[Impact of a quality program in hemodialysis]

One of the requirements of a health care quality management system is to be able to established clinical performance measures (CPM) for its key organisation processes. We described some of the performance measurement that has been used in our hemodialysis unit, since the implementation in the year 2001, of a Quality Management System (QMS). We analyze and compare the effect that the introduction of a ISO 9002 based QMS had in our CPM during the period 2001-2002 (post QMS) vs. the two previous years -1999-2000- (pre QMS).

We defined several CPM for assessment of hemodialysis adequacy and medical management that covered : Anemia, iron status renal osteodystrophy, hemodialysis prescription and nutritional status , follow up of the established guidelines for vascular access care and prevention of nosocomial infections water quality and general performance outcome like annual crude mortality rate and hospitalization (express as hospital days/patient year).

No significant difference was found between both periods regarding annual crude mortality( pre QMS 8.37% vs post QMS 8.95%) or the hospitalization rate ( pre 0.47 patient-days vs. post 0.52 patient-days) . There was a significant difference after implementation of the quality system in the average hemoglobin levels (pre 11.3 +/- 1.5 vs. post 11.9+ +/- .5 p <0,001). Ferritin levels (pre 220 +/- 162 vs. post 313 +/- 373 p<0.01), albumin levels (pre 3.61 +/- 0.46 vs. post 3.82 +/- 0.56 p<0.001) and KTV>1.2 (pre 1.41 +/- 0.26 vs. post 1.50 +/- 0.33 p<0.001). The transferring saturation index (TSI) was unchanged (pre 27.98 +/- 14.39 vs.. post 29.4 +/- 16.66 p=0.11). There was a significant decrease in the average PTH levels (pre 234.9 +/- 285 vs. post 174 +/- 174 p< 0.0001) PTH>300 pg/ml (pre 23.7% vs. post 16.4% p<0.001) calcium levels (pre 10.02 +/- 0.99 vs. 9.83 +/- 0.88 p<0.001), phosphorus (pre 5.50 +/- 1.55 vs. post 5.01 +/- 1.47 p<0.001) as well as serum calcium levels >11 mg/dl (pre 14.6% vs. post 11% p<0.001) and phosphorus >6 g/dl (pre 34% post 21.5% p<0.001). Although the average serum potassium levels decrease (pre 5.51 +/- 0.85 vs. post 5.40 +/- 0.87), the percentage of patients with potassium over 6.5 meq/l was similar in both periods (pre 11.5% vs. post 10. 1%). The number of native A-V vascular access was similar in both periods and above the current DOQI Recommendations. Nevertheless, there was a gradual decrease in native A-V fistula, associated with an increase on the use of permanent catheters. The number of incident patients with a permanent catheter as the only vascular access for hemodialysis increased from 0% in the year 1999, 2000 and 2001 to 6.98% in 2002. There was no hepatitis B and C seroconversión detected in both periods.

From our study we concluded that regular follow-up of quality performance measurement associated with an ongoing corrective action, promotes an improvement of the outcome measures results.