Rocco MV et al. (2006) Relationship between clinical performance measures and outcomes among patients receiving long-term hemodialysis. Ann Intern Med 145: 512–519

Since 1994, the Centers for Medicare & Medicaid Services have conducted a national program to promote adherence to guidelines for the care of patients receiving dialysis. In a retrospective study of over 15,000 patients on long-term hemodialysis from 2,668 dialysis centers, however, Rocco et al. report a surprising failure of the centers to meet recommended targets, and a strong relationship between this inadherence and high hospitalization and mortality rates.

During the 12-month study period, 8,364 (54.7%) patients were hospitalized and 3,062 (20.0%) died. Of the four therapeutic targets analyzed—dialysis adequacy, fistula for vascular access, anemia and serum albumin level—69% of patients failed to meet more than two, and only 7% met all four. The risk of hospitalization or death increased with every additional guideline indicator that was not met in the previous year; unadjusted hospitalization rate ranged from 43% in those meeting four targets to 60% in those meeting no targets, while unadjusted mortality rates ranged from 7% (four targets) to 29% (no targets). The hazard ratio for death increased significantly by 70–90% for each indicator that was not met (P <0.001), while the hazard ratio for hospitalization increased by 10–30%. The authors comment that there is room for improvement in both individual patient care and the methods used to optimize clinical outcomes.