The prevalence of end stage kidney disease and the demand for dialysis services have been steadily increasing worldwide (1), with projections indicating that this trend will continue to rise (1, 2). Although the ability to provide dialysis has improved patient life expectancy (3, 4), those who require dialysis have inferior outcomes compared with the general population, emphasizing the importance of implementing strategies to improve these outcomes. Although many factors shown to affect patient outcome in dialysis programs cannot be changed, such as geography, facility location, and patient comorbidities, there are many others that can be modified (5) (Table 1).
Factors affecting patient outcomes in dialysis programs
The Peer Kidney Care Initiative, an important enterprise to identify some of these factors, was created in 2014 by the chief medical officers of 14 U.S. dialysis provider organizations and the Chronic Disease Research Group (4). Several studies have evaluated several modifiable factors in dialysis care that improve patient outcomes, such as high use of surgical vascular access and increased dialysis time (6). The impact of both structural characteristics of dialysis programs and delivery of care by nephrologists on patient outcomes has also increasingly become a topic of interest.
For example, some studies have evaluated the impact of frequency and duration of provider-patient visits in hemodialysis programs on patient outcomes (7, 8), with variable results (9). Others evaluated whether a dialysis program structure affects patient outcomes (10, 11). To date, there has been no large-scale study, however, to evaluate the impact of nephrologist staffing models on patient outcomes, a topic that has been addressed by Silver and colleagues (12). The authors identified the wide variations in nephrology staffing models and sought to evaluate whether this factor impacts patient outcomes in a large, population-based cohort of over 14,000 individuals receiving hemodialysis in Ontario, Canada. In this retrospective study, Silver and coworkers (12) compared patient outcomes between dialysis programs that used a single, primary nephrologist model with those that used a group of nephrologists on a rotating basis. After adjusting for several predefined patient and center characteristics, no differences were found in rates of mortality, kidney transplantation, or home dialysis initiation between the groups (Figure 1). In dialysis programs with high patient volumes (>500 patients) and in those with medically complex patients (Charlson Comorbidity Index ≥4), the authors did find an interaction between the single nephrologist model and mortality, suggesting that these factors may need to be considered when considering staffing models.
Does longitudinal care provided by a single nephrologist in dialysis centersimprove patient outcomes?
Citation: Kidney News 15, 6
The results of this study suggest a multidisciplinary approach is required to optimize patient outcomes in dialysis programs and that continuity of care alone, while important, is not enough. Worth mentioning, as noted by the authors, is that this study did not assess patient-reported outcome measures, an important point to consider (13). Previous studies evaluating the effect of face-to-face time between patients and providers in dialysis centers have found that length of visits, rather than frequency of visits, was associated with better patient-reported outcome measures, suggesting communication skills were more important for patient satisfaction (14).
The concerning trajectory of the incidence of dialysis initiation worldwide highlights the importance of identifying and optimizing patient care models in dialysis programs. Whereas the abundance of research on this topic has been done at a population-based level, interpretating results must be done cautiously, as there are many confounders that are difficult to adjust for in this study design. Such confounders may include several treatment protocols that vary among programs (i.e., anemia/iron protocols, mineral and bone disorder protocols, the transplant-referral process, etc.), a limitation that was also noted appropriately by the authors.
Improvement initiatives implemented within individual dialysis centers have the potential to enhance objective patient outcomes by targeting factors that are specific to the patient population served by that center. Finally, it is crucial to keep in mind that the identification of factors that improve patient outcomes is just the initial stage, and it is essential to follow through with implementation to effectively achieve the desired change. This is not a simple task, as some factors, such as dialysis frequency and time, require change at the level of health policymakers because reimbursement is currently pre-set for three times weekly for in-center hemodialysis (15). This complexity of policy change further emphasizes the importance of building strong evidence for change to improve outcomes of patients requiring dialysis.
References
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Centers for Medicare & Medicaid Services. End Stage Renal Disease (ESRD) Prospective Payment System (PPS). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment#:~:text=ESRD%20facilities%20furnishing%20dialysis%20treatments%20in%20facility%20and,medical%20justification%20for%20more%20than%20three%20weekly%20treatments
