Commentary on Rocco MV, Frankenfield DL, Hopson SD, McClellan WM: Relationship between clinical performance measures and outcomes among patients receiving long-term hemodialysis. Ann Intern Med 14:512-519, 2006.
The incidence and prevalence of patients treated by dialysis continues to increase.1 The mortality rate of dialysis patients is high, and worse than that of many cancers.1 Therefore it is important to identify modifiable mortality risk factors, to determine whether interventions to treat these risk factors are efficacious, to develop practice guidelines on the use of efficacious interventions in practice, and to define performance measures to monitor the outcomes of treatment.
In the October 2006 issue of Annals of Internal Medicine, Rocco et al reported that attainment of multiple performance measures in dialysis patients was associated with lower mortality and hospitalization rates.2
serum albumin value of 4 g/dL (40 g/L) or greater or 3.7 g/dL (37 g/L) or greater (bromcresol green and bromcresol purple laboratory methods, respectively);
use of a fistula for vascular access; and
measured single-pool Kt/V urea value of 1.2 or greater.
In multivariable analysis, they determined whether achieving these performance measures was associated with better mortality and hospitalization rates during the next 12 months. During the initial period,
6% of patients did not meet any target,
24% met 1 target,
39% met 2 targets,
24% met 3 targets, and
7% met all 4 targets
During the 12-month follow-up,
55% of patients were hospitalized and
20% died.
Patients who met all targets were more likely to be
male,
younger,
of white race,
of Hispanic ethnicity,
have hypertension or glomerulonephritis as the cause of ESRD,
have a lower body mass index, and
to have received dialysis for more years;
they were less likely to have diabetes mellitus and comorbid conditions (both cardiovascular and noncardiovascular).
In other words they were healthier and they were survivors.
What Should Clinicians and Researchers Do?
Of the 4 quality indicators studied by Rocco et al,2only a higher dialysis dose has RCT evidence to support the expectations that achievement of these targets would be associated with better hard clinical outcomes.13 Thus, a clinical performance measure to achieve Kt/V > 1.2 is justified. One cannot conclude from the Rocco et al analyses that achievement of other clinical performance targets will lead to reduction in mortality and hospitalization. However achievement of some targets should be associated with other clinical benefits. RCTs demonstrate that treatment of anemia to a target hemoglobin value of 11 g/dL (110 g/L) or greater will improve quality of life and limit blood transfusions.14 It is likely that preferential use of fistulas rather than grafts should lead to better vascular access outcomes.15 Consequently quality assurance initiatives to achieve these targets can be supported. However, a serum albumin target of 4 g/dL (40g/L) as a clinical performance measure is illusory at present, as it is not currently modifiable.
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