimally with more than 30 other patient characteristics and facility mean hemoglobin levels. Several anemia management practices were associated strongly with facility-level hemoglobin SD and having a hemoglobin level of 10.5-12.0 g/dL. When examined in CMS data, facility-level hemoglobin SD was positively associated with within-patient hemoglobin SD during the prior 6 months. Patient mortality rates were higher with greater facility-level hemoglobin SD (DOPPS: HR, 1.08 per 0.5-g/dL greater facility-level hemoglobin SD [95% CI, 1.02-1.15; P = 0.006]; CMS: HR, 1.16 per 0.5-g/dL greater facility-level hemoglobin SD [95% CI, 1.11-1.21; P < 0. 001]).


CONCLUSIONS
Residual confounding.


CONCLUSIONS
Facility-level hemoglobin SD was associated strongly and positively with patient mortality, not tightly linked to numerous patient characteristics, but related strongly to facility anemia management practices. Facility-level hemoglobin variability may be modifiable and its optimization may improve hemodialysis patient survival.
Arbor Research Collaborative for Health, Ann Arbor, MI, USA. ronald.pisoni@arborresearch.org
Ronald L
RL
Pisoni
Jennifer L
JL
Bragg-Gresham
Douglas S
DS
Fuller
Hal
H
Morgenstern
Bernard
B
Canaud
Francesco
F
Locatelli
Yun
Y
Li
Brenda
B
Gillespie
Robert A
RA
Wolfe
Friedrich K
FK
Port
Bruce M
BM
Robinson
D000740:Anemia / Q000517:prevention & control; D015331:Cohort Studies; D004305:Dose-Response Relationship, Drug; D005260:Female; D006397:Hematinics / Q000627:therapeutic use; D006454:Hemoglobins / Q000378:metabolism*; D006801:Humans; D007564:Japan; D007676:Kidney Failure, Chronic / Q000097:blood / Q000401:mortality* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D006435:Renal Dialysis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013030:Spain; D015996:Survival Rate; D014481:United States
D006397:Hematinics; D006454:Hemoglobins