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Attaining clinical targets among hemodialysis patients is linked to better outcomes

Doctors caring for patients undergoing hemodialysis for end-stage renal disease (ESRD) ideally set clinical targets for nutrition, bone disease management, anemia management, dialysis adequacy, and vascular access placement for dialysis tubes. When patients achieve these targets, they have improved outcomes, concludes the ESRD Quality Study. Johns Hopkins University researchers prospectively studied attainment of these 5 clinical targets within 6 months of study enrollment for 668 hemodialysis patients from 74 U.S. not-for-profit dialysis clinics.

The targets included albumin (a type of protein) of 4.0 g/dl or higher (higher serum albumin is a marker of better nutrition and lower inflammation), hemoglobin of 11 g/dl or higher (a marker of better anemia management), calcium-phosphate product of more than 55 mg2/dl2 (a marker of effective bone disease management and less bone loss), dialysis dose of Kt/V 1.2 or higher, and vascular access for hemodialysis via fistula (joined artery and vein, usually in the forearm) rather than graft.

Attainment of each of the clinical targets was strongly associated with better outcomes, including fewer deaths and hospitalizations, fewer days in the hospital, and lower overall Medicare hospital payments. In addition, attainment of each additional target reduced risk of dying by about 35 percent, risk of hospitalization by about 20 percent, and the number of days hospitalized by 24 percent, and decreased annual Medicare hospital payments by about $762 per patient-year.

The study validates professional clinical practice guidelines for care of ESRD patients on hemodialysis. It also should reassure physicians of chronic disease patients that efforts to attain clinical targets in their patients can improve their health. For example, patients who attained the albumin target had 45 percent decreased mortality, 33 percent fewer hospital admissions, 39 percent fewer hospital days, and average annual cost reductions of $3,282 compared with patients who did not achieve the target.

The study was supported in part by the Agency for Healthcare Research and Quality (HS08365). More details are in "Attainment of clinical performance targets and improvement in clinical outcomes and resource use in hemodialysis care: A prospective cohort study," by Laura C. Plantinga, Sc.M., Nancy E. Fink, M.P.H., Bernard G. Jaar, M.D., M.P.H., and others, in the BMC: Health Services Research 7(5), 2007, available online at www.biomedcentral.com.

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