title: Differences between hospitals in attainment of parathyroid hormone treatment targets in chronic kidney disease do not reflect differences in quality of care.
abstract: BACKGROUND
  Transparency in quality of care (QoC) is stimulated and hospitals are compared and judged on the basis of indicators of performance on specific treatment targets. In patients with chronic kidney disease, QoC differed significantly between hospitals. In this analysis we explored additional parameters to explain differences between centers in attainment of parathyroid hormone (PTH) treatment targets.
  
  
  METHODS
  Using MASTERPLAN baseline data, we selected one of the worst (center A) and one of the best (center B) performing hospitals. Differences between the two centers were analyzed from the year prior to start of the MASTERPLAN study until the baseline evaluation. Determinants of PTH were assessed.
  
  
  RESULTS
  101 patients from center A (median PTH 9.9 pmol/l, in 67 patients exceeding recommended levels) and 100 patients from center B (median PTH 6.5 pmol/l, in 34 patients exceeding recommended levels), were included. Analysis of clinical practice did not reveal differences in PTH management between the centers. Notably, hyperparathyroidism resulted in a change in therapy in less than 25% of patients. In multivariate analysis kidney transplant status, MDRD-4, and treatment center were independent predictors of PTH. However, when MDRD-6 (which accounts for serum urea and albumin) was used instead of MDRD-4, the center effect was reduced. Moreover, after calibration of the serum creatinine assays treatment center no longer influenced PTH.
  
  
  CONCLUSIONS
  We show that differences in PTH control between centers are not explained by differences in treatment, but depend on incomparable patient populations and laboratory techniques. Therefore, results of hospital performance comparisons should be interpreted with great caution.
authors.affiliation: Department of Nephrology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. M.Peeters@nier.umcn.nl
authors.forename: Mieke J
authors.initials: MJ
authors.lastname: Peeters
authors.forename: Arjan D
authors.initials: AD
authors.lastname: van Zuilen
authors.forename: Jan A J G
authors.initials: JA
authors.lastname: van den Brand
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Blankestijn
authors.forename: Marc A G J
authors.initials: MA
authors.lastname: ten Dam
authors.forename: Jack F M
authors.initials: JF
authors.lastname: Wetzels
mesh_terms: D015415:Biomarkers / Q000097:blood; D015984:Causality; D015897:Comorbidity; D005260:Female; D006761:Hospitals / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D006962:Hyperparathyroidism, Secondary / Q000097:blood* / Q000453:epidemiology / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D017063:Outcome Assessment, Health Care; D010281:Parathyroid Hormone / Q000097:blood*; D015995:Prevalence; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D051436:Renal Insufficiency, Chronic / Q000097:blood* / Q000453:epidemiology / Q000628:therapy*; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D010281:Parathyroid Hormone