Improving compliance with the dialysis prescription as a strategy to increase the delivered dose of hemodialysis: an ESRD Network 4 quality improvement project.

Delivery of an inadequate dose of hemodialysis is associated with a significant increase in the relative risk of both hospitalization and death. We hypothesized that noncompliance with the dialysis prescription, defined as failure to achieve the prescribed blood flow, failure to dialyze for the prescribed duration, or failure to use the prescribed dialyzer, was a significant factor in patients not achieving a urea reduction ratio (URR) of > or =0.65. We identified the 29 dialysis facilities in ESRD Network 4 that had the lowest average URR and/or lowest percent of patients with a URR > or =0.65 based on quarterly data reports. Each facility was surveyed by review of all dialysis treatment sheets from a single week by network staff to evaluate for noncompliance with the dialysis prescription. Facility-specific data were reported back to each facility. Each facility was required to develop a facility-specific quality improvement plan after receiving intensive education on the quality improvement process. After 9 months the facilities were resurveyed. Although the compliance with the dialysis prescription decreased from 54.0% to 53.6% (P =.026), the delivered URR increased from 0.679 +/- 0.072 to 0.688 +/- 0.070 (P =.026) with an increase in the percentage of patients with a URR > or = 0.65 from 69.7% to 75% (P =.0096). Kt/V increased from 1.37 +/- 0.26 to 1.41 +/- 0.27 (P =. 0001). Analysis of the process changes instituted by the individual facilities showed an increase in the prescribed dose of dialysis. Thus, although the process goal of improved compliance with the dialysis prescription was not achieved, the outcome goal of an increased delivered dose of dialysis was met through an alternative process change of an augmented dialysis prescription.

Palevsky PM ，Washington MS ，Stevenson JA ，Rohay JM ，Dyer NJ ，Lockett R ，Perry SB ... -  《advances in renal replacement therapy》

Improving adequacy of hemodialysis in Northern California ESRD patients: a final project report. Provider Participants and Medical Review Board of the TransPacific Renal Network.

Brown J ，Josephson M 《advances in renal replacement therapy》

Barriers to the delivery of adequate hemodialysis in ESRD Network 4.

Dialysis dose has been established as a determinant of morbidity and mortality in chronic hemodialysis patients. To identify remediable barriers to the delivery of adequate hemodialysis, we examined factors that affected adherence to prescribed dialysis dose. End-Stage Renal Disease (ESRD) Network 4 facilities that fell into the lowest quintile in measures of dialysis adequacy were studied. At the time of this study, Network 4 was composed of 178 dialysis facilities in Delaware and Pennsylvania. Those 29 facilities had an average delivered urea reduction ratio (URR) of <0.67 and/or 71% of patients with a URR of 0.65. (The mean URR value of Network 4 was 0. 699 with a compliance ratio of 80%.) Dialysis treatment sheets were reviewed for all patients in the 29 facilities for all treatments during a calendar week. Predialysis and postdialysis blood urea nitrogen (BUN) values from 1 treatment during this week were used to calculate URR and Kt/V. A total of 1,339 patients with a mean age of 61.9 +/- 15.1 years and a mean duration of ESRD of 3.4 +/- 3.3 years were dialyzed in the 29 units. Mean prescribed duration of dialysis (T) was 219 +/- 26 min. with a mean blood flow rate (BFR) of 393 +/- 62 mL/min. Concordance between the prescribed and delivered T (-5 min), BFR (-50 mL/min), and hemodialyzer were assessed, by patient, for each treatment (Tx). Characteristics of a delivered Kt/V < 1.2 were duration <4 hours, BFR < 350 mL/min, patient weight > 100 kg, and delivered BFR 50 mL/min less than prescribed BFR. Multivariate analysis of the relationship between delivered dose of dialysis and patients and treatment characteristics identified black race, male gender, and younger age as demographic factors associated with low delivered dose. Potential remediable barriers identified by this analysis included reduced treatment time (>10%) and use of catheters for angioaccess. These data suggest components of the dialysis process that might be targeted in future quality improvement projects to improve the adequacy of dialysis delivery.

Palevsky PM ，Washington MS ，Stevenson JA ，Rohay JM ，Dyer NJ ，Lockett R ，Perry SB ... -  《advances in renal replacement therapy》

Can dialysis therapy be improved? A report from the ESRD Core Indicators Project.

McClellan WM ，Frankenfield DL ，Frederick PR ，Flanders WD ，Alfaro-Correa A ，Rocco M ，Helgerson SD ... -  《-》

Adequacy of peritoneal dialysis: a quality improvement project of The Renal Network, Inc (Illinois, Indiana, Kentucky, and Ohio).

The Renal Network, Inc, (end-stage renal disease [ESRD] Networks 9 and 10) from the states of Illinois, Indiana, Kentucky, and Ohio includes approximately 4,250 peritoneal dialysis patients. To better assess the state of peritoneal dialysis in Networks 9 and 10, we undertook a peritoneal dialysis prescription adequacy quality improvement project. Adequacy and facility practice information were obtained from a 100% sample of peritoneal dialysis patients in the Networks. The mean total Kt/V urea for those facilities with a written policy for adequacy measurement was 2.18 +/- 0.66 versus a mean of 2.13 +/- 0.70 for those facilities without a written policy (P = not significant [NS]). The mean total Kt/V urea for those facilities with a written procedure was 2.17 +/- 0.66 versus a mean of 2.12 +/- 0.70 for those facilities without a written procedure (P = NS). There was a significant positive relationship between the observed total Kt/V urea and the frequency of measurement (P <.001). No relationship existed between the value of the D/P creatinine ratio and the weekly dialysis Kt/V. This study supports the recommendation of frequent measurement of peritoneal dialysis adequacy.

Brier ME ，Erbeck KM 《-》