Dialysis practices that distinguish top- versus bottom-performing facilities by hemoglobin outcomes

Abstract

Background: Because there is wide variation in outcomes across dialysis facilities, it is possible that top-performing units use practices not shared by others. The Identifying Best Practices in Dialysis (IBPiD) Study seeks to identify practices that distinguish top- from bottom-performing facilities by key outcomes, including achievement of recommended hemoglobin targets.

Study design: Observational study with cross-sectional study ascertainment of predictors and outcomes.

Predictors: Facility dialysis practices ascertained using practice surveys of dialysis staff who indicated their level of agreement that each practice occurs in their facility (1-6 on a Likert scale).

Setting & participants: 423 personnel in 90 dialysis facilities from 1 for-profit and 2 not-for-profit dialysis organizations.

Outcomes: Percentage of patients per month per facility with hemoglobin levels of 11-12 g/dL. We divided facilities by median into top- versus bottom-performing groups and compared mean scores for each practice using t tests. We report practices that were statistically significant and achieved at least a medium effect size (ES) >or=0.4.

Results: 17 of 155 tested predictors were significant. Achievement of hemoglobin level targets was related most strongly to the use of chairside computers (ES, 0.8 [95% CI, 0.4-1.4]), extent/quality of educational videos (ES, 0.6 [95% CI, 0.2-1.1]), frequency of calling per diem staff if short staffed (ES, 0.6 [95% CI, 0.21-1.1]), policy that nurses pass written competency examinations before hire (ES, 0.6 [95% CI, 0.2-1.0]), and technician cannulation mastery (ES, 0.6 [95% CI, 0.2-1.1]).

Limitations: This is a cross-sectional study that can address only associations, not causations. Future research should measure the longitudinal predictive value of these practices.

Conclusions: High-performing facilities report more effective education programs, better staff management, higher staff competency, and higher use of chairside computers, a potential marker of information technology proficiency. This suggests that hemoglobin level management is enhanced by processes reflecting a coordinated multidisciplinary environment.