Fink Jeffrey C, Blahut Steven A, Briglia Andrew E, Gardner James F, Light Paul D
The Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland.
J Am Soc Nephrol. 2001 Jan;12(1):164-169. doi: 10.1681/ASN.V121164.
Efforts to improve the delivery of hemodialysis have focused mostly on identifying patient-related factors that lead to inadequate dialysis. Less consideration has been given to the impact of the dialysis center on adequacy. This study evaluated whether the dialysis facility or individual-level factors were the primary influence on variations in dialysis adequacy. This was a retrospective analysis of 4971 hemodialysis patients in 189 centers with urea reduction ratio (URR) values obtained in the final quarter of 1997. The between-center variation and the within-center correlation in URR values were quantified to determine the contribution of a center effect on variations in adequacy; furthermore, the proportion of variance attributable to the centers' effect and individual-level dialysis covariates were compared. There was a wider between-center variation in mean URR values (SD, 4.8%) than expected if there were no center effect (SD, 2.5%). There was a strong within-center correlation in URR values, measured by the parameter rho, which was only minimally diminished after adjusting for individual-level covariates (adjusted rho, 0.14; P < 0.0001). The variation in URR attributable to the center effect, quantified by R(2), was greater than that related to individual-level dialysis factors (facility- and individual-level dialysis covariates R(2), 23.6 and 11.3%, respectively). Initiatives to improve the delivery of dialysis in patients with end-stage renal disease should be directed at facility policies governing dialysis care, along with patient-specific problems, because center effects have a major influence on dialysis adequacy.
改善血液透析服务的努力主要集中在识别导致透析不充分的患者相关因素上。而对于透析中心对透析充分性的影响则较少考虑。本研究评估了透析机构因素还是个体层面因素是透析充分性差异的主要影响因素。这是一项对189个中心的4971例血液透析患者的回顾性分析，这些患者在1997年最后一个季度获得了尿素清除率（URR）值。对URR值的中心间差异和中心内相关性进行量化，以确定中心效应在充分性差异中的作用；此外，还比较了可归因于中心效应和个体层面透析协变量的方差比例。如果不存在中心效应，平均URR值的中心间差异（标准差为4.8%）比预期的要大（标准差为2.5%）。通过参数rho测量，URR值在中心内具有很强的相关性，在调整个体层面协变量后，这种相关性仅略有减弱（调整后的rho为0.14；P<0.0001）。通过R(2)量化的可归因于中心效应的URR差异大于与个体层面透析因素相关的差异（机构层面和个体层面透析协变量的R(2)分别为23.6%和11.3%）。改善终末期肾病患者透析服务的举措应针对管理透析护理的机构政策以及患者特定问题，因为中心效应在透析充分性方面具有重大影响。
