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

3 October 2006 | Volume 145 Issue 7 | Pages 512-519

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.

Design: Cohort study.

Setting: Outpatient hemodialysis centers in the United States.

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

Measurements: 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.

Limitations: 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.

Editors' Notes Context Several intermediate outcomes are used to evaluate care in hemodialysis programs, but the relationship between these measures and patient outcomes is uncertain. Contribution The authors studied 4 intermediate outcome measures (anemia, serum albumin level, functioning vascular access, and dialysis adequacy) in a 5% random sample of all U.S. patients receiving long-term hemodialysis. Annual mortality rates in patients who met 0, 1, 2, 3, or 4 quality measures were 29%, 25%, 21%, 14%, and 7%, respectively. Cautions This study was unable to determine whether failure to meet an outcome measure was due to patient factors, such as severity of illness, or because of poor-quality care. Implications Failure to meet hemodialysis quality measures is associated with increased mortality and hospitalization rates. —The Editors

 

Author and Article 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{at}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.

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