A quality initiative. Reducing rates of hospitalizations by objectively monitoring volume removal.

Morbidity, hospitalizations, and costs for the treatment of individuals with end-stage renal disease are simply not improving at a rate that is acceptable to many physicians and dialysis providers in the United States. Various conferences and papers have suggested what processes need to become part of the dialysis prescription to accelerate change. Controlling cardiovascular disease is a part of that change, and controlling extra-cellular volume (ECV) is necessary to accomplish this. Three dialysis providers joined in a quality initiative to objectively assess the ultrafiltration process and measure "normalized" ECV, with the outcome objective to decrease ECV-related hospitalizations. The results show a decrease in ECV-related hospitalizations by 50%. The model of dialysis prescription needs to now change to Kt/V + objective ECV control.

The economic burden of geriatric ESRD.

The elderly represent the fastest growing segment of incident patients entering end-stage renal disease (ESRD). Increasingly, social scientists and caregivers are faced with changing models of care, which will challenge traditional patterns of patient acceptance into costly medical therapies. This paper analyzes the outcomes and cost of taking care of patients over the age of 65, and compares these costs and outcomes with other age groups. The results are somewhat unexpected, in that the incremental costs are not appreciably higher, although the outcomes are considerably worse compared with that in younger age groups. Proposals are made for addressing these issues.

A crucial lifeline: reducing mortality in the first 120 days.

Data from the United States Renal Data System shows that mortality and hospitalization rates for prevalent ESRD patients is high and has only gradually improved year after year. Furthermore, the same rates are even higher for patients in the first year of care, especially the first 120 days. Renal Ventures Coaching for Actions, Results, and Empowerment (RVCARE) was developed to reduce the high mortality and hospitalization risk, improve cardiovascular disease, decrease the use of catheters, offer optimal modalities of therapy, and change other outcomes in incident patients undergoing in-center hemodialysis. The results demonstrate that it is indeed possible to positively affect these outcomes, even in a small dialysis organization (SDO).