Processes of Care and Reduced Mortality among Hemodialysis Patients in the United States

Abstract

A major accomplishment of clinical nephrology during the past 15 years has been the substantial improvement in the quality of ESRD care. The proportion of underdialyzed patients in the United States was reduced from >60 to <10% of hemodialysis (HD) patients (1) (www.cms.gov/CPMProject/). Additional improvements have been observed during the past decade in the use of arteriovenous fistulas (AVFs) (2). In turn, better HD care has been associated with decreasing mortality among both prevalent and incident patients with ESRD (3). The association between temporal trends in mortality and better care persists after accounting for changes in other case-mix factors, and Wolfe et al. (4) showed that each 10% increase in the proportion of patients who received adequate HD was associated with a 2.2% decrease in case mix–adjusted mortality rates. These observations about improved quality of care and reduced mortality reflect information provided by a comprehensive, population-based ESRD surveillance system and national registry, composed of 18 regional Networks and the US Renal Data System (5). This surveillance system routinely collects, analyzes, and disseminates information about the occurrence, treatment, and outcomes of ESRD in the US population. The information is used to plan, implement, and evaluate interventions to reduce the occurrence and improve outcomes of individuals with ESRD. Examples of quality improvement interventions are those conducted by the ESRD Networks. The Networks use continuous quality improvement (CQI) to foster transfer and adoption of evidence-based HD practices (6) by ESRD treatment facilities (7). These CQI interventions have been shown to contribute independently to improved care (8,9). This system of data-driven, patient-oriented quality improvement predates …