Dialysis Stations Research Articles

Involvement of healthcare staff in hospital hygiene during emergency hemodialysis.

Healthcare-associated infections are still a worrying health problem that complicates patient care and increases morbidity and mortality. The incidence of infections in hemodialysis patients is still high and they constitute the second cause of hospitalization and death in this category. The study's objective was to evaluate nursing and medical staff's involvement in hospital hygiene. This is an observational study that took place within the hemodialysis unit of a Moroccan university hospital from March 2021 to June 2021. A surface swabbing technique for bacteriological examination was also carried out. The study revealed some shortcomings regarding hand hygiene which was respected by the nurses in only 17.5% of sessions and in 42.2% by the doctors. Other shortcomings in asepsis measures, were also noted such as the non-change of gloves after skin preparation (1.03%) and before manual compression. The serological status of patients concerning HBV, HVC, and HIV was also not always known (31.1%). The bacteriological samples from the surfaces also showed colonization of the medical devices and the ultrasound scanner used for the ultrasound-guided introduction of the central catheters. The results of the study showed some deviations concerning the recommendations; however, they are comparable to other studies conducted internationally, especially in terms of hand hygiene. Our study results highlight some shortcomings adherence to hygiene measures like inconsistent disinfection of medical devices and dialysis stations, as well as insufficient hand hygiene practices among some staff members. However, we observed an improvement in practices following the implementation of awareness-raising sessions. To maintain improved hygiene practices and prevent infections, it is crucial to provide ongoing training for staff, ensure adequate resources, and regularly monitor compliance with hygiene standards.

#1705 Central delivery of acid concentrate for haemodialysis: a single-center experience

Abstract Background and Aims Dialysate is produced by mixing ultra-purified water with acid and bicarbonate concentrates. Acidic concentrate for hemodialysis can be supplied to the dialysis machine through single-use bags or central concentrate supply. Central delivery of acid concentrate represents an innovation in hemodialysis settings in terms of practicality and eco-sustainability as this system is able to produce and distribute ready-to-use acid dialysis concentrate without the use of acid concentrate bags. The aim of our study was to compare the amount of material (including packaging) used to supply acid concentrate using a single-use bag (3.8 L or 4.5 L) or central acid supply at the Nephrology Dialysis and Renal Transplant Unit of Azienda Ospedaliero Universitaria di Modena, Modena, Italy. In particular, we reviewed the amount of consumable material before (January-December 2019) and after the implementation of central concentrate supply (July 2022-June 2023). Lastly, a survey was delivered to all dialysis nurses who work in our dialysis Center to evaluate their feedback on central concentrate supply. Method Our center is equipped with 46 dialysis stations for patients on chronic hemodialysis that in 2019 delivered 30 000 hemodialysis treatments distributed across morning, afternoon, and evening shifts. Granumix system® (Fresenius Medical Care, Bad Homburg, Germany) was installed in 2022. It produces and distributes acid concentrate fluid with two different concentrations of K+ (2 and 3 mEq/L) and a unique concentration of Ca2+ 1.5 mmol/L (see Figure). Results The data collected in 2019 at our Dialysis Center showed that 30 000 acid bags corresponding to 121 000 L of acid concentrate fluid were used to perform hemodialysis. Utilization of bags generated 3 750 kg of pallets, 4 500 kg of plastic and 5 367 kg of boxes. Considering that approximately 10% of the acid concentrate fluid remains unused during each dialysis treatment, approximately 12 000 L of unutilized acid concentrate fluid was wasted. Following the introduction of the Granumix® system, there was a significant reduction (−80.6%) in the utilization of single-use acid concentrate bags (n = 5 805) and, consequently, in the use of boxes (n = 2 294 vs. n = 11 667) and pallets (n = 40 vs. n = 208). The centralized distribution system of acid concentrate led to a significant reduction in waste including boxed, plastic and pallets (2 642 kg vs. 13 617 kg), disposal of residual acidic solution (2 351 liters vs. 12 100 liters), and handling of materials by dialysis staff (37 522 kg vs. 158 117 kg). Another advantage of this system is the optimized usage of acid concentrate fluid. This system ensures that only the required amount of acid for a specific treatment is used, effectively minimizing waste and decreasing the production of special waste. The results of the survey (response rate 75%) documented that 79.5% of the nurses received adequate training for its use; 94.9% experienced a reduction in fatigue and 84.6% declared that had more time to dedicate to patients. Lastly, the survey showed that 96.4% of the participants were completely satisfied with the implementation of this new system. Conclusion Central delivery of acid concentrate is an innovative solution with eco-sustainable potentialities in reducing the consumable materials and workload in hemodialysis. Overall, most nurses expressed satisfaction as this system reduces dialysis staff workload and allows more time for patient care.

Facility-Level Factors and Racial Disparities in Cardiopulmonary Resuscitation within US Dialysis Clinics.

Cardiac arrest occurs frequently in outpatient dialysis clinics, and immediate cardiopulmonary resuscitation (CPR) provision improves patient outcomes. However, Black patients in dialysis clinics receive CPR from clinic staff less often compared with White patients. We examined the role of dialysis facility resources and patient factors in the observed racial disparity in CPR receipt and automated external defibrillator application. This was a retrospective cohort study linking the National Cardiac Arrest Registry to Enhance Survival and Medicare Annual Dialysis Facility Report registries from 2013 to 2017. We identified patients experiencing cardiac arrests within US outpatient dialysis clinics via geolocation matching (N=1554). Differences in facility size, quality, staffing, and patient-related factors were summarized and compared according to patient race. Multilevel multivariable logistic regression models including these factors were used to examine the influence of these factors on the observed disparity in CPR rates between Black and White patients. Compared with White patients, Black cardiac arrest patients dialyzed in larger facilities (26 versus 21 dialysis stations; P<0.001), facilities with fewer registered nurses per station (0.29 versus 0.33; P<0.001), and facilities with lower quality scores (# citations 6.8 versus 6.3; P=0.04). Facilities treating Black patients cared for a higher proportion of patients with a history of cardiac arrest (41% versus 35%; P<0.001), HIV/hepatitis B, and Medicaid-enrolled patients (15% versus 11%; P<0.001). Even after accounting for these differences and other covariates, the racial disparity for CPR in Black versus White patients persisted (OR=0.45; 95% CI, 0.27 to 0.75). The racial disparity in CPR was greater among older patients compared with younger patients (interaction P=0.04). The racial disparity in CPR delivery within dialysis clinics was not explained by differences in facility resources and quality. Reducing this disparity will require a multifaceted approach, including developing dialysis clinic-specific protocols for CPR and addressing potential implicit bias.

Oral Mucosa Status and Saliva Parameters of Multimorbid Adult Patients Diagnosed with End-Stage Chronic Kidney Disease.

There has been an increasing number of patients diagnosed with chronic diseases. Many of those diseases determine changes in patients’ social and even professional life. The aim of the present work was to analyze saliva and oral mucosa parameters in adult patients diagnosed with chronic diseases. A total of 228 patients took part in the research. A total of 180 patients were hemodialyzed in Diaverum dialysis stations, and there were 48 patients from the Conservative Dentistry with Endodontics Clinic of the Academic Centre of Dentistry of Silesian Medical University in Bytom and patients from the dentistry division of the Arnika Clinic in Zabrze not diagnosed with any such diseases. Selected saliva parameters (secretion, pH and buffer capacity) and mucosa status were examined. In order to obtain information regarding xerostomia, patients were given a questionnaire. Patients assigned to the control group rarely used water to make swallowing easier or used candies to lessen the feeling of oral cavity dryness. They also rarely suffered from eye dryness. The feeling of dryness also did not influence their social life. The amount of produced saliva was higher in the control group. There was a significantly lower percentage of patients with a low buffer capacity of saliva. There were no differences in terms of saliva pH values between the two groups of patients. A significantly lower number of patients were diagnosed with ecchymosis, candidiasis, scrotal tongue and mechanical damages. Patients diagnosed with chronic diseases need to be provided with long-term care.

COVID-19 modeling and non-pharmaceutical interventions in an outpatient dialysis unit.

This paper describes a data-driven simulation study that explores the relative impact of several low-cost and practical non-pharmaceutical interventions on the spread of COVID-19 in an outpatient hospital dialysis unit. The interventions considered include: (i) voluntary self-isolation of healthcare personnel (HCPs) with symptoms; (ii) a program of active syndromic surveillance and compulsory isolation of HCPs; (iii) the use of masks or respirators by patients and HCPs; (iv) improved social distancing among HCPs; (v) increased physical separation of dialysis stations; and (vi) patient isolation combined with preemptive isolation of exposed HCPs. Our simulations show that under conditions that existed prior to the COVID-19 outbreak, extremely high rates of COVID-19 infection can result in a dialysis unit. In simulations under worst-case modeling assumptions, a combination of relatively inexpensive interventions such as requiring surgical masks for everyone, encouraging social distancing between healthcare professionals (HCPs), slightly increasing the physical distance between dialysis stations, and—once the first symptomatic patient is detected—isolating that patient, replacing the HCP having had the most exposure to that patient, and relatively short-term use of N95 respirators by other HCPs can lead to a substantial reduction in both the attack rate and the likelihood of any spread beyond patient zero. For example, in a scenario with R0 = 3.0, 60% presymptomatic viral shedding, and a dialysis patient being the infection source, the attack rate falls from 87.8% at baseline to 34.6% with this intervention bundle. Furthermore, the likelihood of having no additional infections increases from 6.2% at baseline to 32.4% with this intervention bundle.

Variation in Waitlisting Rates at the Dialysis Facility Level in the Context of Goals for Improving Kidney Health in the United States

Variation in Waitlisting Rates at the Dialysis Facility Level in the Context of Goals for Improving Kidney Health in the United States

COVID-19 infection control measures and outcomes in urban dialysis centers in predominantly African American communities

BackgroundEmory Dialysis serves an urban and predominantly African American population at its four outpatient dialysis facilities. We describe COVID-19 infection control measures implemented and clinical characteristics of patients with COVID-19 in the Emory Dialysis facilities.MethodsImplementation of COVID-19 infection procedures commenced in February 2020. Subsequently, COVID-19 preparedness assessments were conducted at each facility. Patients with COVID-19 from March 1–May 31, 2020 were included; with a follow-up period spanning March–June 30, 2020. Percentages of patients diagnosed with COVID-19 were calculated, and characteristics of COVID-19 patients were summarized as medians or percentage. Baseline characteristics of all patients receiving care at Emory Dialysis (i.e. Emory general dialysis population) were presented as medians and percentages.ResultsOf 751 dialysis patients, 23 (3.1%) were diagnosed with COVID-19. The median age was 67.0 years and 13 patients (56.6%) were female. Eleven patients (47.8%) were residents of nursing homes. Nineteen patients (82.6%) required hospitalization and 6 patients (26.1%) died; the average number of days from a positive SARS-CoV-2 (COVID) test to death was 16.8 days (range 1–34). Two patients dialyzing at adjacent dialysis stations and a dialysis staff who cared for them, were diagnosed with COVID-19 in a time frame that may suggest transmission in the dialysis facility. In response, universal masking in the facility was implemented (prior to national guidelines recommending universal masking), infection control audits and re-trainings of PPE were also done to bolster infection control practices.ConclusionWe successfully implemented recommended COVID-19 infection control measures aimed at mitigating the spread of SARS-CoV-2. Most of the patients with COVID-19 required hospitalizations. Dialysis facilities should remain vigilant and monitor for possible transmission of COVID-19 in the facility.

Periodontal Treatment Needs of Hemodialized Patients.

End-stage renal failure is the reason for complications in many systems and organs, and the applied pharmacotherapy often causes the deepening of already existing pathologies within the oral cavity, such as: caries, periodontal diseases, mucosal lesions or reduced saliva secretion. Reduced saliva secretion results in an increased accumulation of dental plaque, its mineralization and prolonged retention, which leads to the development of gingival and periodontal inflammation. There is some evidence that chronic kidney diseases are influenced by periodontal health. The aim of the work was to evaluate the dental needs by the usage of clinical assessment of periodontal tissues of patients suffering from end-stage chronic kidney disease, arterial hypertension or/and diabetes mellitus. Material and methods: 228 patients underwent the research. 180 patients were hemodialized in Diaverum dialysis stations (42 of them were diagnosed with end stage chronic disease, 79 with the end stage chronic disease and arterial hypertension, 16 with end stage chronic kidney disease and diabetes, 43 with end-stage chronic disease, arterial hypertension and diabetes) and 48 patients of the Conservative Dentistry with Endodontics Clinic of Academic Centre of Dentistry of Silesian Medical University in Bytom and patients of the dentistry division of Arnika Clinic in Zabrze not diagnosed with any of the aforementioned diseases. The scheme of the research comprised 2 parts: analysis of the general health and assessment of the periodontal status which contain the following indices: Periodontal Probing Depth (PPD), Clinical Attachment Lost (CAL), Bleeding Index or Bleeding on Probing Index (BI or BOP), Community Periodontal Index for Treatment Needs (CPITN). Results: Significantly lower percentage of patients with healthy periodontal tissues and higher percentage with periodontal pockets deeper than 3.5 mm and the loss of trainers connective of 5 mm or higher were in the examined group. The values of the bleeding index were significantly lower in control group. The analysis of the CPITN index indicates higher percentage of patients qualified as CPI 1 or 2 in the control group while in the examined one most of the patients turned out to require specialist periodontal treatment. Conclusions: there is a direct relationship between periodontal status and end-stage renal disease which typically includes other chronical civilization ailments. It is important to develop a scheme for the easy and rapid examination of periodontal status, to determine the treatment needs in this area, which will allow precise assignment of long-term dialyzed patients to the range of prophylactic and therapeutic procedures.

Distribution of SARS-CoV-2 Positive Tests, Dialysis Stations, and Household Poverty Within Cook County, Illinois

Distribution of SARS-CoV-2 Positive Tests, Dialysis Stations, and Household Poverty Within Cook County, Illinois

Dialysis, COVID-19, Poverty, and Race in Greater Chicago: An Ecological Analysis

Rationale & ObjectivePersons with end-stage kidney disease receiving in-center maintenance hemodialysis may be at high risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure and severe outcomes with coronavirus disease 2019 (COVID-19). The objective of this study was to examine the correlation of SARS-CoV-2 positivity rate per capita and COVID-19–associated deaths with number of dialysis stations and demographics of residents within zip codes in Cook County, IL.Study DesignEcological analysis.Setting & ParticipantsData for SARS-CoV-2 test results and COVID-19–associated deaths during January 21 to June 15, 2020, among the 5,232,412 residents living within the 163 zip codes in Cook County, IL, were merged with demographic and income data from the US Census Bureau. The total number of positive test results in this population was 84,353 and total number of deaths was 4,007.AssessmentsNumber of dialysis stations and stations per capita within a zip code were calculated. SARS-CoV-2–positive test results per capita were calculated as number of positive test results divided by the zip code population. COVID-19–associated deaths per capita were calculated as COVID-19 deaths among residents for a given zip code divided by the zip code population.Analytic ApproachSpearman rank correlation coefficients were calculated to examine the correlation of SARS-CoV-2–positive tests per capita and COVID-19–associated deaths per capita with dialysis stations, demographics, and household poverty. To account for multiple testing, statistical significance was considered as P < 0.005.ResultsAmong the 163 Cook County zip codes, there were 2,501 dialysis stations. Positive test results per capita were significantly associated with number of dialysis stations (r = 0.25; 95% CI, 0.19 to 0.29; P < 0.005) but not with dialysis stations per capita (r = 0.02; 95% CI, −0.03 to 0.08; P = 0.7). Positive test results per capita also correlated significantly with number of households living in poverty (r = 0.57; 95% CI, 0.53-0.6; P < 0.005) and percentage of residents reporting Black race (r = 0.28; 95% CI, 0.23-0.33; P < 0.005) and Hispanic ethnicity (r = 0.68; 95% CI, 0.65-0.7; P < 0.001;). COVID-19–associated deaths per capita correlated significantly with the percentage of residents reporting Black race (r = 0.24; 95% CI, 0.19-0.29; P < 0.005) and with percentage of households living in poverty (r = 0.34; 95% CI, 0.29-0.38; P < 0.005). The association between the number of COVID-19–associated deaths per capita and total number of dialysis stations (r = 0.20; 95% CI, 0.14-0.25; P = 0.01) did not achieve a priori significance, whereas the association with dialysis stations per capita (r = 0.12; 95% CI, 0.07-0.17; P = 0.01) was not significant.LimitationsAnalysis is at the zip code level and not at the person level.ConclusionsThe number of dialysis stations within a zip code correlates with the SARS-CoV-2 positivity rate per capita in Cook County, IL, and this correlation may be driven by population density and the demographics of the residents. These findings highlight the high risk of SARS-CoV-2 exposure for patients with end-stage kidney disease living in poor urban areas.

The Impact of Chain Organization Size on Efficiency and Quality of Affiliated Facilities—Implications for Multi‐Unit Organizational Forms

This study investigates how the affiliation of dialysis facilities within chain organizations of varying sizes impacts efficiency and quality outcomes of these facilities. We develop our hypotheses by building on the literature base that relates to organizational learning. The paper uses a panel dataset spanning the years 2008–2013. The efficiency of the dialysis facilities is operationalized by means of a data envelopment analysis model. This model considers the number of treatments in the dialysis facility as the output variable. The model uses four inputs—number of dialysis stations, number of full‐time equivalents of physicians, number of full‐time equivalents of clinical staff, and the number of employee hours per week at a dialysis facility. Quality is operationalized by considering facilities’ performance scores on three measures developed by the Center for Medicaid and Medicare Services. The findings point to distinct effects of chain organization size on quality and efficiency performance of dialysis facilities. Specifically, the results obtained by analyzing a dynamic panel data model show that chain organization size has an inverse U‐shaped curvilinear effect on quality outcomes and a U‐shaped curvilinear effect on efficiency. The findings suggest that dialysis facilities affiliated with chain organizations of varying sizes experience learning effects and causal ambiguities depending on the specific performance measure under consideration. We discuss the implications of our findings for theory and practice and present directions for future research.

Delivering Safe and Effective Hemodialysis in Patients with Suspected or Confirmed COVID-19 Infection: A Single-Center Perspective from Italy.

New “Severe Acute Respiratory Syndrome Coronavirus 2” (SARS-CoV-2) is responsible for a clinical entity named Coronavirus Disease 2109 (COVID-19) by the World Health Orgazination, which is now a pandemic (1). In Europe, Italy was the first, and so far the largest, epicenter of the epidemic. It is now clear that many asymptomatic and paucisymptomatic patients went undetected, causing significant diffusion of the disease. Asymptomatic infections are common: among 634 confirmed patients on board the “Diamond Princess” cruise ship, 306 were symptomatic and 328 asymptomatic at the time of testing (2). It is now clear that when a patient with atypical severe pneumonia was diagnosed as COVID-19 in a small city, Codogno, in a previously healthy 38-year-old man, on February 20, 2020, more patients with undetected COVID-19 were present in Northern Italy. In addition to the cluster around Codogno, about 50 km south of Milan, which was promptly put under strict lockdown, two additional relevant clusters emerged near the cities of Bergamo and Brescia. The delay in enforcing a lockdown in the latter areas is probably one of the leading causes of the more severe outbreak now affecting these provinces. Extensive testing in the initial phase of disease diffusion was adopted in the Italian Veneto area, resulting in better containment of new cases. A nationwide lockdown measure was passed by the Italian government when Northern Italy, which has the highest concentration of well organized hospitals in the country, started showing signs of difficulty handling the rapid increase of patients in need of treatment in intensive care units (ICUs). A comparison of Chinese and Italian data on COVID-19 may be of interest to other countries where the disease is now spreading. The Chinese Center for Disease Control and Prevention described the characteristics of a large cohort of COVID-19 patients (3), showing that …

Oral cavity status of long-term hemodialized patients vs. their socio-economic status.

The chronic kidney disease, blood hypertension and diabetes are recognized as civilization diseases that affect more and more people. The probability of encountering a patient suffering from these diseases is increasing. As such, it appears crucial to better understand the specific dental needs of such groups of patients. The aim of the work was to assess the oral hygiene status and the needs of patients suffering from the end-stage chronic kidney disease, arterial hypertension or/and diabetes. Two hundred and twenty eight patients were included in the research. One hundred and eighty patients were hemodialized in Diaverum dialysis stations and 48 patients were from the Conservative Dentistry with Endodontics Clinic of the Academic Centre of Dentistry in Bytom, Silesian Medical University in Katowice, and from the Dentistry Division of the Arnika Clinic in Zabrze, and were not not diagnosed with any of the diseases mentioned. The research scheme was divided into 3 parts, consisting of an analysis of the general health socio-economic status, a survey and an assessment of oral health. The patients who were not suffering from any of the discussed diseases were more aware of how to properly perform hygienic procedures. Most of the patients from both the control and examined groups were not using any rinsing solutions. A higher percentage of patients in the control group was using dental floss, changing their toothbrush every 3 months and brushing their teeth for ≥2 min. The Aproximal Plaque Index and the Oral Hygiene Index-Simplified values in the control group were significantly lower in comparison to the examined group. The socio-economic status of hemodialized patients was low, which in most cases was a result of the difficulties in starting a job. Due to the lower standards of life, the neglect of oral hygiene maintenance and its consequences could be observed. Med Pr. 2020;71(3):279-88.

Association between Freestanding Dialysis Facility Size and Medicare Quality Incentive Program Performance Scores

Background: Medicare uses a quality incentive program (QIP) criteria to evaluate care in dialysis facilities and apply monetary penalties on underperforming facilities. Smaller dialysis facilities are likely to be rural and operate on lower profit margin; therefore, such facilities are likely to underperform and face Medicare penalties. The variation in QIP scores by facility size is not yet known. We investigated the association between freestanding dialysis facility size and QIP scores. Methods: Our cross-sectional analysis compared QIP scores across levels of facility size for 5,193 freestanding dialysis facilities that received QIP scores in 2015. We used Medicare facility data including Dialysis Facility Compare, Performance Scores, Facility-Level Impact, and Area Health Resource and United States Renal Data System files for the payment year 2015. We measured the facility size using the number of dialysis stations per dialysis facility. QIP scores were used to determine the quality of care. A generalized linear model was estimated at an alpha level of 0.05. Results: Facilities operating more than 10 dialysis stations scored higher than those operating fewer. Further, facilities in the South and Northeast, not offering peritoneal dialysis, affiliated with chains (except chain 3) and spending more hours per dialysis achieved higher QIP scores. Facilities reporting a higher proportion of Hispanic patients and of patients with access to pre-end-stage renal disease (ESRD) nephrologist care achieved higher QIP scores. Conversely, facilities with a higher Black patient population and higher patient travel distances scored lower. Conclusions: The current study provides important finding about the performance of the dialysis facilities with ≤10 dialysis stations. Quality improvement strategies are needed, especially for the dialysis facilities with ≤10 stations, to prevent penalties and eventual closure of such facilities due to financial insolvency. Failure to address these issues will increase further disparities in ESRD care.

Antecedents of patient health outcomes in dialysis clinics: a national study

PurposeThe purpose of this study is to evaluate the determinants of health outcomes of dialysis patients, while specifically focusing on the role of dialysis process measures and dialysis practice characteristics. The dialysis industry is facing a major transition from a volume-based health care system to a value-based cost-efficient care model, in the USA. Under the bundled Prospective Payment System, the treatment-based payment model is subject to meeting quality thresholds as defined by clinical process measures including dialysis adequacy and anemia management. Few studies have focused on studying these two processes and their association with the quality of patient health outcomes.Design/methodology/approachIn this study, the authors focus on identifying the determinants of patient health outcomes among freestanding dialysis clinics, using a large cross-sectional data set of 4,571 dialysis clinics in the USA. The authors use econometric analyses to estimate the association between dialysis facility characteristics and practice patterns and their association with dialysis process measures and hospitalization risk.FindingsThe authors find that reusing dialyzers and increasing the number of dialysis stations is associated with higher levels of clinical quality. This research indicates that deploying more nurses on-site allows patients to avail adequate dialysis, while increasing the supply of physicians can hurt anemia control process. In addition, the authors report that offering peritoneal dialysis and late night shifts are not beneficial practices in terms of their impact on the hospitalization risk.Research limitations/implicationsWhile early studies of dialysis care mainly focused on the associations between practice patterns and patient outcomes, this research reveals the underlying mechanisms of these relationships by exploring the mediation effects of clinical dialysis processes on patient outcomes. The results indicate that dialysis process measures mediate the impact of the operational characteristics of dialysis centers on patient hospitalization rates.Practical implicationsThis study offers several managerial insights for owners and operators of dialysis clinics with respect to the association between managerial and clinical practices that they deploy within dialysis clinics and their impact on clinical quality measures as well as hospitalization risk of patients. Managers can draw on this study to optimize staffing levels in their dialysis clinics, and implement innovative clinical practices.Social implicationsConsidering the growth in healthcare expenditures in developing and developed countries, and specifically for costly diagnoses such as dialyses, this study offers several insights related to the inter-relationships between dialysis practice patterns and their clinical quality measures.Originality/valueThis study makes several major contributions. First, the authors address the extant gap in the literature on the relationships between dialysis facility and practice characteristics and clinical outcomes, while specifically highlighting the role of clinical process measures as antecedents of patient hospitalization ratio, a key metric used to measure performance of dialysis clinics. Second, this study sheds light on the underlying mechanisms that serve as enablers of the dialysis adequacy and anemia management. To the best of the authors’ knowledge, this is the first study to explore these relationships in the dialysis industry. The authors’ approach provides a new direction for future studies to explore the pathways that may impact clinical quality measures in the delivery of dialysis services.

A Large Outbreak of Hepatitis C Virus Infections in a Hemodialysis Clinic.

BACKGROUND In November and December 2012, 6 patients at a hemodialysis clinic were given a diagnosis of new hepatitis C virus (HCV) infection. OBJECTIVE To investigate the outbreak to identify risk factors for transmission. METHODS A case patient was defined as a patient who was HCV-antibody negative on clinic admission but subsequently was found to be HCV-antibody positive from January 1, 2008, through April 30, 2013. Patient charts were reviewed to identify and describe case patients. The hypervariable region 1 of HCV from infected patients was tested to assess viral genetic relatedness. Infection control practices were evaluated via observations. A forensic chemiluminescent agent was used to identify blood contamination on environmental surfaces after cleaning. RESULTS Eighteen case patients were identified at the clinic from January 1, 2008, through April 30, 2013, resulting in an estimated 16.7% attack rate. Analysis of HCV quasispecies identified 4 separate clusters of transmission involving 11 case patients. The case patients and previously infected patients in each cluster were treated in neighboring dialysis stations during the same shift, or at the same dialysis station on 2 consecutive shifts. Lapses in infection control were identified. Visible and invisible blood was identified on multiple surfaces at the clinic. CONCLUSIONS Epidemiologic and laboratory data confirmed transmission of HCV among numerous patients at the dialysis clinic over 6 years. Infection control breaches were likely responsible. This outbreak highlights the importance of rigorous adherence to recommended infection control practices in dialysis settings.

Cost analysis of in-centre nocturnal compared with conventional hemodialysis.

BackgroundProvision of in-centre nocturnal hemodialysis (ICNHD; 6–8 hours thrice weekly) is associated with health benefits, but the economic implications of providing this treatment are unclear.ObjectiveWe conducted a health care costing study comparing ICNHD to in-centre thrice-weekly conventional hemodialysis (CvHD).DesignMicro-costing of both ICNHD and CvHD as practiced at our centre.SettingHemodialysis unit at a tertiary-care hospital in Edmonton.ParticipantsAn informal survey of 2 other Canadian ICNHD programs was conducted to inform practices that may deviate from ours to guide sensitivity analysis.MeasurementsResources consumed for each strategy were determined, and the cost of each unit (CAN $2012) was used to calculate incremental costs of ICNHD and CvHD.MethodsWe focused on resources that differ between strategies (staffing, dialysis materials, and utilities). The reference case considered 1:3 staff to patient ratio; alternate scenarios explored nursing pay grade and ratio, full care vs. self-care dialysis (including training costs), and medication costs.ResultsIn the reference case, ICNHD was $61 more costly per dialysis treatment compared with CvHD ($9,538 per patient per year). Incremental annual costs for staffing, dialysis materials, and utilities were $8,201, $1,193, and $144, respectively. If ICNHD reduces medication use (anti-hypertensives, bone mineral metabolism medications), the incremental cost of ICNHD decreases to $8,620 per patient per year. In a scenario of self-care ICNHD utilizing a staff-to-patient ratio of 1:10, ICNHD is more costly in year 1 ($15,196), but results in cost savings of $2,625 in subsequent years compared with CvHD.LimitationsThe findings of this cost analysis may not be generalizable to other health care systems, including other parts of Canada.ConclusionsCompared to CvHD, provision of ICNHD is more expensive, largely driven by increased staffing costs as patients dialyze longer. Alternate staffing models, including self-care ICNHD with minimal staff, may lead to net cost savings. The incremental cost of treatment should be considered in the context of impact on patient health outcomes, staffing model, and pragmatic factors, such as current capacity for daytime CvHD and the capital costs of new dialysis stations.Electronic supplementary materialThe online version of this article (doi:10.1186/2054-3581-1-14) contains supplementary material, which is available to authorized users.

Regulation and Capacity Competition in Health Care: Evidence from U.S. Dialysis Markets

Abstract This paper studies entry and capacity decisions by dialysis providers in the United States. We estimate a structural model where providers make continuous strategic choices of capacity based on their private information about own costs and knowledge of the distribution of competitors’ private information. We evaluate the impact on the market structure and providers’ profits under counterfactual regulatory policies that increase the costs or reduce the payment per unit of capacity. We find that these policies reduce the market capacity as measured by the number of dialysis stations. However, the downward-sloping reaction curve shields some providers from negative profit shocks in certain markets. The paper also has a methodological contribution in that it proposes new estimators for Bayesian games with continuous actions.

Regulation and Capacity Competition in Health Care: Evidence from Dialysis Markets

This paper studies entry and capacity decisions by dialysis providers in the U.S. We estimate a structural model where providers make strategic continuous choices of capacities based on private information about own costs and beliefs about competitors’ behaviors. We evaluate the impact on market structure and provider profits under counterfactual regulatory policies that increase per capacity cost or reduce per capacity payment. We find that these policies reduce the market capacity of dialysis stations. However, the downward sloping reaction curve shields some providers from negative profit shocks in certain markets. The paper also has a methodological contribution in that it proposes new estimators for Bayesian games with continuous actions, which differ qualitative from discrete Bayesian games such as those with binary entry decisions.

The 50th anniversary of haemodialysis in Krakow, Poland.

The 50th anniversary of haemodialysis in Krakow, Poland.