Vancomycin-resistant enterococci colonization in patients at seven hemodialysis centers.

BACKGROUND: Vancomycin-resistant enterococci (VRE) are increasing in prevalence at many institutions, and are often reported in dialysis patients. We studied the prevalence of and risk factors for VRE at seven outpatient hemodialysis centers (three in Baltimore, MD, USA, and four in Richmond, VA, USA). METHODS: Rectal or stool cultures were performed on consenting hemodialysis patients during December 1997 to April 1998. Consenting patients were recultured during May to July 1998 (median 120 days later). Clinical and laboratory data and functional status (1 to 10 scale: 1, normal function; 9, home attendant, not totally disabled; 10, disabled, living at home) were recorded. RESULTS: Of 478 cultures performed, 20 (4.2%) were positive for VRE. Among the seven centers, the prevalence of VRE-positive cultures varied from 1.0 to 7.9%. Independently significant risk factors for a VRE-positive culture were a functional score of 9 to 10 (odds ratio 6.9, P < 0.001), antimicrobial receipt within 90 days before culture (odds ratio 6.1, P < 0.001), and a history of injection drug use (odds ratio 5.4, P = 0.004). CONCLUSIONS: VRE-colonized patients were present at all seven participating centers, suggesting that careful infection-control precautions should be used at all centers to limit transmission. In agreement with previous studies, VRE colonization was more frequent in patients who had received antimicrobial agents recently, underscoring the importance of judicious antimicrobial use in limiting selection for this potential pathogen.

A prospective study of vascular access infections at seven outpatient hemodialysis centers.

Vascular access infections are a major cause of morbidity and mortality in hemodialysis patients, and the use of antimicrobials to treat such infections contributes to the emergence and spread of antimicrobial-resistant bacteria. To determine the incidence of and risk factors for vascular access infections, we studied hemodialysis patients at 7 outpatient dialysis centers (4 in Richmond, VA, and 3 in Baltimore, MD) during December 1997 to July 1998. Vascular access infections were defined as local signs (pus or redness) at the vascular access site or a positive blood culture with no known source other than the vascular access; and hospitalization or receipt of an intravenous (IV) antimicrobial. A total of 796 patients were followed for 4,134 patient-months. The vascular access infection rate was 3.5/100 patient-months, ie, patients had a 3.5% risk of infection each month. Independent risk factors were the specific dialysis unit where the patient was treated (relative hazard varying from 1.0 to 4.1 among the 7 centers), catheter access (relative hazard, 2.1 v implanted access), albumin level (relative hazard, 2.4 for lowest v highest quartile), urea reduction ratio (relative hazard, 2.2 for lowest v highest quartile), and hospitalizations during the previous 90 days (relative hazard, 4.9 for >/=6 v zero hospitalizations). These data confirm that vascular access infections are common in hemodialysis patients and that infection rates differ substantially among different centers. Catheter use should be minimized to reduce these infections. Additionally, the possibility that improved serum albumin and urea reduction ratio could reduce vascular access infections should be evaluated.

The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital.

PURPOSE: To evaluate the impact of implementing a hospitalist service with a nurse discharge planner in an academic teaching hospital. SUBJECTS AND METHODS: Inpatient medicine service was provided by hospitalists, general internists, and specialists. Service personnel were identical except that the hospitalist service also had a nurse discharge planner. Hospitalists attended 4 months per year (compared with the 1 month by most other attending physicians) and had no outpatient responsibilities during the ward months. Patients were admitted alternately based on resident call schedule. Major outcomes included average costs of hospitalization, length of stay, and resource utilization. Quality measures included inpatient mortality, 30-day readmission rates, and satisfaction of patients, residents and students. RESULTS: Hospitalist-attended services had lower mean (+/- SD) inpatient costs per patient ($4289 +/- $6512) compared with specialist-staffed services ($6066 +/- $7550, P < 0.0001), with a trend toward lower costs when compared with generalist-attended services ($4850 +/- $7027, P = 0.11). Hospitalist services had shorter mean lengths of stay (4.4 +/- 4.0 days), compared with generalists (5.2 +/- 5.2 days) and specialists (6.0 +/- 5.5 days, P < 0.0001 for hospitalists vs. both groups). Readmission rates were similar in all groups. Mortality rates were higher in the specialist group [5.0% (44 of 874)] compared with hospitalists [2.2% (18 of 829)] and generalists [2.6% (20 of 761), P = 0.002 for specialists vs. both groups, P = 0.09 for generalists vs hospitalists]. Satisfaction results were uniformly high in all groups, with no significant differences. CONCLUSION: Hospitalist services with a nurse discharge planner were associated with lower average cost and shorter average length of hospital stay, without any apparent compromise in clinical outcomes or patient satisfaction.

Racial disparities in access to renal transplantation--clinically appropriate or due to underuse or overuse?

BACKGROUND: Despite abundant evidence of racial disparities in the use of surgical procedures, it is uncertain whether these disparities reflect racial differences in clinical appropriateness or overuse or underuse of inappropriate care. METHODS: We performed a literature review and used an expert panel to develop criteria for determining the appropriateness of renal transplantation for patients with end-stage renal disease. Using data from five states and the District of Columbia on patients who had started to undergo dialysis in 1996 or 1997, we selected a random sample of 1518 patients (age range, 18 to 54 years), stratified according to race and sex. We classified the appropriateness of patients as data on candidates for transplantation and analyzed rates of referral to a transplantation center for evaluation, placement on a waiting list, and receipt of a transplant according to race. RESULTS: Black patients were less likely than white patients to be rated as appropriate candidates for transplantation according to appropriateness criteria based on expert opinion (71 blacks [9.0 percent] vs. 152 whites [20.9 percent]) and were more likely to have had incomplete evaluations (368 [46.5 percent] vs. 282 [38.8 percent], P<0.001 for the overall chi-square). Among patients considered to be appropriate candidates for transplantation, blacks were less likely than whites to be referred for evaluation, according to the chart review (90.1 percent vs. 98.0 percent, P=0.008), to be placed on a waiting list (71.0 percent vs. 86.7 percent, P=0.007), or to undergo transplantation (16.9 percent vs. 52.0 percent, P<0.001). Among patients classified as inappropriate candidates, whites were more likely than blacks to be referred for evaluation (57.8 percent vs. 38.4 percent), to be placed on a waiting list (30.9 percent vs. 17.4 percent), and to undergo transplantation (10.3 percent vs. 2.2 percent, P<0.001 for all three comparisons). CONCLUSIONS: Racial disparities in rates of renal transplantation stem from differences in clinical characteristics that affect appropriateness as well as from underuse of transplantation among blacks and overuse among whites. Reducing racial disparities will require efforts to distinguish their specific causes and the development of interventions tailored to address them.

1999 facility Profile Reports.

In November 1999, the Mid-Atlantic Renal Coalitions (MARC) developed and distributed its first version of a facility-specific Profile Report to the medical directors and head nurses of dialysis facilities in Washington, DC, Maryland, Virginia, and West Virginia. The profiles were distributed to support the facilities' internal quality improvement efforts and were not intended to be released as public documents. Facility characteristic and profiling indicators were selected based on the availability, reliability, and value of the data. The Profile Report consisted of 2 data displays with corresponding definition tables. An evaluation mechanism was discussed, but it was determined that the initial report would not be formally evaluated and that this would be included as a feature of future versions. Future versions will be expanded, as additional data become available, and will include rankings and data trending where appropriate.

Within-center correlation in dialysis adequacy.

The purpose of this study was to determine whether patients with end stage renal disease treated with hemodialysis were correlated in dialysis adequacy within facilities. This was a retrospective analysis of dialysis adequacy based on urea reduction ratio (URR) values from 6969 patients dialyzed at 154 facilities. The within-center correlation was quantified using the between-center variation and the parameter p that was derived using ANOVA tables and mixed effects models. The variation in center means for URR was wider than expected for independent observations (52.9-76.1 versus 60.7-73.8, respectively). Furthermore, there was a significant within-center correlation in URR values across all facilities (p = 0.136, P<0.0001), which persisted after adjusting for patient specific covariates, facility characteristics, and state. In conclusion, there was a substantial within-center correlation in dialysis adequacy that reflected important center effects on the outcome of ESRD patients.

Significance of serum creatinine values in new end-stage renal disease patients.

The appropriate use of serum creatinine level as a surrogate for time in the course of renal failure when dialysis commences requires it to be a significant predictor of mortality in incident patients with end-stage renal disease (ESRD). This study evaluated factors that account for variations in creatinine level before the initiation of dialysis and whether incident creatinine level after controlling for these factors was a risk factor for mortality. This is a retrospective cohort study of patients from Maryland and Virginia who initiated dialysis between April 1, 1995, and December 31, 1996, with data ascertained from the Health Care Financing Administration Form 2728. Multivariate models were used to evaluate both the factors that predict incident serum creatinine level and the association between creatinine level and mortality. There were 5, 388 patients followed up for an average of 23.6 +/- 0.2 months. Mean creatinine level was 9.2 +/- 0.1 mg/dL, with case-mix factors most predictive of serum creatinine level and accounting for 9% of its variance. Hematocrit and blood urea nitrogen levels as additional surrogates for progression of renal disease accounted for 7.4% of the variance, whereas the nutritional parameters, body mass index, and albumin level only explained an additional 1% of the total variance in creatinine level. Creatinine level was inversely correlated with mortality risk, and this relationship was sustained both with transformation into an estimated glomerular filtration rate and multivariate adjustment for confounders (relative risk = 0. 96; P < 0.0001). Creatinine values from an incident ESRD population have a weak relationship with the timing of dialysis initiation but represent a strong measure of health status.

Hemodialysis adequacy in Network 5: disparity between states and the role of center effects.

The purpose of this study was to determine whether an observed difference in hemodialysis adequacy between states in Network 5 was due to variations in patient characteristics and to what extent dialysis center effects played a role in the observed disparity between states. This was a retrospective observational study of 6,969 patients dialyzed at centers in Maryland and Virginia. There were 3,919 patients on hemodialysis at 89 facilities in Virginia and 3,050 subjects dialyzed at 65 centers in Maryland. The mean urea reduction ratio (URR) was higher in Virginia compared with Maryland (68.2 +/- 0.1% v 66.0 +/- 0.2%, P < 0.0001, respectively), and there continued to be a mean difference in URR of 1.8% between VA and MD (P < 0.0001) after adjusting for several covariates. The differences in URR between states varied depending on facility proprietary status, size as measured by number of stations, and relationship to hospital (free-standing or hospital-based). Furthermore, the center where a patient dialyzed, when treated as a fixed effect, accounted for 15% of the variance in URR. The mean difference of 1.8% in URR between states persisted in a mixed-effects model that included all covariates along with adjusting for dialysis centers as a random effect. The disparity in dialysis adequacy between states in Network 5 could not be accounted for by demographic characteristics, case mix factors, or a large center effect observed in the region. Therefore, we conclude that underlying national reports on dialysis adequacy are heterogeneous results related to differences across regions such as states within a given Network. This difference between states is not explained by the strong center effect found on adequacy in this population of hemodialysis patients.

Working with noncompliant and abusive dialysis patients: practical strategies based on ethics and the law.

The patient population in dialysis facilities today reflects common societal problems such as human immunodeficiency virus infection, illicit drug use, distrust of and disrespect for authority, and a propensity toward violence. An increase in calls from dialysis units for guidance in dealing with noncompliant and abusive patients prompted ESRD Network 5 to examine this problem and develop an educational program, "Working with Noncompliant and Abusive Patients." This article provides an overview of the ESRD Network 5 study of the ethical, legal, psychosocial, and administrative aspects of this problem, presents practical strategies for working with such patients, and demonstrates the application of these strategies in three cases. It emphasizes the importance for dialysis units of four elements in the successful treatment of such patients: instruction for all levels of dialysis staff; a team approach; written policies; and patient education at the time of admission about these policies, including the consequences of verbal and physical abuse and the circumstances under which patients will be discharged from the dialysis unit.

A pilot study of state surveying methods for ESRD facilities.

End Stage Renal Disease (ESRD) facilities must meet certification requirements to receive Medicare reimbursement from the Health Care Financing Administration, Department of Health and Human Services (DHHS). State survey agencies, operating under contract with DHHS, assess compliance with conditions and standards for all Medicare facilities. The survey process has been criticized by renal professionals and organizations for its lack of objective criteria, because thresholds have not been established, and for the lack of a severity index. The current process promotes subjective decision making in determining facility deficiencies. Efforts to reorganize the survey process to make it more outcome-oriented are being initiated and, while this is laudable, there is no assurance that the process will be effective. Network #5 conducted a pilot study of state survey results to profile data for Medical Review Board (MRB) analysis and to identify potential areas where educational activities could be focused. Network #5 consists of dialysis and transplant providers in the District of Columbia (D.C.), Maryland, Virginia, and West Virginia. There are 139 dialysis facilities and 13 transplant centers serving over 7,000 dialysis patients. This pilot study was a retrospective analysis of surveys conducted in dialysis units that were operational as of August, 1988. This study did not include transplant providers.