Network 13 partnership to improve the influenza, pneumococcal pneumonia, and hepatitis B vaccination rates among dialysis patients.

Vaccinations are available for primary prevention of many infections in adults. Morbidity and mortality from invasive diseases such as influenza and Streptococcus pneumoniae (pneumococcus) remain high and may be largely preventable by vaccination of high-risk adults, including dialysis patients. The current 23-valent vaccine-efficacious, with a low adverse event profile-is widely available. Revaccination is also recommended in patients with immunocompromising conditions, including chronic kidney disease. Despite having many opportunities to be vaccinated, adult hemodialysis and peritoneal dialysis patients are often missed During the recent H1N1 influenza outbreak, we conducted a performance improvement project to increase the vaccination rates for pneumococcal pneumonia, hepatitis B, and influenza, with a special focus on prevention. The project included an education phase, baseline assessment of vaccination rates, intervention, and a follow-up assessment of vaccination rates. The geographic jurisdiction of ESRD Network 13 encompasses the states of Arkansas, Louisiana, and Oklahoma. At the beginning of the network-wide project, the documented state-specific rates for influenza immunization were below the average influenza immunization rates for adults reported by Centers for Disease Control and Prevention and far below its target for adults. Our improvement project incorporated educational interventions to improve patient acceptance of vaccinations, educational interventions to improve staff participation in quality improvement activities, and improved techniques of quality improvement data collection and analysis by participants. During this project, the immunization rates for hepatitis B and pneumococcal pneumonia were also reviewed. At project's conclusion, improvement was demonstrated in all three focus areas, with statistically significant improvements noted in both influenza and pneumococcus vaccination rates. The use of educational interventions to improve staff participation in quality improvement, and the collection and analysis of quality improvement data can be replicated in many practice settings to improve immunization rates for dialysis patients and other patients with chronic illnesses.

Advanced glycation end products in foods and a practical guide to their reduction in the diet.

Modern diets are largely heat-processed and as a result contain high levels of advanced glycation end products (AGEs). Dietary advanced glycation end products (dAGEs) are known to contribute to increased oxidant stress and inflammation, which are linked to the recent epidemics of diabetes and cardiovascular disease. This report significantly expands the available dAGE database, validates the dAGE testing methodology, compares cooking procedures and inhibitory agents on new dAGE formation, and introduces practical approaches for reducing dAGE consumption in daily life. Based on the findings, dry heat promotes new dAGE formation by >10- to 100-fold above the uncooked state across food categories. Animal-derived foods that are high in fat and protein are generally AGE-rich and prone to new AGE formation during cooking. In contrast, carbohydrate-rich foods such as vegetables, fruits, whole grains, and milk contain relatively few AGEs, even after cooking. The formation of new dAGEs during cooking was prevented by the AGE inhibitory compound aminoguanidine and significantly reduced by cooking with moist heat, using shorter cooking times, cooking at lower temperatures, and by use of acidic ingredients such as lemon juice or vinegar. The new dAGE database provides a valuable instrument for estimating dAGE intake and for guiding food choices to reduce dAGE intake.

An arteriovenous fistula (AVF) functionality quality improvement tracking tool--developed and implemented to improve newly placed AVF utilization rates and patient outcomes.

The authors developed a reporting tool to assist hemodialysis clinicians to track new arteriovenous fistulas (AVFs), their maturation, and use. The tool identifies impediments to timely use (6 weeks/42 days) of AVFs. The use of this tool in nine dialysis units with high gaps between AVF placement and usage reduced the gap from 19.5% to 13.5% and reflected a reduction in the percentage of AVFs in place but not in use from 31.4% to 23.2%.

Increasing the use of arteriovenous fistulas (AVF): a network QI project.

In 2002, the Intermountain End-Stage Renal Disease Network Inc., Network 15, initiated a quality improvement project, "Increasing Arteriovenous Fistulas Within Network 15." The primary objective of this project was to maximize the placement of arteriovenous fistulas (AVF) within the adult in-center hemodialysis population in Network 15. A closely related objective was to ensure policies and procedures were in place at each facility to encourage placement and maintenance of fistulae after they had been placed. Based on the facility-specific percentage of adult patients reported to have a fistula in January 2001, eight facilities were selected to participate in the project. Approximately 100 project partners (facility staff, nephrologists, and surgeons) collaborated to improve AVF rates for incident and prevalent patients. The interventions for this project were multifaceted and included face-to-face meetings with project partners, dissemination of a National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) summary paper on vascular access, video materials and written information for patient and staff, post-operative "Fistula Care Packages" educational meetings, and data feedback to facility staff nephrologists and surgeons. Of the seven indicators selected for this project, the predicted improvement was met in four. Overall improvement was noted in six of the seven process/outcome measures. A statistically significant (p=0.05) improvement was noted in the rate of fistulas used for treatment for prevalent (all) hemodialysis patients. This rate increased by about one-third from baseline to remeasurement.