Hemodialysis facility-based quality-of-care indicators and facility-specific patient outcomes

Am J Kidney Dis. 2009 Sep;54(3):490-7. doi: 10.1053/j.ajkd.2009.01.260. Epub 2009 Apr 29.


Background: We evaluated whether incremental achievement of up to 8 facility quality goals was associated with improvement in facility-specific mortality and hospitalization rates.

Study design: Prospective observational study.

Setting & participants: 1,085 Fresenius Medical Care, North America facilities providing hemodialysis (HD) for 25 or more patients during January 2006.

Measurements: The facility average for the period up to December 31, 2006, was used to determine achievement of each goal for equilibrated Kt/V, missed HD treatments, hemoglobin level, bicarbonate level, albumin level, phosphorus level, fistulae, and HD catheters. Linear regression models were used to relate facility-wide achievement of goals with facility-specific hospital days and standardized mortality ratios.

Results: Most facilities (64%) achieved 2 to 4 of 8 goals, with only 8% meeting more than 5 quality goals. Achieving more than 5 goals averaged 3.5 fewer hospital days/patient-year and 20% lower standardized mortality ratios (all P < 0.001). The incremental number of goals met also was associated with improvement in facility mortality (P < 0.001) and hospital days (P < 0.001). Catheter and albumin level goals were achieved least (6% and 9% of facilities, respectively), but they had the best outcomes. Facilities achieving more than 5 goals had older patients (64.0 versus 61.5 years; P < 0.001), fewer African American patients (16% versus 38%; P < 0.001), and fewer women (44% versus 46%; P = 0.003) compared with the average.

Limitations: Observational design with residual confounding from unmeasured patient-, facility-, and treatment-related factors.

Conclusions: Achieving more facility quality goals was significantly associated with better facility-based measurements of patient outcomes. Although these results do not establish a causal relationship, findings agree with the present practice of monitoring facility performance for continuous quality improvement.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Aged
  • Female
  • Hospitalization / trends
  • Humans
  • Kidney Failure, Chronic / epidemiology
  • Kidney Failure, Chronic / therapy
  • Male
  • Middle Aged
  • Outcome Assessment, Health Care / standards*
  • Outcome Assessment, Health Care / trends
  • Outpatient Clinics, Hospital / standards*
  • Outpatient Clinics, Hospital / trends
  • Prospective Studies
  • Quality of Health Care / standards*
  • Quality of Health Care / trends
  • Renal Dialysis / standards*
  • Renal Dialysis / trends