DEATH RISK IN HEMODIALYSIS-PATIENTS - THE PREDICTIVE VALUE OF COMMONLY MEASURED VARIABLES AND AN EVALUATION OF DEATH RATE DIFFERENCES BETWEEN FACILITIES
DEATH RISK IN HEMODIALYSIS-PATIENTS - THE PREDICTIVE VALUE OF COMMONLY MEASURED VARIABLES AND AN EVALUATION OF DEATH RATE DIFFERENCES BETWEEN FACILITIES
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DOI：
10.1016/s0272-6386(12)70364-5
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发表时间：
1990-05-01
影响因子：
13.2
通讯作者：
LEW, NL
中科院分区：
文献类型：
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作者：
LOWRIE, EG;LEW, NL
对12,000多名血液透析患者的样本进行了Logistic回归分析，以评估各种患者描述、治疗时间(小时/治疗)和各种实验室测试与死亡概率的关系。高龄、白人和糖尿病都与显著增加的死亡风险有关。在根据实验室测试的价值进行调整之前，透析时间短也与高死亡风险相关。在实验室变量中，低血清白蛋白40g/L(4.0g/dL)与死亡概率高度相关。约三分之二的患者白蛋白水平较低。这些发现表明，营养不足可能是导致血液透析患者死亡的一个重要因素。还给出了其他实验室检测的相对风险分布。其中，血清肌酐水平低，而不是高水平，与高死亡风险相关。血清白蛋白浓度和肌酐均与治疗时间直接相关，两种物质的高值与治疗时间的延长有关。这些数据表明，医生可能会选择肌酐水平较高的患者进行更高强度的透析暴露，而选择肌酐水平较低的患者进行较低强度的治疗。在一项单独的分析中，对这237个机构的观察死亡率与基于病例组合的预期死亡率进行了比较。这些数据表明，当设施规模较小时，实际/预期比率会有很大波动。尽管如此，与样本中所有患者相比，少数设施(≤2%)的发病率可能高于预期。各种实验室变量对死亡率的影响是巨大的，而相对较少的设施观察到的死亡率超过了它们的预期值。因此，我们建议，旨在改善美国透析患者总体死亡率统计数据的策略，应该更好地针对所有患者，特别是高风险患者，在他们通常的治疗环境中提高护理质量，而不是试图找出死亡率较高的机构，以便进行可能的监管干预。
Logistic regression analysis was applied to a sample of more than 12,000 hemodialysis patients to evaluate the association of various patient descriptors, treatment time (hours/treatment), and various laboratory tests with the probability of death. Advancing age, white race, and diabetes were all associated with a significantly increased risk of death. Short dialysis times were also associated with high death risk before adjustment for the value of laboratory tests. Of the laboratory variables, low serum albumin < 40 g/L (< 4.0 g/dL) was most highly associated with death probability. About two thirds of patients had low albumin. These findings suggest that inadequate nutrition may be an important contributing factor to the mortality suffered by hemodialysis patients. The relative risk profiles for other laboratory tests are presented. Among these, low serum creatinine, not high, was associated with high death risk. Both serum albumin concentration and creatinine were directly correlated with treatment time so that high values for both substances were associated with long treatment times. The data suggest that physicians may select patients with high creatinine for more intense dialysis exposure and patients with low creatinine for less intense treatment. In a separate analysis, observed death rates were compared with rates expected on the basis of case mix for these 237 facilities. The data suggest substantial volatility of observed/expected ratios when facility size is small. Nonetheless, a minority of facilities (≤2%) may have higher rates than expected when compared with the pool of all patients in this sample. The effect of various laboratory variables on mortality is substantial, while relatively few facilities have observed death rates that exceed their expected values. Therefore, we suggest that strategies designed to improve the overall mortality statistic for dialysis patients in the United States would be better directed toward improving the quality of care for all patients, particularly high-risk patients, within their usual treatment settings rather than trying to identify facilities with high death rate for possible regulatory intervention.