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Improving the Quality of Hemodialysis Treatment
A Community-Based Randomized Controlled Trial to Overcome Patient-Specific Barriers
Ashwini R. Sehgal, MD;
Janeen B. Leon, MS,RD;
Laura A. Siminoff, PhD;
Mendel E. Singer, PhD;
Lisa M. Bunosky, BA;
Randall D. Cebul, MD
JAMA. 2002;287:1961-1967.
Context Mortality rates among US hemodialysis patients are the highest in the industrialized world at 23% per year. Measures of dialysis dose (Kt/V) correspond strongly with survival and are inadequate in one sixth of patients. Inadequate dialysis is also associated with increased hospitalizations and high inpatient costs. Our previous work identified 3 barriers to adequate hemodialysis: dialysis underprescription, catheter use, and shortened treatment time.
Objective To determine the effect of a tailored intervention on adequacy of hemodialysis.
Design and Setting Community-based randomized controlled trial with recruitment from April 1999 to June 2000 at 29 hemodialysis facilities in northeast Ohio.
Participants Forty-four nephrologists and their 169 randomly selected adult patients receiving inadequate hemodialysis.
Intervention Nephrologists were randomly assigned to an intervention (n = 21) or control (n = 23) group. For patients in the intervention group (n = 85), depending on the barrier(s) present, a study coordinator gave nephrologists recommendations about optimizing dialysis prescriptions, expedited conversion of catheters to surgically created grafts or fistulas, and educated patients about the importance of compliance with treatment time. Patients in the control group (n = 84) continued to receive usual care.
Main Outcome Measures Changes in Kt/V and specific barriers after 6 months.
Results At baseline, intervention and control patients had similar Kt/V measurements, specific barriers, and demographic and medical characteristics. After 6 months, intervention patients had 2-fold larger increases in Kt/V compared with control patients (+0.20 vs +0.10; P<.001) and were more likely to achieve their facility Kt/V goal (62% vs 42%; P = .01). Intervention patients also had nearly 3-fold larger increases in dialysis prescription (+0.16 vs +0.06; P<.001) and were 4 times more likely to change from use of catheters to use of fistulas/grafts (28% vs 7%; P = .04).
Conclusions An intervention tailored to patient-specific barriers resulted in increased hemodialysis dose. Extending this approach to the 33 000 persons in the United States receiving inadequate hemodialysis may substantially enhance patient survival, diminish hospitalizations, and decrease inpatient expenditures.
Author Affiliations: Division of Nephrology, MetroHealth Medical Center (Dr Sehgal, Mss Leon and Bunosky); Center for Health Care Research and Policy, MetroHealth Medical Center (Drs Sehgal, Singer, and Cebul); and Department of Medicine, (Drs Sehgal, Siminoff, and Cebul), Department of Epidemiology and Biostatistics (Drs Sehgal, Singer, and Cebul); and Center for Biomedical Ethics, Case Western Reserve University (Drs Sehgal and Siminoff, Cleveland, Ohio).
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