Use of standardized ratios to examine variability in hemodialysis vascular access across facilities

Sehgal, Ashwini R.; Silver, Marcia R.; Covinsky, Kenneth E.; Coffin, Richard B.; Cain, Jeannette A.

doi:10.1016/s0272-6386(00)70337-4

Cited by 28 publications

(21 citation statements)

References 12 publications

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“…Despite the dissemination of K/DOQI guidelines (11), data indicate that adjusted outcomes vary by up to 30% between U.S. dialysis facilities (12)(13)(14)(15)(16). It is possible that top-performing facilities enact specific practices that bottom-performing facilities do not enact.…”

Section: Discussionmentioning

confidence: 99%

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Identifying Best Practices in Dialysis Care

Desai

Bolus

Nissenson

et al. 2008

Clinical Journal of the American Society of Nephrology

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Background and objectives: Because there is wide variation in case-mix adjusted outcomes across dialysis facilities, it is possible that top-performing facilities use practices not shared by others. We sought to catalogue "best practices" that may account for interfacility variations in outcomes.Design, setting, participants, & measurements: This multidisciplinary study identified candidate best practices in dialysis through a staged process, including systematic review, cognitive interviews, and a national "virtual focus group" of dialysis providers. The resulting candidate practices were rank-ordered by perceived importance as determined by mean RAND Appropriateness Scores from a national survey of nephrologists, nurses, and opinion leaders.Results: A total of 155 candidate best practices were identified. Among these, respondents believed dialysis outcomes are most strongly related to 1) characteristics of multidisciplinary care conferences, 2) technician proficiency in protecting vascular access, 3) training of nurses to provide education in fluid management, vascular access, and nutrition, 4) use of random and blinded audits of staff performance, and 5) communication and teamwork among staff. In contrast, there was wide disagreement about the importance of facility-based health maintenance practices, optimal staffing ratios, frequency of dialysis-based physician visits, and optimal frequency of multidisciplinary care.Conclusions: This study provides a "conceptual map" of candidate dialysis best practices and highlights areas of general agreement and disagreement. These findings can help the dialysis community think critically about what may define "best practice" and provide targets for future research in quality improvement.

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Section: Discussionmentioning

confidence: 99%

“…Yet despite the dissemination of practice guidelines (11), considerable variation remains in achievement of CPM targets and overall mortality across facilities (12)(13)(14)(15)(16). Although outcome variation is a natural byproduct of variations in patient populations, data indicate that outcome variation persists even after case-mix adjustment (12,14,16).…”

mentioning

confidence: 99%

Identifying Best Practices in Dialysis Care

Desai

Bolus

Nissenson

et al. 2008

Clinical Journal of the American Society of Nephrology

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“…Information on the use of dialysis catheters was not reported. However, in a recent analysis involving fewer subjects, significant variation among dialysis units was observed for the chronic use of central vein catheters (14). The observation of substantial variability in the choice of angioaccess after controlling for baseline patient variables suggests that physician practice patterns may play a substantial role in angioaccess selection.…”

Section: Abstract the Centers For Medicare And Medicaid Service's (Cmsmentioning

confidence: 97%

“…These include the patient's gender, race, age, presence of diabetes mellitus, anthropometric attributes, and duration of renal replacement therapy (13,14). In 1993, a profile of angioaccess type in the United States developed from Medicare billing data observed that fewer than 30% of maintenance hemodialysis patients were dialyzed using an AVF (13).…”

Section: Abstract the Centers For Medicare And Medicaid Service's (Cmsmentioning

confidence: 99%

National Profile of Practice Patterns for Hemodialysis Vascular Access in the United States

Reddan

Klassen

Frankenfield³

et al. 2002

Journal of the American Society of Nephrology

118

110

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ABSTRACT. The Centers for Medicare & Medicaid Service’s (CMS), national End-Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project is a data collection initiative to identify opportunities for improvement of care to adult, Medicare maintenance dialysis beneficiaries. This analysis of 1999 CPM data characterizes the profile of hemodialysis vascular access in the United States and identifies determinants of vascular access type 2 yr after the translation of vascular access clinical practice guideline statements into national CPMs. CPM data were collected during October to December 1999 and stratified by the 18 regional ESRD networks. Univariate and multivariable analyses were conducted to examine associations of access type with demographic, laboratory, and geographic variables. Multivariable logistic regression analyses were performed to identify independent variables associated with access type. A total of 8154 hemodialysis patients were sampled; 17% (n = 1399) were incident. Twenty-eight percent were dialyzed through an autologous arteriovenous fistula (AVF), 49% through a prosthetic graft (AVG), and 23% through a percutaneous catheter. Independent predictors of having a catheter for hemodialysis were female gender, white race, incident to hemodialysis status, and lower hemoglobin and serum albumin. For patients with a fistula or AVG, female gender (odds ration [OR], 2.46 [2.18 to 2.78]) and black race (OR, 1.70 [1.50 to 1.93]) were the strongest predictors of dialysis through an AVG. Other predictors of dialysis through an AVG were older age, increased body mass index (BMI), diabetes mellitus as the cause of ESRD, and lower serum albumin. Even in adjusted analyses, there was significant geographic variability with respect to hemodialysis access type. Despite translation of practice guidelines for hemodialysis vascular access into national CPMs, there is substantial geographic variability and gender and racial disparity in angioaccess allocation in the United States. Quality improvement strategies to improve the prevalence of fistulae should focus on selected regions and include physician education about their practice patterns and potential biases.

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“…The prevalence of autologous fistulae in the USA varies markedly among dialysis units, with a significant increase in those units adopting the DOQI recommendations [6,7]. Various factors such as age, gender, or late referral cannot explain the large regional variation, and adjustment for patient characteristics using standardized ratios was unable to clarify the variability of access types across facilities [8]. Easily one comes to the conclusion that the access surgeon is probably the source of variance.…”

Section: Discussionmentioning

confidence: 99%

Influence of Surgeons’ Specialty on the Selection of Vascular Access for Hemodialysis Treatment

et al. 2002

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Background/Aim: Various patient-related factors could not explain the variability of access types across facilities in the published literature. The aim of this study was to investigate the influence of surgeons’ specialty on access type selection for hemodialysis treatment. Methods: The directors (nephrologists) of all renal units in Greece (n = 92) were surveyed by a closed questionnaire. Results: The response rate was 75%. There was no statistically significant difference in the percentage of patients predominantly with autologous arteriovenous fistulae between units where only vascular surgeons were performing access surgery and those where either general surgeons or transplant surgeons were operating (mean value in all renal units 80.8% , range 43–97%). However, the difference between the three groups of renal units regarding their surgeons’ ability to create complex access procedures and to correct complications (as an index of surgeons’ skill) was statistically significant (p < 0.001). Conclusion: The general surgeons of the new generation are not often using vascular surgical techniques and may have less opportunities to develop expertise in vascular access creation.

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Use of standardized ratios to examine variability in hemodialysis vascular access across facilities

Cited by 28 publications

References 12 publications

Identifying Best Practices in Dialysis Care

Identifying Best Practices in Dialysis Care

National Profile of Practice Patterns for Hemodialysis Vascular Access in the United States

Influence of Surgeons’ Specialty on the Selection of Vascular Access for Hemodialysis Treatment

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