Division of Rheumatology, Department of Medicine, University of California, San Francisco.
Division of Nephrology, Department of Medicine, University of California, San Francisco.
JAMA Netw Open. 2024 Mar 4;7(3):e241722. doi: 10.1001/jamanetworkopen.2024.1722.
Dialysis patient care technicians (PCTs) play a critical role in US in-center hemodialysis (HD) care, but little is known about the association of PCT staffing with patient outcomes at US HD facilities.
To estimate the associations of in-center HD patient outcomes with facility-level PCT staffing.
DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study, with data analysis performed from March 2023 to January 2024. Data on US patients with end-stage kidney disease and their treatment facilities were obtained from the US Renal Data System. Participants included patients (aged 18-100 years) initiating in-center HD between January 1, 2016, and December 31, 2018, who continued receiving in-center HD for 90 days or more and had data on PCT staffing at their initial treating HD facility.
Facility-level patient-to-PCT ratios (number of HD patients divided by the number of PCTs reported by the treating facility in the prior year), categorized into quartiles (highest quartile denotes the highest PCT burden).
Patient-level outcomes included 1-year patient mortality, hospitalization, and transplantation. Associations of outcomes with quartile of patient-to-PCT ratio were estimated using incidence rate ratios (IRRs) from mixed-effects Poisson regression, with adjustment for patient demographics and clinical and facility factors.
A total of 236 126 patients (mean [SD] age, 63.1 [14.4] years; 135 952 [57.6%] male; 65 945 [27.9%] Black; 37 777 [16.0%] Hispanic; 153 637 [65.1%] White; 16 544 [7.0%] other race; 146 107 [61.9%] with diabetes) were included. After full adjustment, the highest vs lowest quartile of facility-level patient-to-PCT ratio was associated with a 7% higher rate of patient mortality (IRR, 1.07; 95% CI, 1.02-1.12), a 5% higher rate of hospitalization (IRR, 1.05; 95% CI, 1.02-1.08), an 8% lower rate of waitlisting (IRR, 0.92; 95% CI, 0.85-0.98), and a 20% lower rate of transplant (IRR, 0.80; 95% CI, 0.71-0.91). The highest vs lowest quartile of patient-to-PCT ratio was also associated with an 8% higher rate of sepsis-related hospitalization (IRR, 1.08; 95% CI, 1.03-1.14) and a 15% higher rate of vascular access-related hospitalization (IRR, 1.15; 95% CI, 1.03-1.28).
These findings suggest that initiation of treatment in facilities with the highest patient-to-PCT ratios may be associated with worse early mortality, hospitalization, and transplantation outcomes. These results support further investigation of the impact of US PCT staffing on patient safety and quality of US in-center HD care.
在美国，透析患者护理技术员（PCT）在中心血液透析（HD）护理中发挥着至关重要的作用，但对于 PCT 人员配备与美国 HD 设施患者结局之间的关联知之甚少。
评估中心 HD 患者结局与设施级 PCT 人员配备的关联。
设计、设置和参与者：这是一项回顾性队列研究，数据分析于 2023 年 3 月至 2024 年 1 月进行。从美国肾脏数据系统中获取了美国终末期肾病患者及其治疗设施的数据。参与者包括自 2016 年 1 月 1 日至 2018 年 12 月 31 日开始接受中心 HD 治疗且在初始治疗 HD 设施接受中心 HD 治疗 90 天或以上并具有 PCT 人员配备数据的患者（年龄 18-100 岁）。
设施级患者与 PCT 的比例（报告的 HD 患者人数除以治疗设施前一年报告的 PCT 人数），分为四分位数（最高四分位数表示 PCT 负担最高）。
患者水平的结局包括 1 年患者死亡率、住院和移植。使用混合效应泊松回归估计结局与患者与 PCT 比例四分位数的关联，调整了患者人口统计学和临床及设施因素。
共纳入 236126 名患者（平均[SD]年龄 63.1[14.4]岁；135952 名[57.6%]男性；65945 名[27.9%]黑人；37777 名[16.0%]西班牙裔；153637 名[65.1%]白人；16544 名[7.0%]其他种族；146107 名[61.9%]患有糖尿病）。经过完全调整，与设施级患者与 PCT 比例的最高四分位相比，最高四分位与死亡率增加 7%相关（IRR，1.07；95%CI，1.02-1.12）、住院率增加 5%相关（IRR，1.05；95%CI，1.02-1.08）、候补名单率降低 8%相关（IRR，0.92；95%CI，0.85-0.98）和移植率降低 20%相关（IRR，0.80；95%CI，0.71-0.91）。患者与 PCT 比例的最高四分位与败血症相关住院率增加 8%相关（IRR，1.08；95%CI，1.03-1.14），血管通路相关住院率增加 15%相关（IRR，1.15；95%CI，1.03-1.28）。
这些发现表明，在患者与 PCT 比例最高的设施中开始治疗可能与早期死亡率、住院和移植结局较差相关。这些结果支持进一步调查美国 PCT 人员配备对美国中心 HD 护理患者安全和质量的影响。
