Improving adequacy of hemodialysis in Northern California ESRD patients: Afinal project report

The National Core Indicators Project, initiated in 1994, has brought progre ssive changes in adequacy of dialysis for end-stage renal disease (ESRD) pa tients in the TransPacific Renal Network and across the United States. The 1998 Core Indicator Project showed each Network's standing for percentage o f patients with urea reduction ratio (URR) greater than or equal to 0.65 an d average URR. The TransPacific Renal Network ranked 12th among the 18 Netw orks for this adequacy measure. The goals of this project were to improve t he Network standing in the United States for the percent of patients with U RR greater than or equal to 0.65, eliminate or reduce the barriers to achie ving adequate dialysis, and evaluate URR versus KT/V data and the variances occurring with these measures. In January 1999, data were collected from a ll 113 Northern California hemodialysis facilities for quarter 4, 1998, to evaluate adequacy. Each facility provided patient population (N) for KT/V a nd URR samples, facility averages for KT/V and URR, number of patients with KT/V greater than or equal to 1.2 and URR greater than or equal to 0.65, a nd data on post-blood-urea-nitrogen (BUN) sampling methods. A random select ion of 10% (12) providers with data below the US and Network standards was selected for an intensive assessment. Using baseline measurements, on-site data were collected from a random selection of the patient population. Char t data were reviewed, analyzed, and discussed in an exit interview with the facility management. On-site visits were performed in July/June 1999. The primary focus included adequacy data and process of care that affect adequa cy outcomes, concurrent review of patients receiving treatment at the time of the site visit, and general medical record review. In Phase I, only 12 f acilities showed an average URR below 0.65. All facilities reported an aver age KT/V greater than the DOQI target of 1.2. Forty-two facilities had thei r percentage of patients with a URR below the national benchmark; only 18 f acilities had their percentage of patients with a KT/V below the national b enchmark. Only 9% (n = 8) of the 113 providers had a variance in post-BUN s ampling methodologies that could be related to the clinical measure of adeq uacy. In Phase II, a random selection of 12 providers with data below US an d Network standards was made for an intensive assessment. A total of 217 pa tient records were reviewed from a population of 1,027. In addition to comp arison of baseline data, each facility was assessed for barriers to achievi ng adequacy outcomes. The number of problems was extensive and specific to each facility; however, a common reoccurring theme in the majority of event s was the lack of supporting documentation for changes to the plan of care when variances occur. The most common occurrences were incorrect blood flow and dialysate flow with no supporting documentation on record for the pres cription not being met. In Phase III, Network interventions for facilities not meeting US and Network standards for adequacy as measured by URR and KT /V included required quarterly reporting on their facility-specific quality improvement programs for adequacy. In addition the 12 facilities that part icipated in the intensive assessment had additional interventions that incl uded an educational "tool box" focused on documentation, legal implications of charting, and general medical records management, and an educational pr ogram to review information to be shared with facility staff. All on-site f acilities reported ongoing quality improvement programs. In some facilities they did provide a focus on processes and not only a measurement of an ind icator. All facilities reported a team concept of some type used in their program. Although there were similarities in the facilities, each facility presented with a unique combination of barriers. In addition to a large patient-to-R N ratio, the lack of technical education for the unlicensed assistive perso nnel on processes and outcomes appears to play a significant role in the ac hievement of adequate dialysis. Although there were enhanced hemodialysis a dequacy outcomes, it is likely that the project itself generated an intense focus on this clinical measure. All hemodialysis facilities in Northern Ca lifornia use KT/V as the preferred measurement tool for adequacy. A number of facilities related that URR alone does not adequately or accurately pred ict outcomes of a treatment. In some facilities it was reported that URR wa s not used in planning treatment options for their beneficiaries, only a KT /V measurement. (C) 2000 by the National Kidney Foundation, Inc.