Original Investigation
Dialysis
Association Between Achievement of Hemodialysis Quality-of-Care Indicators and Quality-of-Life Scores

https://doi.org/10.1053/j.ajkd.2009.07.017Get rights and content

Background

Incremental achievement of quality indicator goals has been associated with progressive improvement in mortality and hospitalization risk in hemodialysis (HD) patients.

Study Design

Descriptive cross-sectional study.

Setting & Participants

All 33,879 HD patients treated at Fresenius Medical Care North America facilities for >90 days with scorable 36-Item Short Form Health Survey responses from January 1, 2006, to December 31, 2006.

Predictor

We hypothesized that achieving up to 5 HD goals before the survey (albumin ≥ 4.0 g/dL, hemoglobin of 11-12 g/dL, equilibrated Kt/V ≥ 1.2, phosphorus of 3.5-5.5 mg/L, and absence of HD catheter) results in better self-reported quality of life (QoL).

Outcomes & Measurements

Distributions of Physical and Mental Component Summary (PCS/MCS) scores within and across quality indicator categories determined during the prior 90 days from survey date (compared using analysis of covariance and linear regression models, with adjustment for case-mix and each of the quality indicators).

Results

Incremental achievement of up to 5 goals was associated with progressively higher PCS and MCS scores (both P for trend < 0.001). Compared with patients meeting all 5 goals (n = 4,208; reference group), case-mix–adjusted PCS score was lower by 1.8 point with only 4 goals met (n = 11,785), 3.4 points for 3 goals (n = 10,906), 4.9 points for 2 goals (n = 5,119), 5.9 points for 1 goal (n = 1,592), and 7.8 points in the 269 patients who failed to meet any goal (each P < 0.001 vs the reference group). The corresponding decreases in case-mix–adjusted MCS scores were 1.0 point for 4 goals met, 1.7 point for 3 goals, 2.3 points for 2 goals, 3.0 points for 1 goal, and 4.7 points with no goal met, with each P < 0.001 compared with the MCS score from patients who achieved all 5 goals.

Limitations

Potential residual confounding from unmeasured covariates.

Conclusion

Patients progressively meeting more quality goals report incrementally better QoL. Further studies are needed to determine whether prospective achievement of quality goals will result in improved QoL for HD patients.

Section snippets

Study Population

An automated reminder alerts the social worker to offer the SF-36 survey to all patients initiating dialysis therapy in Fresenius Medical Care, North America (FMCNA) facilities after their 45th day, and upon completion (or refusal to participate), at 6-month intervals thereafter. Between January 1, 2006, and December 31, 2006, a total of 61,033 maintenance HD patients from 1,084 FMCNA-legacy dialysis facilities with vintage >90 days were provided the opportunity to complete the survey. Of

Results

Characteristics of the 33,879 patients who formed our study cohort (56% response rate) are listed side by side with those from 27,154 nonresponders in Table 1. The responders' mean age was 61.5 ± 14.8 years, with 54% white, 47% women, 55% with diabetes, and a mean vintage of ∼3.7 years, similar to nonresponders' characteristics except for slight overrepresentation of white race. Mean PCS and MCS scores obtained for the study cohort were 33.2 ± 10.6 and 48.2 ± 11.2, respectively. Each of 8 SF-36

Discussion

To our knowledge, this national cross-sectional study represents the largest cohort of patients with ESRD on HD therapy with QoL information reported to date. The SF-36 response rate of 56% compares favorably with 47.6% for American patients reported in the Dialysis Outcomes and Practice Pattern Study (DOPPS).11 Responders were demographically similar to nonresponders, although there was slight overrepresentation of white race. We found the distribution of PCS and MCS scores remarkably

Acknowledgements

We thank Dr Fred Finkelstein for providing helpful suggestions for analyzing QoL information; FMCNA social workers for diligently attempting to collect QoL information from our dialysis patients; and Norma Ofsthun and Lori Vienneau for sharing their automated SF-36 scoring algorithm (in SAS) that has been used extensively in prior FMCNA projects.

Support: None.

Financial Disclosure: None.

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    Originally published online as doi:10.1053/j.ajkd.2009.07.017 on September 27, 2009.

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