目标:自1998年以来,病例混合调整后的血液透析死亡率有所下降。影响死亡率的许多因素可能导致了这一趋势,这些关联可能因大陆地区而异。我们研究了血液透析设施实践随时间的变化及其在介导患者生存变化中的潜在作用。
方法:观察性前瞻性队列研究。
方法:1999年至2015年在美国参加透析结果实践模式研究(DOPPS)的500家血液透析设施中接受治疗的成年血液透析患者,Japan,和4个欧洲国家:德国,意大利,西班牙,和英国。
方法:每个设施的四种实践措施:Kt/V>1.2,透析间体重增加[IDWG]<5.7%的患者百分比,磷<6mg/dL,使用房室瘘。
结果:患者生存。
方法:调解分析,针对案例组合进行了调整,使用3年的研究阶段作为暴露和设施实践措施作为潜在的介体。
结果:在欧洲,我们观察到每十年总病例混合校正生存率提高13%.设施实践措施的趋势,特别是Kt/V和磷,解释了病例组合生存率每十年提高10%,代表观察到的改善的77%(10%解释为13%的改善)。在日本,观察到的病例组合调整后生存率12%/十年的改善中,有73%可归因于设施实践,特别是Kt/V和IDWG。在美国,观察到的病例组合调整后生存率47%/十年的改善中,有56%可归因于设施实践,尤其是房室瘘的使用和磷的控制。
结论:在此期间患者群体特征的未测量变化可能混淆了观察到的关联。
结论:欧洲调整后血液透析患者生存率的改善,Japan,美国从1999年到2015年可以在很大程度上解释为具体设施实践的改进。患者生存率的未来变化可能会响应于共同临床实践实施的进一步发展。
OBJECTIVE: Case-mix adjusted hemodialysis mortality has decreased since 1998. Many factors that influence mortality may have contributed to this trend and these associations may differ by continental region. We studied changes in hemodialysis facility practices over time and their potential role in mediating changes in patient survival.
METHODS: Observational prospective cohort study.
METHODS: Adult hemodialysis patients treated in hemodialysis 500 facilities participating in the Dialysis Outcomes Practice Patterns Study (DOPPS) between 1999 and 2015 in the US, Japan, and 4 four European countries: Germany, Italy, Spain, and UK.
METHODS: Four practice measures at each facility: the percentages of patients with Kt/V>1.2, interdialytic weight gain [IDWG]<5.7%, phosphorus<6 mg/dL, and using AV fistulae.
RESULTS: Patient survival.
METHODS: Mediation analyses, adjusted for case mix, were conducted using 3-year study phase as the exposure and facility practice measures as potential mediators.
RESULTS: In Europe, we observed a 13% improvement in overall case-mix adjusted survival per decade. Trends in facility practice measures, especially Kt/V and phosphorus, explained 10% improvement in case-mix survival per decade, representing 77% (10% explained of 13% improvement) of the observed improvement. In Japan, 73% of the observed 12%/decade improvement in case-mix adjusted survival could be attributed to facility practices, especially Kt/V and IDWG. In the US, 56% of the observed 47%/decade improvement in case-mix adjusted survival could be attributed to facility practices, especially AV fistula use and phosphorus control.
CONCLUSIONS: Unmeasured changes in the characteristics of the patient population over this period may confound the observed associations.
CONCLUSIONS: The improvements in adjusted hemodialysis patient survival in Europe, Japan, and the US from 1999 to 2015 can be largely explained by improvements in specific facility practices. Future changes in patient survival may be responsive to further evolution in the implementation of common clinical practices.