Characteristics such as patient engagement, physician communication, and staff coordination may help to explain why some dialysis centers achieve higher patient survival rates than others, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN).
"The purpose of this study was simple: to figure out what top-performing dialysis units might be doing differently from bottom-performing units, and to translate those findings into a blueprint for action," comments Brennan M.R. Spiegel, MD, MSHS (VA Greater Los Angeles Healthcare System). "We identified many factors that may enhance survival in dialysis, and we hope our findings can pave the way for future quality improvement initiatives."
The researchers surveyed clinical staff members at 90 dialysis centers within three large dialysis organizations about center characteristics that could potentially affect patient outcomes. "We focused on a wide range of factors, including patient-level, provider-level, and facility-level characteristics," says Spiegel.
Nineteen unique characteristics were found to be associated with lower-than-expected mortality rates. These characteristics remained significant even after adjustment for "case mix" factors affecting mortality risk.
Staff at centers with above-expected survival rates reported that their patients were more "engaged" in their own care. Top-performing centers also reported stronger physician communication skills and interpersonal relationships.
The top-performing dialysis centers also had superior coordination and staff management and dietitians who were "more resourceful and knowledgeable. "Altogether, these characteristics explained more than 30 percent of the variation in mortality risk between dialysis centers, after other factors were taken into account.
Dialysis center characteristics "reflecting a coordinated, multidisciplinary environment" are associated with lower mortality rates, the results suggest. "Our study could not say for certain whether there is a cause-and-effect relationship between these factors and patient mortality," Spiegel adds. "But it can lay the groundwork for future research in this area as part of broader quality improvement efforts."
This study had some important limitations: it was based on reports by staff members from different dialysis facilities and did not include follow-up to assess patient outcomes over time. "Future research should take our list of potential 'best practices' for dialysis and see if implementing those practices makes a difference," adds Spiegel. "Optimally, this would happen in a randomized controlled trial."
Disclosures: The study was a joint effort of university investigators, Amgen, Inc., and several dialysis organizations, including DaVita, Inc., DCI, Renal Ventures Management, L.L.C, and Satellite Healthcare. Support was provided by a research grant from Amgen, Inc. Dr. Gitlin is an employee of Amgen, Inc. Dr. Allen Nissenson, Dr. Amar Desai, and John Moran are employees of DaVita, Inc. (Dr. John Moran was an employee of Satellite Healthcare, when the study was conducted.) Dr. Philip Zager is an employee of DCI. Dr. Tom Parker is an employee of Renal Ventures Management, L.L.C.
The article, entitled "Dialysis Practices That Distinguish Facilities with Below- versus Above-Expected Mortality" is online at http://cjasn.asnjournals.org, doi 10.2215/CJN.01620210.
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Journal
Clinical Journal of the American Society of Nephrology