Quality Control in Haemodialysis Delivery

Lars-Göran Nilsson, Juan P Bosch, Maria Alquist
European Nephrology, 2011;5(2):132-137
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Abstract

Haemodialysis (HD) patients anticipate that all treatments are delivered to their individual needs. However, as the management of HD delivery is complex and every treatment differs, efficient quality control activities are required to ensure that the therapy is effectively provided. Contemporary dialysis machines have integrated tools to support the control process. Ionic clearance measurement alerts when treatment effectiveness is impaired and provides a means to decrease dose variability. Blood volume monitoring and biofeedback control support the achievement of dry weight, treatment by treatment, with reduced risk of intradialytic hypotension and other symptoms related to fluid removal. Available evidence indicates that structured quality control may have a significant effect on patient outcome as well as on the cost efficiency of dialysis care.

Support: The publication of this article was funded by Gambro.
Keywords
Haemodialysis delivery, quality control, dose variability, ionic clearance, Kt/V, dry weight, blood volume monitoring, blood volume tracking
Disclosure Lars-Göran Nilsson, Juan P Bosch and Maria Alquist are all employees of Gambro.
Received: May 30, 2011 | Accepted June 20, 2011 | Citation European Nephrology, 2011;5(2):132-137
Correspondence: Lars-Göran Nilsson, Gambro, PO Box 10101, SE-22010 Lund, Sweden. E: Lars-Goran.Nilsson@gambro.com

Haemodialysis (HD) makes survival possible for more than a million people with end-stage renal disease (ESRD) throughout the world. Still, it is a continuing notion everywhere that the survival rate for prevalent dialysis patients is low and without significant improvement in later years. At the same time, the healthcare spending for ESRD patients on dialysis is immense and the growing population of ESRD patients represents a significant economic burden to countries worldwide.1 Dialysis providers are facing increasing pressure to become more cost efficient; reducing costs for dialysis delivery, while at the same time improving or at least maintaining quality of care.

Older age and a high and increasing rate of co-morbidities, like cardiovascular diseases, inflammation, frequent infections and bleeding disorders, may partly explain the unsatisfactory outcome for patients on chronic dialysis. Age and co-morbid condition are also related to cost-effectiveness in dialysis care, which shows considerable variability between patients.2 In addition, a key variable affecting both outcome and cost in this patient population is the way dialysis care is provided. The time when patients are referred to a nephrologist, what type of dialysis therapy is offered to them and how well that therapy is implemented, all have a profound effect on the therapy results. Implementation of the therapy involves prescription – dialysis dose, fluid removal, dialysis fluid composition, administration of erythropoiesis-stimulating agents, vitamin D analogues, phosphate binders and other drugs – but also consistent delivery of therapy to that prescription.

Like healthcare in general, inability to deliver therapy to the prescription represents a source of inefficiency in dialysis care. A systematic treatment mapping in dialysis clinics has shown that dialysis delivery is often poorly standardised with significant process variability between and within clinics.3 The variability is related to factors such as patient characteristics, dialysis prescription, dialysis equipment design and clinic practices, such as scheduling of patients and staff resources.3,4 When the process is poorly controlled it also becomes difficult to implement individualisation of the therapy.

It is often perceived in medicine that new technologies with potential to improve patient outcomes are contributing to rising health expenditures. However, quality improvements are not necessarily associated with increased costs and there is a substantial cost associated with poor quality. A US analysis on the general Medicare health cost statistics, focusing on key severity-adjusted diagnosis-related groups, supports the concept that poor outcomes lead to greater expenditures and that improving quality can help to reduce costs significantly.5

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