Dialysis practices that distinguish facilities with below- versus above-expected mortality

Area of Science:

• Nephrology
• Healthcare Quality Improvement
• Health Services Research

Background:

• Significant variation exists in dialysis facility mortality rates, even after adjusting for patient factors using standardized mortality ratios (SMRs).
• This variation may stem from unique practices in high-performing facilities or limitations in the SMR methodology.
• Identifying distinguishing practices is crucial for improving dialysis care quality.

Purpose of the Study:

• To identify specific patient-, provider-, and facility-level practices that differentiate dialysis facilities with below-expected mortality from those with above-expected mortality.
• To understand the contribution of these practices to the variation in standardized mortality ratios (SMRs).

Main Methods:

• A cross-sectional survey assessed staff perceptions of practice quality across three organizations.
• Facilities were categorized based on observed versus expected mortality using U.S. Renal Data Service SMRs.
• Statistical analyses, including t tests and linear regression, identified significant practices associated with lower mortality.

Main Results:

• Facilities with lower mortality reported higher patient activation and engagement.
• Stronger physician communication, enhanced dietician expertise, and superior staff coordination were noted in high-performing units.
• These identified practices accounted for 31% of the variance in standardized mortality ratios (SMRs).

Conclusions:

• Patient, provider, and facility practices partially explain variations in dialysis facility SMRs.
• Improving SMRs necessitates a focus on coordinated, multidisciplinary care environments.
• A holistic approach to facility operations is essential for understanding and enhancing dialysis outcomes.