Early Intervention Improves Outcomes in Patients Receiving Long-Term Hemodialysis

October 26, 2007 — A structured program of prompt medical and educational strategies in patients receiving long-term hemodialysis was associated with improved morbidity and mortality lasting up to 1 year, according to the results of a study in the November issue of the Clinical Journal of the American Society of Nephrology.
"Annualized mortality rates of chronic hemodialysis (CHD) patients in their first 90 d of treatment range from 24 to 50%," write Rebecca L. Wingard, from Vanderbilt University Medical Center in Nashville, Tennessee, and colleagues. "Limited studies also show high hospitalization rates. It was hypothesized that a structured quality improvement program (RightStart [RS]), focused on medical needs and patient education and support, would improve outcomes for incident CHD patients."
In this multicenter study, 918 patients receiving incident long-term hemodialysis who were prospectively enrolled in the RS program were compared with a group of 1020 control patients enrolled contemporaneously in non-RS clinics. The 3-month RS intervention consisted of anemia management; focus on dosage of dialysis, nutrition, and dialysis access; and a comprehensive educational program. Patients were observed for up to 12 months for determination of outcomes.
Compared with control patients, patients in the RS program had higher albumin and hematocrit values at 3 months, but the dose of dialysis and permanent access placement were not statistically significantly different between groups. Mental Composite Score for the RS patients improved significantly from baseline. Mean hospitalization days per patient year were lower in RS than in control patients.
At 3, 6, and 12 months, mortality rates for RS vs control patients were 20, 18, and 17 vs 39, 33, and 30 deaths per 100 patient-years, respectively. At the end of 1 year of follow-up, the RS intervention was associated with an approximately 40% reduction in death rates.
Limitations of the study include not being randomized and controlled; unavoidable selection biases, such as exclusion of patients with cognitive impairment in the RS group; missing demographic and clinical data, primarily for the control group; and labor costs of the program, placing an additional financial burden on the participating facilities.
"A targeted program of medical and teaching intervention to meet the specific needs of incident long-term hemodialysis patients results in improved morbidity and mortality," the study authors write. "Notably, the most impressive mortality difference occurs in the first 90 d, and this beneficial effect lasts up to 12 mo, indicating the critical importance of early intensive intervention in this patient population."
Amgen, Inc, the maker of epoetin alfa (Epogen), partly supported this study and employs one of its authors. NovoNordisk, Inc, employs another author.
Clin J Am Soc Nephrol. 2007;2:1170-1175.