부산대학교 도서관

BACKGROUND: Mortality rates during the first 90 days following dialysis initiation are unacceptably high. OBJECTIVE: To establish whether a quality improvement program ('RightStart') comprising patient education and prompt implementation of best practice improves outcomes in incident hemodialysis patients. DESIGN: Incident hemodialysis patients were prospectively selected for the program within 2 weeks of starting outpatient dialysis at 39 US centers, during the period May 2002 to November 2005. The control group comprised randomly selected patients who initiated maintenance hemodialysis between May 2002 and March 2005 at 31 other centers in the same regions. Patients lacking sufficient cognitive function to follow the program were excluded from the RightStart group. INTERVENTION: The 3-month RightStart program involved regular visits from a case manager. The program comprised intensive patient education combined with anemia control, evaluation of dialysis adequacy, optimization of vascular access, dietary supplementation, review of medications, logistical support and psychosocial monitoring. Outcomes were assessed at 3 months, 6 months and 12 months (study end). OUTCOME MEASURES: Hospitalization rate, mortality rate, hematocrit, serum albumin level and urea reduction ratio (URR) were compared between the RightStart patients and the controls. RESULTS: The mean age of patients was 62 years in both the RightStart group (n = 918) and the control group (n = 1,020), and female participants comprised 54% of each group. Mean hematocrit, serum albumin level and URR were similar in the two groups at initiation of dialysis. Case manager visits in the RightStart group took place on average 1-2 times per week during the first month and every 1-2 weeks thereafter. The RightStart patients had a higher mean serum albumin level than the control patients at 3 months, 6 months and 12 months (P<0.05 for all) and a higher mean hematocrit at 3 months (P<0.001). There was no significant difference between the groups in mean URR at any point. Catheter use was greater in the RightStart group than in the control group at baseline and all subsequent time points. There were significantly fewer deaths per 100 patient-years in the RightStart group than in the control group (20 vs 39 at 3 months, 18 vs 33 at 6 months and 17 vs 30 at 12 months; P<0.001 for all). In addition, the RightStart patients experienced significantly fewer days in hospital per patient-year than the controls (mean of 2.1 vs 3.1 at 3 months, 4.5 vs 6.3 at 6 months and 7.2 vs 10.5 at 12 months; P<0.001 for all). In the RightStart patients, mean mental composite score on the Kidney Disease Quality of Life Short Form questionnaire was significantly higher at 6 months than during the first 3 months (P<0.05). Mean Dialysis Knowledge Test scores in the patients who participated in the RightStart program were significantly higher than baseline at all subsequent time points (P<0.001 for all). CONCLUSION: Short-term outcomes in incident hemodialysis patients can be improved by an early program of education and intervention.