A Randomized Evaluation of Two Health Care Quality Improvement Program (HCQIP) Interventions to Improve the Adequacy of Hemodialysis Care of ESRD Patients

Abstract

Abstract. End-stage renal disease (ESRD) Networks are quality improvement organizations that collect, analyze, and report information to clinicians and allied health providers about discrepancies between observed patterns of care of ESRD patients and what has been recommended by clinical practice guidelines. The Networks facilitate response to this information by assisting ESRD treatment centers to develop quality improvement programs to redress inadequate care. The authors evaluated this process of quality improvement by selecting 42 treatment centers in a single ESRD Network with the lowest facility-specific mean urea reduction ratio (URR). The treatment centers were randomly assigned to two intervention strategies: (1) feedback alone; (2) an intensive intervention that included feedback, workshops, distribution of educational materials and clinical practice guidelines, technical assistance with the development of quality improvement plans, and continued monitoring. The intensive intervention had greater improvement in the increased proportions of patients dialyzed with prescribed blood flow (P ϭ 0.02) and documented review of prescription (P ϭ 0.01). Furthermore, the mean center URR increased nearly 3% among intensive intervention centers (from 68.1 to 70.9) but only 0.09% among the feedback centers (68.2 to 69.1) (P ϭ 0.002). Similarly, time on dialysis increased 7.5 min on average among patients in intervention centers but decreased 2 min for patients in comparison centers (P ϭ 0.03). These results demonstrate that Network feedback, coupled with the intensive intervention, resulted in improvement in care that would otherwise not have occurred.

Geographic Concentration of Poverty and Arteriovenous Fistula Use among ESRD Patients

“…However, it is reasonable to suggest that the FF intervention, which included components that have been found effective in changing provider behavior, including feedback on performance 27 and active outreach, 28 and which was similar to earlier interventions by the ESRD networks, 21,22 may have had an independent effect on improvement in care.…”

“…18 Previous ESRD quality improvement interventions have been associated with reduction in gender and racial disparities and with reductions in regional variations in hemodialysis adequacy and anemia control. 19 Observational studies 20 and controlled evaluations 21,22 found an independent effect of these interventions on improved quality of care. Finally, these changes in quality of ESRD care were associated with improved survival 23 and a decreased center-tocenter variability in care.…”

The ‘Centre Effect’ in Nephrology: What Do Differences between Nephrology Centres Tell Us about Clinical Performance in Patient Management?

“…For example, a quality improvement program demonstrated an improvement in URR values in a prospective cohort design as well as a reduction in centre variation [28]. The same investigators followed this up by a randomised controlled trial of an intensive quality improvement intervention compared to standard feedback, and this showed significantly improved URR values in centres which used the intensive intervention [29]. …”

Learning from practice variation to improve the quality of care

“…There are undoubted methodological problems in evaluating QI interventions, because the 'unit of randomisation' is often at organisational level (eg a hospital or outpatient clinic) rather than at the level of the individual patient. However, randomised controlled trials are possible, 24,37 and other methodologies (eg rigorous time series analyses or stepped wedge design) can also provide convincing evidence. In addition, given that potential confounders are more difficult to predict than in traditional observational epidemiology, and that QI interventions cost money and might well have unintended consequences, rigorous evaluation should be considered mandatory.…”