Manuscript in progress.

CITATION:
Jadoul M, Lameire N, Bragg-Gresham JL, Eichleay MA, Pisoni RL, Port FK. DOPPS estimate of patient life years attributable to modifiable haemodialysis practices in Belgium. Acta Clin Belg 2007; 62(2):102-110x

ABSTRACT:
BACKGROUND: Various organizations have published clinical practice guidelines for the care of haemodialysis patients. However, it is unknown to what extent improving or even reaching perfect compliance with guidelines would improve the survival of HD patients in Belgium. METHODS: Using data from the second phase of the Dialysis Outcomes and Practice Patterns Study (DOPPS), the proportion of haemodialysis patients failing to meet six key practice targets (Kt/V > or = 1.2, haemoglobin > or =11 g/dl, phosphate 1.1-1.5 mmol/l, calcium 2.1-2, 4 mmol/l, albumin > or =40 g/l, and facility catheter use < or =10%) was calculated along with the relative risk of mortality associated with being outside these targets.The life years potentially gained from adherence to the six targets, both separately and all six together were then estimated. RESULTS: The percentage of patients outside the targets were as follows: 30.3%, Kt/V; 33.6%, haemoglobin; 56.2%, phosphate; 58.2%, calcium; 67.1%, albumin; and 91.1%, catheter. Estimated patient life years gained with improved compliance with guidelines was highest for albumin (3.670) and catheter use (2.331) but still substantial for the other four targets (ranging from 551 to 1.258).The total of patient years gained if 100% of patients have all six practices brought within target reaches 7.516 years. A conservative estimate of 50% of patients within all targets still yields an improvement of survival of 3.958 patient years. CONCLUSION: This analysis suggests large opportunities to improve HD patient care in Belgium. The avoidance of HD catheters, with the use of AV fistulas whenever possible, should be given a high priority. Admittedly, these calculations assume causality or partial causality that has not been definitively proven. Still, if causality is only partial, the results emphasize that the improvement of patient care through adherence to targets of clinical guidelines might be substantial and all Belgian nephrologists and staff members of dialysis units should carefully pursue every potential effort.

CITATION:
Mendelssohn DC, Yeates K, Ethier J, Trpeski L, Na Y, Bragg-Gresham JL, Eichleay MA, Pisoni RL, Port FK. DOPPS Estimate of Patient Life Years Attributable to Modifiable Hemodialysis Practices in Canada. Nephrol News Issues 2007; 21(5): 69-70, 72, 74-6

ABSTRACT:
We examined data from the Canadian Organ Replacement Registry (CORR), and from a special substudy of CORR, to determine whether changes have occurred in practice patterns related to Canadian Society of Nephrology (CSN) guidelines before and after the 1999 CSN hemodialysis guidelines were published. Second, we used data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) to calculate the impact of observed deviations from guideline targets and estimated potential gains in life years that might accrue if guideline targets were achieved in all Canadian hemodialysis patients. For dialysis dose and hemoglobin targets, there was a significant improvement in Canadian facility performance over time. On the other hand, vascular access use patterns showed a worse pattern with increased catheter use. A calculation of attributable risk, which assumes causality, suggests that 49% of deaths could be averted if all patients currently outside the guidelines achieved them over the next five years. When expressed as an annual death rate per hundred patient years, this corresponds to a decrease from 18 to 10.1 per 100 patient years. In conclusion, promotion of a facility-based culture of quality improvement based on achievement of guideline targets is supported by international and Canadian observational data from the DOPPS. In the future, the impact of such an approach should be assessed empirically by correlating changes in practice over time with changes in outcomes.

CITATION:
Canaud B, Combe C, Bragg-Gresham JL, Eichleay MA, Pisoni RL, Port FK. DOPPS estimate of patient life years attributable to modifiable hemodialysis practices in France. Nephrol Ther 2008; 4(4): 256-265

ABSTRACT:
In this study we used a prevalent cross-sectional sample of French hemodialysis patients from DOPPS II (2002-2004) to determine the percentage of patients whose values failed to meet targets in six different areas of hemodialysis practice (dialysis dose, anemia, serum phosphorus (PO4), serum calcium (Ca), serum albumin, and catheter use for vascular access). Cox survival models, with adjustments for patient characteristics, were used for these analyses to estimate mortality hazard ratios (HR). Based on the mortality HR, the fraction of patients outside each target, and the total HD population in France, we estimated the number of patient life years that could potentially be gained if every chronic, in-center hemodialysis patient in France who is currently outside of the specified target was able to achieve it. The proportion of patients failing to meet one of the six practice targets in France varied from 15% (dialysis dose) to 75% (albumin) while the percentage of patients complying with all six targets was restricted to 1,2%. The relative risk of mortality (RR) associated with being outside these targets varied from 1,12 to 1,46. Based on these two measures the life-years survival was estimated. The projected number of patients and life years potentially gained from adherence to the six targets was estimated close to 10 600 years-patient. In conclusion, this study suggests large opportunities to improve hemodialysis patient care in France still exist. Compliance with two major practice targets, such as albumin and restriction of catheter use will save highly significant life years of hemodialysis patient. Implementing and strict adherence to national and international guidelines should serve as a basic inspiration for continual improvement of hemodialysis patient care.

CITATION:
Bommer J, Bragg-Gresham JL, Eichleay MA, Pisoni RL, Port FK. DOPPS Schätzung der Auswirkungen veränderbarer Hämodialyseverfahren auf die Überlebensrate von Dialysepatienten in Deutschland. Nieren und Hochdruckkrankheiten, in press

ABSTRACT:
Many factors contribute to the increased mortality of hemodialysis patients, compared to normal population. To improve the survival of patients, various guidelines have been published during recent years. The Dialysis Outcomes and Practice Patterns Study (DOPPS) estimated the percentage of patients who are outside the published KDOQI hemodialysis guidelines and the associated mortality risk of several factors, including serum albumin, interdialytic weight gain, Kt/V, calcium, use of catheters, hemoglobin, and hyperphosphatemia. By analyzing the relative importance of these factors, it was possible to estimate the increase in survival if the factors, separately or together, were kept within the target range of guidelines in Germany. In Germany the highest relative risk of mortality, 1.40 (P<0.0001), was associated with an albumin level below 40g/L and 56.6% of patients were outside this target range. If all patients were brought within the albumin guideline, a potential 23,578 life years could be saved. In addition, the adjusted sum of the patient years attributable to all six practice patterns was 44,186 years. A 50% adherence rate to the six factors for the next 5 years would save 23,126 patient years. These data encourage greater adherence to the guidelines. The detailed analysis of this study allows patients and nephrologists to choose the most appropriate way for patients to improve their dialysis outcome.

CITATION:
Pontoriero G, Locatelli F, Andreucci VE, Bragg-Gresham JL, Eichleay MA, Pisoni RL, Port FK. Stima DOPPS dell'impatto delle linee guida sulla sopravvivenza in emodialisi in Italia. G Ital Nefrol 2007; 24(3):2 21-229.

ABSTRACT:
Knowing the relative risk (RR) of mortality associated with being outside the guideline targets and the percentage of patients in this situation, it is possible to estimate the number of patient life years that could be gained from adhering to guideline recommendations. We used a prevalent cross-sectional sample of 576 Italian patients from the Dialysis Outcomes and Practices Patterns Study (DOPPS) phase II (2002-2004) to determine the percentage of patients who failed to meet the Italian Society of Nephrology's targets for dialysis dose (spKt/V >/= 1.3), anemia management (hemoglobin >/= 11 g/dL), and mineral metabolism (serum calcium and phosphorus: < /= 2.6 and < /= 1.8 mmol/L, respectively), and the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (K/DOQI) targets for nutritional status (serum albumin >/= 4 g/dL) and vascular access (facility catheter use < /= 10%). We used a larger random sample of DOPPS patients to establish the adjusted RRs of mortality associated with the 6 examined targets. The percentage of patients outside the targets and the adjusted RRs were 34% and 1.12 for dialysis dose, 37.7% and 1.20 for anemia management, 40.8% and 1.14 for phosphorus, 14.4% and 1.22 for calcium, 62.5% and 1.46 for albumin, and 40.1% and 1.20 for facility catheter use. The adjusted sum of life years potentially gained by complete adherence to all 6 guidelines was 25,156 over a period of 5 years (2006-2010); a more conservative estimate, modeling life years potentially gained by bringing half of all patients outside targets within them, was 13,382. In conclusion, this analysis suggests opportunities to improve hemodialysis patient care in Italy. The magnitude of potential savings in life years should encourage greater adherence to guidelines and practices that are significantly associated with better survival.

CITATION:
Saito A, Akiba T, Akizawa T, Fukuhara S, Asano Y, Kurokawa K, Bragg-Gresham JL, Eichleay MA, Pisoni RL, Port FK. The DOPPS Estimate of Patient Life Years Attributable to Modifiable Hemodialysis Practices in Japan. Japanese Society for Dialysis Therapy 2008; 41 (8): 473-482

ABSTRACT:
A prevalent cross-sectional sample of Japanese hemodialysis (HD) patients from the Dialysis Outcomes and Practice Patterns Study was analyzed to determine the percentage of patients whose values failed to meet targets in six different areas of hemodialysis practice. Cox survival models, with adjustments for patient characteristics, were used for these analyses to estimate mortality hazard ratios. Patient-years attributable to each of the six practice patterns were estimated. To calculate the expected gain in patient-years, the five-year survival curve for the Japanese HD population (based on actual current death rates) was compared with the projected five-year survival curve for the Japanese HD population if all patients were within the six practice guidelines. These calculations were performed separately for the Japanese guidelines and the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines. The proportion of patients failing to meet the six practice targets in Japan and the relative risk of mortality associated with being outside the targets were the basis for all life-years estimation. A considerably high number of Japanese HD patients were found to be outside the target ranges. Very few Japanese patients are within the targets for five or six indicators. The vast majority of patients (78.1%) are within two to four of the six indicators, and 20.5% of patients are within zero to one of the practice targets. The two individual practices resulting in the greatest life-year gains were increasing the proportion of patients with albumin levels above 4.0 g/dL (43,525 life-years, 3.1% gained) and increasing the proportion of patients with hemoglobin levels above 11 g/dL (24,878 life-years, 1.8% gained). The total potential life-years gained (72,958) is 27% lower than suggested by the simple sum of patient-years obtained from the six individual practice patterns when modeled independently from one another (99,815). Results for hemoglobin in Japan vary depending on which target cutoff is used. If, instead of 11 g/dL, a target value of hemoglobin =10 g/dL is used, 16,580 patient-years could be saved if all patients achieved the target. Japanese guidelines should be renewed by addition of prospective, randomized controlled studies.

CITATION:
Piera L, Cruz JM, Bragg-Gresham JL, Eichleay MA, Pisoni RL, Port FK. Estimación según el estudio DOPPS de los años de vida de paciente atribuibles a las prácticas de hemodiálisis modificables en España. Nefrologia 2007; 27(4): 496-504

ABSTRACT:
The increased mortality risk in hemodialysis (HD) patients unable to meet six targets in different areas of HD practice has been reported previously. Using a prevalent cross-sectional sample of Spanish HD patients (n = 613) from the second stage of the Dialysis Outcomes and Practice Patterns Study to determine the percentage with low dialysis dose, hyperphosphatemia, hypercalcemia, hypoalbuminemia, anemia, and catheter use and based on the mortality hazard ratios and the total HD population in Spain, according to the Spanish Society of Nephrology Report, we estimated the number of patient life years that could potentially be gained in our country. These characteristics of HD practice were selected because each is modifiable through changes in practice, each is associated with mortality, and each has a large number of patients outside the target guidelines. The targets that define "within guidelines" are as follows: dialysis dose (single pool Kt/V >1.2), anemia (hemoglobin >110 g/L), albumin after standardization (>40 g/L), serum phosphorus (1.1-1.5 mmol/L), serum calcium (2.1-2.4 mmol/L), and facility catheter use (<10%). Cox proportional hazards regression models were used to calculate the relative risk of mortality for all patients outside each guideline. In all models, calcium values were adjusted for low serum albumin. A separate Cox survival model adjusted for all six HD practices simultaneously to account for correlation that may exist between some facility practices. All models were adjusted for age, sex, race, time on ESRD, and 14 summary comorbid conditions. Patient years attributable to each of the six practice patterns were estimated and are reported here as the potential patient years gained. Comparison of the estimates by individual guideline shows that, in Spain, increasing patient albumin above 40 g/L in all patients would lead to an estimated gain of 9,269 patient years (a 7.9% increase). Additionally, if all facilities could decrease catheter use to less than 10%, 2,842 patient years could be gained (a 2.4% increase). Though it may be an unrealistic goal, if all Spanish patients currently outside the guidelines achieved all six target levels, an estimated 17,300 life years could be gained over the next five years (a 15% increase).

Manuscript in progress.

CITATION:
Rayner HC, Greenwood R, MacTier R, Bragg-Gresham J, Eichleay MA, Pisoni RL, Port FK. Estimated life expectancy of UK HD patients if clinical practice guidelines are met. Br J Renal Med 2007; 12(3):11-14

ABSTRACT:
Clinical practice guidelines for haemodialysis (HD), based on the best available evidence, have been developed in Australasia, Canada, Europe and the USA, as well as the UK. The fourth edition of the Renal Association's Clinical Practice Guidelines in HD is currently undergoing peer review. Guidelines in these countries have helped identify and promote best practices in the delivery of haemodialysis and have set clinical standards to allow audits of key aspects of the haemodialysis prescription, laboratory data and patient outcomes. The annual reports of the UK Renal Registry have shown that performing regular audits improves clinical standards.

CITATION:
Port FK, Pisoni RL, Bragg-Gresham JL, Satayathum SS, Young EW, Wolfe RA, Held PJ. DOPPS estimates of patient life years attributable to modifiable hemodialysis practices in the United States. Blood Purif. 2004; 22(1):175-80

ABSTRACT:
Data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) allow estimation of the percentage of patients outside published hemodialysis guidelines and their associated mortality risk. We estimated the number of life years that could be gained from adherence to four of these guidelines and two other modifiable practices, i.e. dialysis dose, phosphate control, improved anemia, partial correction of serum albumin, reduced interdialytic weight gain and less use of catheters for vascular access. We extrapolated DOPPS data on these practices and guidelines to the US hemodialysis population for a 5-year projected period. Of the practices we examined, the highest relative risk of mortality was associated with having albumin <3.5 g/dl (relative risk=1.38, p<0.0001); 20.5% of the patients in the study fell outside the target range. The adjusted sum of the patient years attributable to all six practice patterns was 143,617; a more conservative estimate, modeling life years potentially gained by bringing half of all patients outside targets within them, is 69,367. The magnitude of potential savings in life years should encourage greater adherence to guidelines and practices that are significantly associated with better survival.