Dialysis Practices That Distinguish Top- Versus Bottom-Performing Facilities by Hemoglobin Outcomes

Spiegel, Brennan M.R.; Bolus, Roger; Desai, Amar A.; Zager, Philip; Parker, Tom; Moran, John; Bolus, Sally; Solomon, Matthew D.; Khawar, Osman; Gitlin, Matthew; Sul, Hack; Talley, Jennifer; Nissenson, Allen

doi:10.1053/j.ajkd.2010.02.346

« Previous Next »American Journal of Kidney Diseases
Volume 56, Issue 1 , Pages 86-94, July 2010

Dialysis Practices That Distinguish Top- Versus Bottom-Performing Facilities by Hemoglobin Outcomes

Brennan M.R. Spiegel, MD, MSHS
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
- UCLA/VA Center for Outcomes Research and Education (CORE), Los Angeles, CA
- Address correspondence to Brennan M.R. Spiegel, MD, MSHS, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, UCLA/VA Center for Outcomes Research and Education (CORE), 11301 Wilshire Blvd, Bldg 115, Rm 215, Los Angeles, CA 90073
Roger Bolus, PhD
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
- UCLA/VA Center for Outcomes Research and Education (CORE), Los Angeles, CA
Amar A. Desai, MD, MPH
- Department of Medicine, University of California, San Francisco, CA
- Department of Medicine, Stanford University, Palo Alto, CA
Philip Zager, MD
- Dialysis Clinic Inc (DCI), Nashville, TN
Tom Parker, MD
- Renal Ventures Managements LLC, Lakewood, CO
John Moran, MD
- Satellite Healthcare, Mountain View, CA
Sally Bolus, MBA
- UCLA/VA Center for Outcomes Research and Education (CORE), Los Angeles, CA
Matthew D. Solomon, MD, PhD
- UCLA/VA Center for Outcomes Research and Education (CORE), Los Angeles, CA
- Department of Medicine, Stanford University, Palo Alto, CA
Osman Khawar, MD, MPH
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
Matthew Gitlin, PharmD
- Amgen Inc, Thousand Oaks, CA
Hack Sul, MD, MPH
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
- UCLA/VA Center for Outcomes Research and Education (CORE), Los Angeles, CA
Jennifer Talley, MSPH
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- UCLA/VA Center for Outcomes Research and Education (CORE), Los Angeles, CA
Allen Nissenson, MD
- DaVita Inc, Segundo, CA

Received 19 July 2009; accepted 17 February 2010. published online 21 May 2010.

Background

Because there is wide variation in outcomes across dialysis facilities, it is possible that top-performing units use practices not shared by others. The Identifying Best Practices in Dialysis (IBPiD) Study seeks to identify practices that distinguish top- from bottom-performing facilities by key outcomes, including achievement of recommended hemoglobin targets.

Study Design

Observational study with cross-sectional study ascertainment of predictors and outcomes.

Predictors

Facility dialysis practices ascertained using practice surveys of dialysis staff who indicated their level of agreement that each practice occurs in their facility (1-6 on a Likert scale).

Setting & Participants

423 personnel in 90 dialysis facilities from 1 for-profit and 2 not-for-profit dialysis organizations.

Outcomes

Percentage of patients per month per facility with hemoglobin levels of 11-12 g/dL. We divided facilities by median into top- versus bottom-performing groups and compared mean scores for each practice using t tests. We report practices that were statistically significant and achieved at least a medium effect size (ES) ≥0.4.

Results

17 of 155 tested predictors were significant. Achievement of hemoglobin level targets was related most strongly to the use of chairside computers (ES, 0.8 [95% CI, 0.4-1.4]), extent/quality of educational videos (ES, 0.6 [95% CI, 0.2-1.1]), frequency of calling per diem staff if short staffed (ES, 0.6 [95% CI, 0.21-1.1]), policy that nurses pass written competency examinations before hire (ES, 0.6 [95% CI, 0.2-1.0]), and technician cannulation mastery (ES, 0.6 [95% CI, 0.2-1.1]).

Limitations

This is a cross-sectional study that can address only associations, not causations. Future research should measure the longitudinal predictive value of these practices.

Conclusions

High-performing facilities report more effective education programs, better staff management, higher staff competency, and higher use of chairside computers, a potential marker of information technology proficiency. This suggests that hemoglobin level management is enhanced by processes reflecting a coordinated multidisciplinary environment.

Index Words: Dialysis, anemia, best practice, outcomes