Lacson Eduardo, Wang Weiling, Lazarus J Michael, Hakim Raymond M
Clinical Science, Epidemiology, and Research, Fresenius Medical Care North America, Waltham, MA 02451-1457, USA.
Am J Kidney Dis. 2009 Sep;54(3):490-7. doi: 10.1053/j.ajkd.2009.01.260. Epub 2009 Apr 29.
We evaluated whether incremental achievement of up to 8 facility quality goals was associated with improvement in facility-specific mortality and hospitalization rates.
Prospective observational study.
SETTING & PARTICIPANTS: 1,085 Fresenius Medical Care, North America facilities providing hemodialysis (HD) for 25 or more patients during January 2006.
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.
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.
Observational design with residual confounding from unmeasured patient-, facility-, and treatment-related factors.
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.
我们评估了逐步实现多达8项机构质量目标是否与机构特定的死亡率和住院率的改善相关。
前瞻性观察性研究。
2006年1月期间，北美1085家为25名或更多患者提供血液透析（HD）的费森尤斯医疗护理机构。
使用截至2006年12月31日期间的机构平均值来确定在平衡Kt/V、错过的HD治疗、血红蛋白水平、碳酸氢盐水平、白蛋白水平、磷水平、动静脉内瘘和HD导管方面每个目标的达成情况。线性回归模型用于将全机构目标的达成情况与机构特定的住院天数和标准化死亡率相关联。
大多数机构（64%）实现了8项目标中的2至4项，只有8%的机构达到了5项以上的质量目标。实现5项以上目标平均每位患者每年的住院天数减少3.5天，标准化死亡率降低20%（所有P<0.001）。达成的目标增量数量也与机构死亡率的改善（P<0.001）和住院天数的改善（P<0.001）相关。导管和白蛋白水平目标达成率最低（分别为6%和9%的机构），但它们的结果最佳。与平均水平相比，实现5项以上目标的机构患者年龄更大（64.0岁对61.5岁；P<0.001），非裔美国患者更少（16%对38%；P<0.001），女性更少（44%对46%；P = 0.003）。
观察性设计，存在来自未测量的患者、机构和治疗相关因素的残余混杂。
实现更多的机构质量目标与基于机构的患者结局测量结果更好显著相关。尽管这些结果并未确立因果关系，但研究结果与目前监测机构绩效以持续质量改进的做法一致。
