Continuous Quality Improvement (CQI) is an iterative process of: planning to improve a product or process, plan implementation, analyzing and comparing results against those expected, and corrective action on differences between actual and expected results. It is little used in clinical medicine. Anemia, a complex problem in End Stage Renal Disease patients, served to test the ability of an unique electronic medical record (EMR) optimized for daily care to empower CQI in practice. We used data collected during daily care, stored in the EMR, and organized to display temporal relationships between clinical, laboratory, and therapeutic events. Our aims were optimal hemoglobin with minimum epoetin, and maintaining stable hemoglobin and epoetin. The study was done on 250 patients treated by maintenance hemodialysis (HD), receiving epoetin prior to February 1, 2010 and followed to July 31, 2011. Repleting iron, ensuring iron sufficiency, slow epoetin reduction, and decision support tools enabling data display over long periods in patient-centered reports were key elements. Epoetin dose, adjusted 6-8 weekly, was based on current clinical conditions and past responses. Hemoglobin increased by months 1-2; epoetin decreased from month 4. By months 16-18, epoetin had decreased 42% to 9,720 units/week while hemoglobin increased 8% to 123.6 g/L. Hemoglobin and epoetin were stable from month 7 onward. New epoetin orders decreased 83%. Transferrin saturation increased after the study start. Individual patient hemoglobin variation decreased by 23%, range by 27%. Mortality, 11.78 per 100 patient years, was 42% less than United States dialysis patient mortality. Allowable epoetin charges decreased by $15.33 per treatment and were $22.88 less than current Medicare allowance. The study validates the hypothesis that an EMR optimized for daily patient care can empower CQI in clinical medicine and serve to monitor medical care quality and cost.

As the new Centers for Medicare & Medicaid Services' Quality Incentive Program takes effect, the implications are enormous for dialysis patients. Contrary to its intention, the Quality Incentive Program, with its upper hemoglobin limit, may well stifle innovative practice-based research and practical approaches to anemia management. An opportunity to move away from an excessive preoccupation with ESAs to substantially improve patient outcomes, and to do so at a much lower cost, may well be lost to patients, providers, and CMS as a result.

Dialysis, pp. 775-789 (2012) No AccessElectronic Medical Records in Nephrology and End-Stage Renal Disease: A Proven ModelVictor E. Pollak and Jonathan A. LorchVictor E. Pollak and Jonathan A. Lorchhttps://doi.org/10.1142/9789814289764_0078Cited by:0 PreviousNext AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsRecommend to Library ShareShare onFacebookTwitterLinked InRedditEmail Abstract: The following sections are included: Introduction Desirable Characteristics of an EMR for ESRD Reporting with a Model EMR for ESRD The Patient History Feedback Reports in Care of Individual Patients: The Pivotal Issue Finding Other Needed Information About the Individual Patient Feedback and Other Reports on Multiple Patients Alerts and Reminders CQI with a Model EMR Outcome Research with a Model EMR Using the Model EMR for Administrative and Billing Functions Using the Model EMR Reduces Costs Editors' Notes References FiguresReferencesRelatedDetails DialysisMetrics History PDF download

Title: The importance of iron in long-term survival of maintenance hemodialysis patients treated with epoetin-alpha and intravenous iron: analysis of 9.5 years of prospectively collected data

BACKGROUND:In chronic disease, health information technology promises but has yet to demonstrate improved outcomes and decreased costs. The main aim of the study was to determine the effects on mortality and cost of an electronic patient record used in daily patient care in a model chronic disease, End Stage Renal Disease, treated by chronic maintenance hemodialysis. Dialysis treatment is highly regulated, and near uniform in treatment modalities and drugs used.METHODS:The particular electronic patient record, patient-centered and extensively coded, was used first in patient care in 3 dialysis units in New York, NY in 1998, 1999, and 2000. All data were stored "live"; none were archived. By December 31, 2006, the patients had been treated by maintenance hemodialysis for a total of 3924 years. A retrospective analysis was made using query tools embedded in the software. The United States Renal Data System dialysis population served as controls. In all there were 1790 patients, with many underlying primary diseases and multiple comorbid conditions affecting many organ systems. Year by year mortality, hospital admissions, and staffing were analyzed, and the data were compared with national data compiled by the United States Renal Data System.RESULTS:Analyzed by calendar year after electronic patient record implementation, mortality decreased strikingly. In years 3-9 mortality was lower than in years 1-2 by 23%, 48%, and 34% in the 3 units, and was 37%, 37%, and 35% less than that reported by the United States Renal Data System. Clinical staffing was 25% fewer per 100 patients than the national average, thereby lowering costs.CONCLUSION:To our knowledge, this is the first demonstration that an electronic patient record, albeit of particular design, can have a favorable effect on outcomes and cost in chronic disease. That the population studied has many underlying diseases affecting all organ systems suggests that the electronic patient record design may enable application to many fields of medical practice.

Serial c/i,, i(’(Il observations and /ii.stoIogie .ctu(be.s were ?na(/e on t/l(’ ki(/ne/Js of 8 7 patientx with SI/stem ?C lu/)14s er jthemato.su.s over /)(rwd. ranging from 7 mont/is to 5 years. A total of I 76 renal biopsy 0,1(1 neerop.s// Speeil?lefl.S 7te’re (mnalyzed in (/11(11/fig, (1 .S(’lfl i-quanti/a/ize method, (mild the /lis1o/ogiefindi?l g.s were etu.s.sifie(/ jfl 1Iiefo11owiri, ’foii rgrosIJ)s: normal kidneq, luJ)us g1ome ru1iu.s. (I(Iil( lU/)ii.S glomeruloneph ri/is. and mnembranou.s lu/)u.s ‘lomerii/onep/iritis. Forl,j /)ati(’nt.s ii? w/iomn 1/me in itialfinding.s we’re norman! kidne j.s, IU/)U.S j ’lomeruii1is, and nu’,nbranou.s lupus glomerulonephritis were followed f or 16() /)atient-ijears. I)uring Ibis period onl;j 2 (leveloped minld lupu.s glomeru/onep/iritis ct/i ie/, re.sponde(/ to treatment. (mild 2 others (/eZY’/OJ)ed .severt’ (li.sea.s( (lad died in renalfailu re. Pro ’rex.sion from the in ilthrform.s of renal involvement to xevere aetir(’ lupu.s glomerulonepli ntis ztas uneom mon.

We describe a solid-phase adsorbent enzyme-linked immunoassay for measuring the amount of antibody in serum. The assay consists of adsorbing an excess of DNA to a polystyrene test-tube support, reacting the anti-DNA serum with the coated tube, following with an additional reaction of an anti-human -y-globulin peroxidase enzyme conjugate with the coated tube, and finally developing a colored reaction product by the action of peroxidase on substrate. In principle, the amount of lgG bound to the tube is proportional to the amount of anti-DNA contained in the serum, and the conjugate also reacts proportionally to the amount of human lgG that has reacted. The assay gives data Consistent with that expected for serum from patients with systemic lupus erythematosus, and it is possible to titrate the serum for micrograms of DNA antibody. At present the method still has considerable variability, but offers a new approach to measurement of antibody in autoimmune diseases.

Background Correction of anemia in hemodialysis patients is seldom completely attained, and the response of parameters other than hemoglobin concentration to anemia correction has not been evaluated in detail. Methods Laboratory parameters that suggest iron deficiency occurred in 10-15% of 206 recombinant human erythropoietin (rhEPO)-treated patients. Oral iron was given for 9 months and intravenous iron thereafter on a patient-specific basis when iron deficiency was evident. Eighty-seven hemodialysis patients with data for 12 months were followed for another 12 months. A computerized information system enabled data management and analysis. Results With oral iron, serum ferritin decreased ( P<0.001), indicating further iron depletion. With intravenous iron, hemoglobin increased, evidence of iron deficiency decreased, and less rhEPO was needed. Striking macrocytosis appeared. Serum albumin and serum creatinine/kg body weight (an index of muscle mass) increased, while blood pressure decreased. Data were reanalyzed in four mean corpuscular volume (MCV) quartiles and two ferritin subsets at study onset. Iron deficient erythropoiesis (low MCV, mean corpuscular hemoglobin [MCH], and transferrin saturation) was striking in quartile 1; low ferritin was prevalent in all quartiles. With intravenous iron, hemoglobin increased only in quartile 1, the quartile with the greatest decrease (52%) in rhEPO dose. MCV increased in all quartiles ( P<0.001). Serum albumin increased in all MCV quartiles and both ferritin subsets, but significant creatinine/kg increase and blood pressure decrease occurred only in the low-ferritin subset. Conclusions Macrocytosis occurred with intravenous iron replacement. The universal MCV increase suggests unrecognized, inadequately treated, folic acid deficiency unmasked by an adequate iron supply. There was also improved well being. Effects were most clearly evident in patients with deficient iron stores.

Effective application of information technology has transformed many facets of modern life, such as manufacturing and finance, but has had little measurable effect on medicine in general, or on nephrology and dialysis in particular. The failure of information technology in medicine can, in our opinion, be traced to poor design and implementa-tion of medical software. Even today, nurses and physicians still spend 50% and 33%, respectively, of their time on paperwork. Our approach to computerization of the patient record, begun 24 years ago, treats the patient as the central core of the computerized record system, and makes use of a comprehensive, clinically relevant, time-oriented, digitally coded database. An embedded query tool allows quick and easy organization of the database at the point of care to make knowledge available about individuals and groups of patients, and without delay. In those scenarios where effective computerization has been combined with effective clinical and administrative management, the results have been striking. Demonstrated and published results include: 1) Improved patient welfare, with a decrease in both mortality (20-25% less than the U.S. average) and in morbidity (increased serum albumin and muscle mass, and decreased blood pressure and hospitalisation). 2) More escient and effective use of personnel caring for the patient (5.9 fewer full-time staff per 100 hemodialysis patients than the national average), with consequent increase in patient satisfaction and saving of staff time. 3) Reduction and containment of costs of medical supplies. 4) Effective management of the processes involved in billing, collection, and accounts receivable. 5) Online, continuous quality improvement and effective clinical and administrative management of the dialy-sis unit based on timely, complete knowledge of relevant information (especially when unexpected events occur). 6) Significantly improved return on investment; net savings of at least $13.69 to $17.40 per hemodialysis treatment have been achieved.

The evidence for the important role of coagulation in the genesis and perpetuation of glomerular injury in diffuse proliferative lupus glomerulonephritis is reviewed. The importance of early detection is emphasized, so that treatment can be started before irreversible glomerular injury has occurred. Urinalysis and simple tests of renal function are effective means of early detection.

Seminars in DialysisVolume 6, Issue 3 p. 192-196 Bioincompatibility Plays a Major Role in β2-Microglobulin Amyloidosis Carol R. DiRaimondo, Corresponding Author Carol R. DiRaimondo Division of Nephrology, Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OhioAddress correspondence to: Carol R. DiRaimondo, MD, Diablo Nephrology Medical Group, 120 La Casa Nia, Suite 210, Walnut Creek, CA 94598.Search for more papers by this authorVictor E. Pollak, Victor E. Pollak Division of Nephrology, Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OhioSearch for more papers by this author Carol R. DiRaimondo, Corresponding Author Carol R. DiRaimondo Division of Nephrology, Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OhioAddress correspondence to: Carol R. DiRaimondo, MD, Diablo Nephrology Medical Group, 120 La Casa Nia, Suite 210, Walnut Creek, CA 94598.Search for more papers by this authorVictor E. Pollak, Victor E. Pollak Division of Nephrology, Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OhioSearch for more papers by this author First published: May 1993 https://doi.org/10.1111/j.1525-139X.1993.tb00295.xCitations: 2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume6, Issue3May 1993Pages 192-196 RelatedInformation

We have previously derived an index, based on retrospective data, for mortality in patients with end-stage renal disease (ESRD) treated by dialysis and transplantation. We used this index to calculate probability of death and rates of hospitalization, two measures of severity of illness, for 436 patients enrolled in our ESRD program after the original index was derived. Applied when ESRD treatment was initiated, it predicted future mortality and hospitalization rates. We then analyzed clinical characteristics, including variables in the predictive model, in all 718 patients enrolled in 3-year cohorts from 1976 to 1989. Over time, there was a trend toward enrolling patients with a higher likelihood of dying, ie, more severely ill. The severity index facilitated description of the patients and their changing characteristics over time, and proved useful in comparing the degree of illness in different population groups.

beta 2-Microglobulin (beta 2M) forms synovial and bony amyloid deposits in long-term hemodialysis patients. To define the kinetics of beta 2M during hemodialysis and the effects of dialyzer reprocessing, we measured serum beta 2M, plasma C3a, and neutrophil counts immediately predialysis; 15, 90, and 180 minutes after beginning dialysis; and 15 minutes postdialysis in ten chronic hemodialysis patients. The studies were performed during first and third uses of cuprammonium rayon and polysulfone dialyzers processed by rinsing with water, then bleach, in an automated system (Seratronics DRS 4) and then packed in 1.5% formaldehyde. Mean serum beta 2M (corrected for ultrafiltration) decreased by 16.6% +/- 18.1% with new cuprammonium dialyzers and 57.1% +/- 12.8% with new polysulfone dialyzers. Dialyzer reprocessing had no significant effect on this decline. Predialysis serum beta 2M decreased by 30.4% +/- 15.5% 1 month after switching from cuprammonium to polysulfone dialyzers; these levels remained stable after 3 months of dialysis with polysulfone. Complement activation and neutropenia during dialysis were significantly more marked with cuprammonium, but were not affected by reprocessing of either dialyzer. In vitro adsorption of 124I-beta 2M to polysulfone fibers was greater than to cuprammonium; adsorption was not influenced by dialyzer reprocessing.