The morbidity and cost implications of hemodialysis clinical performance measures

Abstract

Clinical performance measures, including dialysis dose, hemoglobin, albumin, and vascular access, are the focus of monitoring and quality improvement activities. However, little is known about the implications of clinical performance measures for hospital utilization and health care costs. We obtained clinical performance measures and hospitalization records for a national random sample of 10,650 hemodialysis patients and analyzed the relationship between changes in clinical performance measures and hospital utilization after adjustment for patient demographic and medical characteristics. Higher hemoglobin, higher albumin, and fistula or graft use were independently associated with fewer hospitalizations, fewer hospital days, and decreased Medicare inpatient reimbursement. For example, a 0.5 g/dL higher hemoglobin, a 0.25 g/dL higher albumin, fistula use, and graft use were associated with hospitalization rate ratios of 0.90 (95% confidence interval 0.85, 0.96), 0.64 (0.53, 0.77), 0.60 (0.52, 0.69), and 0.79 (0.71, 0.89), respectively. Moreover, there was a 2-3-fold variation in hospital utilization across end-stage renal disease networks that was still evident after adjustment for patient characteristics and clinical performance measures. Clinical performance measures, especially albumin and vascular access, are strongly associated with hospital utilization and health care costs. These results highlight the importance of targeting nutrition and vascular access in quality improvement efforts. The marked variation in hospital utilization across networks deserves further examination.

Attainment of clinical performance targets and improvement in clinical outcomes and resource use in hemodialysis care: a prospective cohort study

“…This national longitudinal study shows that attainment of each of the individual targets is strongly associated with better outcomes, including decreased mortality, fewer hospitalizations, fewer days in the hospital, and lower overall Medicare hospital payments, validating the professional clinical practice guidelines [4]. A few studies of prevalent hemodialysis patients have shown associations of clinical performance target attainment with decreased hospital admissions and related costs [37,38], but this study adds to our knowledge of the effect of clinical performance target attainment in incident hemodialysis patients. Importantly, our results also provide new evidence that each additional target attained results in incremental improvement in these outcomes, regardless of which targets are attained, and provide a comprehensive examination of a variety of performance measures and outcomes.…”

“…However, whether attainment of accepted clinical performance targets for nutrition, bone disease management, anemia management, dialysis adequacy, and vascular access placement by hemodialysis patients have led to fewer hospitalizations, fewer hospital days, or decreased hospitalization costs, in addition to better patient survival, has been less well-studied [23,24]. In addition, the attainment of multiple clinical performance targets may or may not confer greater protection than the attainment of any single target.…”

Poor Hemodialysis Outcome Identifying Social Risk Factors in Elderly and Non-elderly Patients in Singapore

“…For hospitalization outcomes in particular, a study by Metcalfe, Khan, Prescott, Simpson, and Macleod (2003) on 526 hemodialysis patients showed that 77% of them required hospitalization during the first year of renal replacement therapy, with a median of 13 hospitalization days for each patient. This is a worrying trend, as hospitalization is the major component of the cost of care of patients on dialysis (O'Connor, Wish, & Sehgal, 2005;St. Peter, Khan, & Ebben, 2004).…”

Should a Fistula Always be “First”?

“…Abundant observational data support arteriovenous fistulas (fistulas) as the gold standard for vascular access in hemodialysis (HD) patients due to their optimal outcomes, such as better survival and lower cost (1)(2)(3). In contrast, central venous catheters (catheters), often placed for urgent dialysis or when a fistula has failed to mature, have been associated with increased risk of hospitalization (4) and death (5)(6)(7).…”