Effects of a Nationwide Predialysis Educational Program on Modality Choice, Vascular Access, and Patient Outcomes
Effects of a Nationwide Predialysis Educational Program on Modality Choice, Vascular Access, and Patient Outcomes
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DOI：
10.1053/j.ajkd.2011.04.015
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发表时间：
2011-08-01
影响因子：
13.2
通讯作者：
Pulliam, Joseph
中科院分区：
文献类型：
--
作者：
Lacson, Eduardo, Jr.;Wang, Weiling;Pulliam, Joseph
背景资料：肾科医生根据需要和时间允许的情况下，通常会对患者进行移植、血液透析（HD）、腹膜透析（PD）和保守治疗方面的教育。研究设计：质量改进报告。开始长期透析治疗的国家治疗选择计划（TOP）参与者（中位数为3.4个月）与接受常规护理的周期性流行事件患者进行比较。质量改进计划：标准化透析前治疗方案教育。结果：选择PD模式的比率、开始时的动静脉HD通路和早期（90天）死亡风险。测量：构建Logistic回归（用于PD和HD通路类型的选择）和考克斯模型（用于早期死亡率），包括1：1匹配的队列。事后的敏感性分析也比较了倾向评分匹配cohol.Results：3,165 TOPs与会者（10.5%的30,217事件患者之间的2008年1月1日至12月31日），年轻，更有可能是白色，并有略大的体表面积。TOP参与者选择PD治疗的未校正OR为8.45（95% CI，7.63-9.37），病例组合加实验室校正OR为5.13（95% CI，3.58-7.35）。对于选择中心内HD治疗的患者，从瘘管或移植物开始的OR为2.14（95% CI，1.96-2.33），调整后的OR为2.06（95% CI，1.88-2.26）。TOPs参与者未校正的早期死亡率HR为0.51（95%CI，0.43-0.60），病例组合加实验室校正的校正HR为0.61（95%CI，0.50-0.74）（所有结局，P < 0.001）。这些结果在1：1匹配分析和倾向评分匹配分析中是一致的。局限性：可能是指这些程序的医生更有可能处方PD治疗或放置动静脉通路。动机，治疗依从性的患者（谁会有更好的结果）可能有自我选择参加教育sessions.Conclusion：参加选项类透析前与更频繁的选择家庭透析，更少的隧道HD导管，并在透析治疗的前90天死亡率较低的风险。美国肾脏病杂志58（2）：235-242。(C)2011年，美国国家肾脏基金会（National Kidney Foundation，Inc.）
Background: Patients' education about transplant, hemodialysis (HD), peritoneal dialysis (PD), and conservative care often is provided by nephrologists as needed and occurs as time allows.Study Design: Quality improvement report.Setting & Participants: Attendees of a national treatment options program (TOPs) who initiated long-term dialysis therapy (median, 3.4 months) at Fresenius Medical Care, North America facilities throughout 2008 were compared with period-prevalent incident patients receiving usual care.Quality Improvement Plan: Standardized predialysis treatment options education.Outcomes: Rates of opting for PD modality, arteriovenous HD access at initiation, and early (90-day) mortality risk.Measurements: Logistic regression (for choice of PD and HD access type) and Cox models (for early mortality) were constructed, including a 1: 1 matched cohort. A post hoc sensitivity analysis also compared a propensity score-matched cohort.Results: 3,165 TOPs attendees (10.5% of 30,217 incident patients admitted between January 1 and December 31, 2008), were younger, more likely to be white, and had slightly larger body surface area. The unadjusted OR for TOPs attendees for selecting PD therapy was 8.45 (95% CI, 7.63-9.37) with a case-mix plus laboratory-adjusted OR of 5.13 (95% CI, 3.58-7.35). For patients who opted for in-center HD therapy, the OR was 2.14 (95% CI, 1.96-2.33) and adjusted OR was 2.06 (95% CI, 1.88-2.26) for starting with a fistula or graft. The unadjusted early mortality HR was 0.51 (95% CI, 0.43-0.60) and case-mix plus laboratory-adjusted adjusted HR was 0.61 (95% CI, 0.50-0.74) for TOPs attendees (all outcomes, P < 0.001). These results were consistent in the 1: 1 matched analysis and propensity score-matched analysis.Limitations: It is possible that physicians who referred to these programs were more likely to prescribe PD therapy or place arteriovenous accesses. Motivated, treatment-adherent patients (who would have better outcomes) may have self-selected to attend education sessions.Conclusion: Attending an options class predialysis was associated with more frequent selection of home dialysis, fewer tunneled HD catheters, and lower mortality risk during the first 90 days of dialysis therapy. Am J Kidney Dis. 58(2): 235-242. (C) 2011 by the National Kidney Foundation, Inc.