Improving compliance with the dialysis prescription as a strategy to increase the delivered dose of hemodialysis: an ESRD Network 4 quality improvement project.

Delivery of an inadequate dose of hemodialysis is associated with a significant increase in the relative risk of both hospitalization and death. We hypothesized that noncompliance with the dialysis prescription, defined as failure to achieve the prescribed blood flow, failure to dialyze for the prescribed duration, or failure to use the prescribed dialyzer, was a significant factor in patients not achieving a urea reduction ratio (URR) of > or =0.65. We identified the 29 dialysis facilities in ESRD Network 4 that had the lowest average URR and/or lowest percent of patients with a URR > or =0.65 based on quarterly data reports. Each facility was surveyed by review of all dialysis treatment sheets from a single week by network staff to evaluate for noncompliance with the dialysis prescription. Facility-specific data were reported back to each facility. Each facility was required to develop a facility-specific quality improvement plan after receiving intensive education on the quality improvement process. After 9 months the facilities were resurveyed. Although the compliance with the dialysis prescription decreased from 54.0% to 53.6% (P =.026), the delivered URR increased from 0.679 +/- 0.072 to 0.688 +/- 0.070 (P =.026) with an increase in the percentage of patients with a URR > or = 0.65 from 69.7% to 75% (P =.0096). Kt/V increased from 1.37 +/- 0.26 to 1.41 +/- 0.27 (P =. 0001). Analysis of the process changes instituted by the individual facilities showed an increase in the prescribed dose of dialysis. Thus, although the process goal of improved compliance with the dialysis prescription was not achieved, the outcome goal of an increased delivered dose of dialysis was met through an alternative process change of an augmented dialysis prescription.