Outpatient Dialysis Facilities Research Articles

Peritoneal Dialysis for Acute Kidney Injury Treatment in the United States: Brought to You by the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has created unprecedented strain on health care resources in the United States. Initial reports of AKI rates from Wuhan, China ranged between 3% and 9%, although rates as high as 15% have been reported (1,2). For AKI requiring RRT, intermittent hemodialysis (HD) and continuous RRT (CRRT) have been mainstays of therapy in the United States. However, shortages in supplies, staffing, and available equipment among critically ill patients with COVID-19, particularly in the New York City area, have demanded alternative strategies such as acute peritoneal dialysis treatment for AKI (AKI-PD) that are being implemented. Here, we will review the rationale for the use of AKI-PD and describe potential advantages, criteria for patient selection, and practical considerations on the basis of initial experiences to consider when prescribing and delivering peritoneal dialysis (PD). PD was routine for AKI treatment worldwide well into the 1980s. However, by the 1990s with the development of the central venous catheter for HD and the advent of CRRT, PD became rarely used in higher-resource countries to treat adult patients with AKI (3). The utility and efficacy of PD to treat patients with AKI were re-examined after the publication of a series of articles from Brazil, including a randomized trial, demonstrating that PD provided acceptable care, was not inferior to daily HD in treating acutely ill patients with AKI in terms of patient mortality, and was associated with a shorter duration of AKI and need for RRT (4,5). These findings were confirmed in a randomized trial from Saudi Arabia comparing PD with hemodiafiltration (6). AKI-PD expanded dramatically in lower-resource countries with the advent of the Saving Young Lives Program in 2012, which promoted the use of PD because of minimal infrastructural requirements, including a lack of need for water …

Management of Hemodialysis Patients with Suspected or Confirmed COVID-19 Infection: Perspective of Two Nephrologists in the United States.

The coronavirus disease 2019 (COVID-19) pandemic is unprecedented and information about the severe acute respiratory syndrome coronavirus 2 is evolving rapidly. New York is one of the epicenters of the COVID-19 outbreak in the United States, reporting >1000 confirmed cases as of March 17, 2020, and cases are escalating exponentially. The majority of cases are in Westchester County ( n =220) and New York City (NYC; n =463), which includes Bronx (1). The local index patient case was a Westchester man who became ill on February 22, was not associated with a recent travel exposure to a country on the watch list (China, Iran, South Korea, and Italy), or known to have had direct contact with a COVID-19–confirmed patient. At the present time it is estimated that community-wide transmission accounts for 87% of confirmed cases. Nephrologists in the Bronx have been handicapped in managing patients with ESKD during the early weeks of the COVID-19 pandemic due to the limitations of available rapid testing for severe acute respiratory syndrome coronavirus 2. Montefiore Medical Center, located in the north Bronx in close proximity to Westchester, has been one of the main tertiary care hospitals in NYC caring for persons under investigation (PUIs) and for COVID-19–confirmed patients. Our nephrology division’s clinical faculty care for approximately 850 patients with ESKD (approximately 800 on hemodialysis and approximately 50 on peritoneal dialysis) in 12 outpatient hemodialysis facilities (two Fresenius and 10 DaVita facilities) in the Bronx. We report our experience with caring for the ESKD population and patients who are hospitalized with AKI in the Bronx during the first 3 weeks of the local NYC COVID-19 pandemic. Strategies proposed for the prevention and management of COVID-19 transmission for patients with ESKD in the outpatient dialysis facilities have been dynamic. The American Society of Nephrology’s (ASN’s) Nephrologists Transforming …

Safety-Net Care for Maintenance Dialysis in the United States.

Although most American patients with ESKD become eligible for Medicare by their fourth month of dialysis, some never do. Information about where patients with limited health insurance receive maintenance dialysis has been lacking. We identified patients initiating maintenance dialysis (2008-2015) from the US Renal Data System, defining patients as "safety-net reliant" if they were uninsured or had only Medicaid coverage at dialysis onset and had not qualified for Medicare by the fourth dialysis month. We examined four dialysis facility ownership categories according to for-profit/nonprofit status and ownership (chain versus independent). We assessed whether patients who were safety-net reliant were more likely to initiate dialysis at certain facility types. We also examined hospital-based affiliation. The proportion of patients <65 years initiating dialysis who were safety-net reliant increased significantly over time, from 11% to 14%; 73% of such patients started dialysis at for-profit/chain-owned facilities compared to 76% of all patients starting dialysis. Patients who were safety-net reliant had a 30% higher relative risk of initiating dialysis at nonprofit/independently owned versus for-profit/independently owned facilities (odds ratio, 1.30; 95% CI, 1.24 to 1.36); they had slightly lower relative risks of initiating dialysis at for-profit and non-profit chain-owned facilities, and were more likely to receive dialysis at hospital-based facilities. These findings primarily reflect increased likelihood of dialysis among patients without insurance at certain facility types. Although most patients who were safety-net reliant received care at for-profit/chain-owned facilities, they were disproportionately cared for at nonprofit/independently owned and hospital-based facilities. Ongoing loss of market share of nonprofit/independently owned outpatient dialysis facilities may affect safety net-reliant populations.

Delivery of a patient-friendly functioning report to improve patient-centeredness of dialysis care: a pilot study

BackgroundProvider recognition of level of functioning may be suboptimal in the dialysis setting, and this lack of recognition may lead to less patient-centered care. We aimed to assess whether delivery of an app-based, individualized functioning report would improve patients’ perceptions of patient-centeredness of care.MethodsIn this pre-post pilot study at three outpatient dialysis facilities in metropolitan Atlanta, an individualized functioning report—including information on physical performance, perceived physical functioning, and community mobility—was delivered to patients receiving hemodialysis (n = 43) and their providers. Qualitative and quantitative approaches were used to gather patient and provider feedback to develop and assess the report and app. Paired t test was used to test for differences in patient perception of patient-centeredness of care (PPPC) scores (range, 1 = most patient-centered to 4 = least patient-centered) 1 month after report delivery.ResultsDelivery of the reports to both patients and providers was not associated with a subsequent change in patients’ perceptions of patient-centeredness of their care (follow-up vs. baseline PPPC scores of 2.35 vs. 2.36; P > 0.9). However, patients and providers generally saw the potential of the report to improve the patient-centeredness of care and reacted positively to the individualized reports delivered in the pilot. Patients also reported willingness to undergo future assessments. However, while two-thirds of surveyed providers reported always or sometimes discussing the reports they received, most (98%) participating patients reported that no one on the dialysis care team had discussed the report with them within 1 month.ConclusionsPotential lack of fidelity to the intervention precludes definitive conclusions about effects of the report on patient-centeredness of care. The disconnect between patients’ and providers’ perceptions of discussions of the report warrants future study. However, this study introduces a novel, individualized, multi-domain functional report that is easily implemented in the setting of hemodialysis. Our pilot study provides guidance for improving its use both clinically and in future pragmatic research studies, both within and beyond the dialysis population.

A Qualitative Study on Factors Affecting Adherence Among Indian Haemodialysis Patients at a Tertiary Teaching Hospital of Southern India

Non-adherence to treatment regimen can have a detrimental effect on the heath of dialysis patients, increase mortality, morbidity and increase in healthcare service utilization and cost of hospitalization. This qualitative study explores the factors affecting adherence among the dialysis population visiting a tertiary care teaching hospital in southern India by conducting one-to-one in-depth interviews with the patients as well as key informant interview with the caregivers at the outpatient dialysis facility of a tertiary care teaching hospital. Interview transcripts were thematically analyzed using ATLAS.ti. Patient factors, health financing, cultural beliefs, caregivers’ burden and health systems factors were identified. Understanding the factors affecting adherence can help the healthcare providers and the government to devise strategies to promote adherence and improved well-being among dialysis patients. Universal health coverage for dialysis, regulations to safeguard employment, creating awareness about opting for critical illness policies through private insurance companies when the disease is not pre-existing can reduce the out-of-pocket expenditure; these are some of the important areas for consideration to promote adherence.

Effective prevention bundle to eliminate catheter-related bloodstream infections in ambulatory hemodialysis patients

Background: Hamad General Hospital (HGH) is the principal provider of dialysis in the state of Qatar, comprising a total of four facilities in different cities. Infection rates in dialysis patients are increasingly used as a surrogate marker for measuring patient safety and quality of healthcare. These infections are associated with substantial morbidity, mortality, and excess healthcare costs. We observed an elevated rate of hemodialysis catheter-related bloodstream infections (HD-CRBSI) in our outpatient dialysis facilities (1.4/1,000 Central Venous Catheter [CVC] days) in 2011. Our goal was to reduce our HD-CRBSI rate by 80% within a period of four years in HGH ambulatory dialysis facilities. Methods: HD-CRBSIs are defined as the presence of positive blood cultures in a febrile catheter-dependent patient in the absence of alternative sources of infection upon clinical evaluation. The project was led by the HGH quality improvement program director in coordination with a multidisciplinary team (nephrologists, nurses, vascular coordinators, a patient educator, and an infection control team) after implementation of a bundle of infection prevention measures. Results: The rate of HD-CRBSI was reduced from 1.4/1,000 CVC days in 2011 to 0.014 in 2017, achieving a 99% reduction rate (p &lt; 0.001). Conclusions: Strict implementation of our new infection prevention measures bundle is sufficient to significantly reduce HD-CRBSIs.

Clinical and Economic Benefits of Antimicrobial Stewardship Programs in Hemodialysis Facilities: A Decision Analytic Model.

Infections caused by multidrug-resistant organisms and Clostridium difficile are associated with substantial morbidity and mortality as well as excess costs. Antimicrobial exposure is the leading cause for these infections. Approximately 30% of antimicrobial doses administered in outpatient hemodialysis facilities are considered unnecessary. Implementing an antimicrobial stewardship program in outpatient hemodialysis facilities aimed at improving prescribing practices would have important clinical and economic benefits. We developed a decision analytic model of antimicrobial use on the clinical and economic consequences of implementing a nationwide antimicrobial stewardship program in outpatient dialysis facilities. The main outcomes were total antimicrobial use, infections caused by multidrug-resistant organisms and C. difficile, infection-related mortality, and total costs. The analysis considered all patients on outpatient hemodialysis in the United States. The value of implementing antimicrobial stewardship programs, assuming a 20% decrease in unnecessary antimicrobial doses, was calculated as the incremental differences in clinical end points and cost outcomes. Event probabilities, antimicrobial regimens, and health care costs were informed by publicly available sources. On a national level, implementation of antimicrobial stewardship programs was predicted to result in 2182 fewer infections caused by multidrug-resistant organisms and C. difficile (4.8% reduction), 629 fewer infection-related deaths (4.6% reduction), and a cost savings of $106,893,517 (5.0% reduction) per year. The model was most sensitive to clinical parameters as opposed to antimicrobial costs. The model suggests that implementation of antimicrobial stewardship programs in outpatient dialysis facilities would result in substantial reductions in infections caused by multidrug-resistant organisms and C. difficile, infection-related deaths, and costs.

Dialysate Potassium and Mortality in a Prospective Hemodialysis Cohort

Background: Studies examining the association of dialysate potassium concentration and mortality in hemodialysis patients show conflicting findings. We hypothesized that low dialysate potassium concentrations are associated with higher mortality, particularly in patients with high pre-dialysis serum potassium concentrations. Methods: We evaluated 624 hemodialysis patients from the prospective Malnutrition, Diet, and Racial Disparities in Kidney Disease study recruited from 16 outpatient dialysis facilities over 2011–2015 who underwent protocolized collection of dialysis treatment characteristics every 6 months. We examined the association of dialysate potassium concentration, categorized as 1, 2, and 3 mEq/L, with all-cause mortality risk in the ­overall cohort, and stratified by pre-dialysis serum potassium (< 5 vs. ≥5 mEq/L) using case-mix adjusted Cox models. Results: In baseline analyses, dialysate potassium concentrations of 1 mEq/L were associated with higher mortality, whereas concentrations of 3 mEq/L were associated with similar mortality in the overall cohort (reference: 2 mEq/L): adjusted hazard ratios (aHRs; 95% CI) 1.70 (1.01–2.88) and 0.95 (0.64–1.39), respectively. In analyses stratified by serum potassium, baseline dialysate potassium concentrations of 1 mEq/L were associated with higher mortality in patients with serum potassium ≥5 mEq/L but not in those with serum potassium < 5 mEq/L: aHRs (95% CI) 2.87 (1.51–5.46) and 0.74 (0.27–2.07), respectively (p interaction = 0.04). These findings were robust with incremental adjustment for serum potassium, potassium-binding resins, and potassium-modifying medications. Conclusion: Low (1 mEq/L) dialysate potassium ­concentrations were associated with higher mortality, particularly in hemodialysis patients with high pre-dialysis serum potassium. Further studies are needed to identify therapeutic strategies that mitigate inter-dialytic serum potassium accumulation and subsequent high dialysate serum potassium gradients in this population.

Change in Lactate Levels After Hemodialysis in Patients With End-Stage Renal Disease

Patients with end-stage renal disease commonly visit the emergency department (ED). The purpose of this investigation is to examine the prevalence of baseline abnormal lactate levels and to evaluate the effects of hemodialysis on serum lactate levels. This was a prospective observational cohort study performed at an outpatient dialysis facility at an urban tertiary care hospital. The study consisted of 226 patients with end-stage renal disease who were receiving long-term hemodialysis and were enrolled during a 2-day period at the beginning of December 2015. Blood drawn for lactate levels was immediately analyzed before and after hemodialysis sessions. All patients completed their hemodialysis sessions. The prevalence of an abnormal lactate level (greater than 1.8 mmol/L) before hemodialysis was 17.7% (n=40). Overall, lactate levels decreased by 27% (SD 35%) after hemodialysis, with a decrease of 37% (SD 31%) for subgroups with a lactate level of 1.9 to 2.4 mmol/L, and 62% (SD 14%) with a lactate of 2.5 to 3.9 mmol/L. The data presented help providers understand the prevalence of abnormal lactate values in an outpatient end-stage renal disease population. After hemodialysis, lactate levels decreased significantly. This information may help medical providers interpret lactate values when patients with end-stage renal disease present to the ED.

Long-Term Outcomes and Associated Risk Factors of Post-Hospitalization Dialysis-Dependent Acute Kidney Injury Patients

Background/Aims: Acute kidney injury requiring dialysis (AKI-D) is associated with poor outcomes. Centers for Medicare and Medicaid Services have reversed their clarification allowing AKI-D patients to be dialyzed at outpatient dialysis units. Data assessing long-term outcomes of AKI-D patients and their predictors is needed to adopt guidelines to ensure adequate management. We assessed long-term outcomes and associated risk factors of AKI-D patients who survived 90 days post-hemodialysis (HD) initiation. Methods: AKI-D patients surviving hospitalization and dialyzed at a specialized outpatient AKI dialysis unit between April 11, 2012 and December 25, 2013 were prospectively followed. Long-term outcomes of AKI-D patients were obtained by a single provider through a telephone survey, and factors affecting their outcomes were statistically analyzed. Results: Ninety-one out of 108 patients were reached for telephone survey. At baseline (90 days post-HD initiation), 52/91 patients were declared end-stage renal disease (ESRD; group 1) and 39/91 were dialysis-independent (group 2). At the end of an average follow up period of 859.7 days, 32/91 (35.2%) were dialysis-independent (3/52 from group 1 and 29/39 from group 2), with 28/91 dead (25/52 from group 1 and 3/39 from group 2). After adjusting for demographics and comorbidities, baseline renal function, prior AKI, ESRD, and requirement for continuous renal replacement therapy were associated with poor outcomes. Conclusions: Sustaining long-term dialysis independence in AKI-D patients is significant. Baseline renal function, prior AKI, and hemodynamic changes during hospitalization are predictors of long-term outcomes. Meticulous follow up of AKI-D patients in the outpatient dialysis facilities in their first 90 days post-HD initiation is crucial.

Thyroid Status, Quality of Life, and Mental Health in Patients on Hemodialysis.

In the general population, there is increasing recognition of the effect of thyroid function on patient-centered outcomes, including health-related quality of life and depression. Although hypothyroidism is highly prevalent in hemodialysis patients, it is unknown whether thyroid status is a risk factor for impaired health-related quality of life or mental health in this population. We examined the association of thyroid status, defined by serum thyrotropin, with health-related quality of life and depressive symptoms over time in a prospective cohort of 450 patients on hemodialysis from 17 outpatient dialysis facilities from May of 2013 to May of 2015 who underwent protocolized thyrotropin testing, Short-Form 36 surveys, and Beck Depression Inventory-II questionnaires every 6 months. We examined the association of baseline and time-dependent thyrotropin categorized as tertiles and continuous variables with eight Short-Form 36 domains and Beck Depression Inventory-II scores using expanded case mix plus laboratory adjusted linear mixed effects models. In categorical analyses, the highest baseline thyrotropin tertile was associated with a five-point lower Short-Form 36 domain score for energy/fatigue (P=0.04); the highest time-dependent tertile was associated with a five-point lower physical function score (P=0.03; reference: lowest tertile). In continuous analyses, higher baseline serum thyrotropin levels (+Δ1 mIU/L) were associated with lower role limitations due to physical health (β=-1.3; P=0.04), energy/fatigue (β=-0.8; P=0.03), and pain scores (β=-1.4; P=0.002), equivalent to five-, three-, and five-point lower scores, respectively, for every 1-SD higher thyrotropin. Higher time-dependent thyrotropin levels were associated with lower role limitations due to physical health scores (β=-1.0; P=0.03), equivalent to a three-point decline for every 1-SD higher thyrotropin. Baseline and time-dependent thyrotropin were not associated with Beck Depression Inventory-II scores. In patients on hemodialysis, higher serum thyrotropin levels are associated with impaired health-related quality of life across energy/fatigue, physical function, and pain domains. Studies are needed to determine if thyroid-modulating therapy improves the health-related quality of life of hemodialysis patients with thyroid dysfunction.

Comparing the Effectiveness of Dynamic Treatment Strategies Using Electronic Health Records: An Application of the Parametric g-Formula to Anemia Management Strategies.

To compare the effectiveness of dynamic anemia management strategies by applying the parametric g-formula to electronic health records. Patients with end-stage renal disease from the US Renal Data System who had congestive heart failure or ischemic heart disease and were undergoing hemodialysis in outpatient dialysis facilities between 2006 and 2010. We explicitly emulated a target trial of three ‎erythropoietin dosing strategies (aimed at achieving a low, middle, or high hematocrit) and estimated the observational analog of the per-protocol effect. Of 156,945 eligible patients, 41,970 died during the 18-month follow-up. Compared to the low-hematocrit strategy, the estimated risk of death was 4.6 (95% CI 4.4-4.9) percentage points higher under the high-hematocrit strategy and 1.8 (95% CI 1.7-1.9) percentage points higher under the mid-hematocrit strategy. The corresponding risk differences for a composite outcome of death and myocardial infarction were similar. An explicit emulation of a target trial using electronic health records, combined with the parametric g-formula, allowed comparison of real-world dynamic strategies that have not been compared in randomized trials.

Medication adherence perspectives in haemodialysis patients: a qualitative study

BackgroundEnd-stage kidney disease patients undergoing haemodialysis are prescribed with multiple complex regimens and are predisposed to high risk of medication nonadherence. The aims of this study were to explore factors associated with medication adherence, and, to examine the differential perspectives on medication-taking behaviour shown by adherent and nonadherent haemodialysis patients.MethodsA qualitative exploratory design was used. One-on-one semi-structured interviews were conducted with 30 haemodialysis patients at the outpatient dialysis facility in Hobart, Australia. Patient self-reported adherence was measured using 4-item Morisky Green Levine scale. Interview transcripts were thematically analysed and mapped against the World Health Organization (WHO) determinants of medication adherence.ResultsParticipants were 44–84 years old, and were prescribed with 4–19 medications daily. More than half of the participants were nonadherent to their medications based on self-reported measure (56.7%, n = 17). Themes mapped against WHO adherence model comprised of patient-related (knowledge, awareness, attitude, self-efficacy, action control, and facilitation); health system/ healthcare team related (quality of interaction, and mistrust and collateral arrangements); therapy-related (physical characteristics of medicines, packaging, and side effects); condition-related (symptom severity); and social/ economic factors (access to medicines, and relative affordability).ConclusionsPatients expressed a number of concerns that led to nonadherence behaviour. Many of the issues identified were patient-related and potentially modifiable by using psycho-educational or cognitive-behavioural interventions. Healthcare professionals should be more vigilant towards identifying these concerns to address adherence issues. Future research should be aimed at understanding healthcare professionals’ perceptions and practices of assessing medication adherence in dialysis patients that may guide intervention to resolve this significant issue of medication nonadherence.

Predictors of 30-Day Hospital Readmission among Maintenance Hemodialysis Patients: A Hospital's Perspective.

Over 35% of patients on maintenance dialysis are readmitted to the hospital within 30 days of hospital discharge. Outpatient dialysis facilities often assume responsibility for readmission prevention. Hospital care and discharge practices may increase readmission risk. We undertook this study to elucidate risk factors identifiable from hospital-derived data for 30-day readmission among patients on hemodialysis. Data were taken from patients on maintenance hemodialysis discharged from University of North Carolina Hospitals between May of 2008 and June of 2013 who received in-patient hemodialysis during their index hospitalizations. Multivariable logistic regression models with 30-day readmission as the dependent outcome were used to identify readmission risk factors. Models considered variables available at hospital admission and discharge separately. Among 349 patients, 112 (32.1%) had a 30-day hospital readmission. The discharge (versus admission) model was more predictive of 30-day readmission. In the discharge model, malignancy comorbid condition (odds ratio [OR], 2.08; 95% confidence interval [95% CI], 1.04 to 3.11), three or more hospitalizations in the prior year (OR, 1.97; 95% CI, 1.06 to 3.64), ≥10 outpatient medications at hospital admission (OR, 1.69; 95% CI, 1.00 to 2.88), catheter vascular access (OR, 1.82; 95% CI, 1.01 to 3.65), outpatient dialysis at a nonuniversity-affiliated dialysis facility (OR, 3.59; 95% CI, 2.03 to 6.36), intradialytic hypotension (OR, 3.10; 95% CI, 1.45 to 6.61), weekend discharge day (OR, 1.82; 95% CI, 1.01 to 3.31), and serum albumin <3.3 g/dl (OR, 4.28; 95% CI, 2.37 to 7.73) were associated with higher readmission odds. A decrease in prescribed medications from admission to discharge (OR, 0.20; 95% CI, 0.08 to 0.51) was associated with lower readmission odds. Findings were robust across different model-building approaches. Models containing discharge day data had greater predictive capacity of 30-day readmission than admission models. Identified modifiable readmission risk factors suggest that improved medication education and improved transitions from hospital to community may potentially reduce readmissions. Studies evaluating targeted transition programs among patients on dialysis are needed.

Change in quality of life and one-year mortality risk in maintenance dialysis patients.

Quality of life (QOL) is an important metric of high-quality dialysis care. QOL is commonly measured by the Short Form 36 Questionnaire (SF-36), which provides two summary scores: a mental component score (MCS) and a physical component score (PCS). Poor QOL is associated with mortality in dialysis patients. Small studies show that changes in QOL also predicts mortality. We investigated whether changes in QOL over time are associated with mortality in a large cohort of maintenance hemodialysis patients. This retrospective study was conducted in 1017 outpatient dialysis facilities. Over 10,000 hemodialysis patients completed two SF-36 surveys. We compared 1-year morality rates in those whose MCS or PCS increased or decreased ±5 vs. those whose did not. For those who completed two surveys, mean score for PCS was unchanged, whereas MCS increased slightly (48.6 vs. 48.9, p=0.05). Individual patients, however, showed marked variation. On the second survey, more than half of patients demonstrated a±5 point change in the PCS and/or MCS. After multivariate adjustment, a≥5 decrease in MCS was associated with an increase in mortality (HR=1.33, 95% CI 1.18, 1.50). Clinicians should be aware that many patients experience a significant change in both the MCS and PCS on dialysis. A MCS decrease of ≥5 was associated with increased mortality. More study is needed to determine whether this is a causal relationship. Physicians should evaluate root causes and seek to mitigate declines in QOL whenever possible.

Inertia in health care organizations: A case study of peritoneal dialysis services.

Change is difficult for health care organizations where adoption of new practices is notoriously slow. Inertial behavior may reflect organizations' rational, strategic nonresponse to its environment or latent, institutionalizing preservation of dominant organizational routines and norms. Such strategic and selective influences of organizational inertia have different implications on the efficacy of policy to induce intended change. The aim of this study was to examine whether strategic and selective factors were associated with the provision of peritoneal dialysis (PD) services in outpatient dialysis facilities in the United States between 1995 and 2003. We conducted a longitudinal retrospective study of all outpatient end-stage renal disease dialysis facilities, using 1995-2003 administrative data from the U.S. Renal Data System. Less than half of U.S. dialysis facilities offered PD, and this pattern was stable despite substantial growth of dialysis facilities entering the market. We found little support for strategic influences and some evidence that selective factors were predictive of dialysis facilities' PD provision. Although the design of many policy and health care reform efforts widely accepts the strategic perspective of altering incentives and the environment to induce change, the presence of selective inertial influences raises concerns about the efficacy of policy intervention in the face of institutionalized organizational behavior that may be less amenable to policy intervention. Incentives recently introduced by Medicare to increase facility provision of PD may be less effective than might be expected.

Renal Dietitians' Perceptions of Roles and Responsibilities in Outpatient Dialysis Facilities

This study was designed to determine what job responsibilities renal dietitians working in outpatient dialysis facilities consider as most important and most time-consuming. We hypothesized that more time-consuming activities would not always be considered most important. An online survey was sent to 3,382 renal dietitians via professional organization e-mail lists. The survey included 30 activities that renal dietitians perform, grouped into 3 categories (general responsibilities, assessments, and interventions) and based on the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative nutrition guidelines. For each category of activities, respondents were asked to rank the 10 activities from 1 (most important or time-consuming) to 10 (least important or time-consuming). For analysis, the rankings were combined into 3 groups: 1 to 3 = most; 4 to 6 = mid; and 7 to 10 = least important or time-consuming. Demographic and professional questions were also included. Four hundred sixty six renal dietitians responded, and represented a broad range of experience in renal dietetics and type of dialysis facility. The mean number of patients per 40 hours full-time equivalent dietitian was 115.5 ± 38.4. There was good agreement between the respondents' ranking of importance and time consumed. Those activities identified as most important were traditional dietitian roles such as diet assessment and nutrition education. Many respondents provided write-in response of other activities they considered important and time-consuming such as communicating with family members or caregivers, enrolling and managing patients in the in-house pharmacy program, and serving as a care coordinator. It appears that the renal dietitian's role of providing nutrition assessments and counseling in outpatient dialysis facilities is being expanded to include administrative and coordination responsibilities. The impact of these changes on patient outcomes is unclear; however, previous research has indicated that administrative responsibilities take away from patient care time and decrease dietitian job satisfaction.

Outbreak of Clostridium difficile Infections at an Outpatient Hemodialysis Facility-Michigan, 2012-2013.

Investigation of an outbreak of Clostridium difficile infection (CDI) at a hemodialysis facility revealed evidence that limited intrafacility transmission occurred despite adherence to published infection control standards for dialysis clinics. Outpatient dialysis facilities should consider CDI prevention, including environmental disinfection for C. difficile, when formulating their infection control plans.

Association of Height with Mortality in Patients Undergoing Maintenance Hemodialysis.

Body mass index (BMI), determined as kilograms in body weight divided by the square of the height in meters (m(2)), is inversely associated with mortality in patients undergoing maintenance hemodialysis (MHD). It is commonly inferred that differences in the weight component of the BMI equation are responsible for this negative correlation. However, there are almost no data on the relationship between height and mortality in these patients. This study was conducted to examine the association between height and mortality in MHD patients and to evaluate the contribution of height to the BMI-mortality relationship. A prospective study conducted from July 1, 2001, through June 30, 2006, enrolled a nationally representative cohort of 117,644 MHD patients receiving treatment in DaVita, Inc. outpatient dialysis facilities with (1) known height and weight, (2) age ≥18 years, (3) dialysis vintage ≥90 days, and (4) nonoutlying BMI values (≥12 to ≤60 kg/m(2)). The end date of follow-up was June 30, 2007, and median follow-up was 852 days (interquartile range, 504-1367 days). Mortality hazard ratios were computed within sex-standardized deciles of height and weight, and outcomes included all-cause mortality and cardiovascular, gastrointestinal, cancer, and infection mortality. Hazard models were unadjusted, adjusted for case-mix variables, or adjusted for case-mix variables plus laboratory variables. Mean age was 61±15 years; 45% of patients were women and 57% had diabetes. In adjusted models, height, also adjusted for weight, was directly associated with all-cause mortality and cardiovascular, infection, and cancer mortality. Compared with the median height decile, mortality risk in the highest height decile was 1.18 (95% confidence interval, 1.14 to 1.23) in fully adjusted analyses (P<0.001). Receiver-operating characteristic curves indicated that in adjusted analyses the contribution of height to the relationship between BMI and mortality was almost identical to that of weight. In MHD patients, height is positively associated with mortality risk and contributes similarly to weight with regard to the negative BMI-mortality relationship.

Treatment of vitamin D deficiency/insufficiency with ergocalciferol is associated with reduced vascular access dysfunction in chronic hemodialysis patients.

Vitamin D deficiency or insufficiency is highly prevalent among patients with chronic kidney disease (CKD). This study aims to determine the relationship between vitamin D and frequency of vascular access dysfunction (VAD) in hemodialysis (HD) patients. We reviewed medical records of all HD patients who had serum 25-hydroxyvitamin D (25OHD) levels at 4 outpatient dialysis facilities between January 2011 and January 2012. Patients were included if they were ≥18 years of age, had been on maintenance dialysis for ≥3 months, and had native arteriovenous fistula or synthetic polytetrafluoroethylene grafts for dialysis access. Patients with catheters were excluded. 25-Hydroxyvitamin D levels <30 ng/mL were documented in 183 patients (86%). Median and interquartile range [Q1, Q3] of 25OHD level was 16 [11, 25] ng/mL. Among 213 dialysis patients, 102 had VAD. Median 25OHD level was significantly lower in patients who had VAD than in those without VAD (14.5 [10, 22] vs. 19 [12, 27.5] ng/mL; P = 0.003). There was significant association between VAD and the lowest quartile relative to the highest quartile of 25OHD level. A 25OHD level <12 ng/mL was associated with more than doubling of risk for VAD (OR 2.56; 95% CI [1.05-6.23], P < 0.05). Of 213 patients, 140 were treated with ergocalciferol and 73 were not treated. Treatment was associated with significant reduction in VAD (OR = 0.36; 95% CI [0.19-0.68], P = 0.002). Vitamin D deficiency or insufficiency is an independent risk factor for VAD in HD patients; its treatment with ergocalciferol is associated with decreased VAD.