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The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis centres A Hodsman*, A Casula, J Gilg, Y Ben-Shlomo, P Roderick, C Tomson
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Page 1: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK

haemodialysis centres

A Hodsman*, A Casula, J Gilg, Y Ben-Shlomo, P Roderick,

C Tomson

Page 2: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

Introduction to the ‘centre effect’• Theoretical

– ‘Ecological epidemiology’ – Hierarchical data structures

• Pupils in schools• Patients in hospitals

• Practical– Identify best practices from ‘high performers’– Determine the ‘value added’– Improve quality and equity of healthcare

Page 3: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

The ‘centre effect’ and the UKRR

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Upper 95% confidence interval

% with P04 < 1.8mmol/L

Lower 95% confidence intervalN = 17,319

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Number of patients in unit%

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% with phosphate <1.8mmol/L

Lower 99.9% CI

Upper 99.9% CI

Lower 95% CI

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Mean

Proportion of HD patients with phosphate <1.8mmol/L in each dialysis centre in England, Wales and Northern Ireland

Page 4: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

Change in mean phosphate before and after case mix adjustment using multi level analysis (MLWin)

UnadjustedAdjusted for age, gender, ethnicity,

predialysis creatinine, transplant WL status

Poster 0097, Wednesday 22nd 1pm

Page 5: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

Methods

• Cohort– Prevalent HD cohort 2007

• Exposure variables– Structural characteristics,organisational and clinical

processes

• Outcome variables– Mean centre phosphate, calcium and PTH– Proportion in centre with

• Phosphate<1.8mmol/L,Calcium 2.2-2.6 mmol/L, PTH 16-32 pmol/L

• Confounders– Patient level case mix differences

Page 6: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

Exposure variables

• Literature search of all clinical practice guidelines for management of calcium, phosphate and PTH

• Qualitative pilot study in 6 dialysis centres

• ‘Semi structured’ interviews with MDT

• Final questionnaire sent to 56 centres

• Derived 30 possible indicators

Page 7: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

Statistical model

• Binary or categorical variables

• Linear and logistic regression (Stata)

• Univariable model with a clustering term

• Adjusted for age, gender, ethnicity and predialysis creatinine

• Identified an interaction between gender and predialysis creatinine

Page 8: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

System of care

1. Consultant• Single physician responsible for long term care and

monthly Quality Assurance (QA) at ANY dialysis location (main or satellite)

2. Centre• Single physician responsible for all patients (long

term care and QA) in ONE dialysis location (main or satellite)

3. Mixed• Different physicians responsible for long term care

and monthly QA at any dialysis location (main or satellite)

Page 9: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

Phosphate

Variable

OR for Phosphate <1.8mmol/L

Unadjusted Adjusted

WTE Nephrologists 1.16 1.14

WTE Dietitians 1.12 1.08

WTE Pharmacists 1.11 1.05

Intensity of audit 0.92 0.83

System of Care - Consultant 1.13 1.09

System of Care - Centre 1.27 1.23

QA score - Some MDT 1.34 1.17

QA score - All MDT 1.47 1.27

Proforma 1.23 1.12

Intensity of nephrology review 1.14 1.14

Intensity of dietitian review 1.1 1

Intensity of pharmacist review 1.12 0.92

Intensity of nurse input 0.88 0.96

Intensity of feedback 1.04 1.06

Trigger phosphate 1.07 1.12

Target high risk 1 0.9

p<0.01 p<0.05

Variable

OR for Phosphate <1.8mmol/L

Unadjusted Adjusted

Policy for Cinacalcet - Protocol 0.83 1.05

Policy for Cinacalcet - Unrestricted 0.88 1

Policy for Lanthanum - Protocol 0.97 1.09

Policy for Lanthanum - Unrestricted 0.87 0.89

Hosp supply Al, Ca binders/Vit D 0.96 0.83

Hosp supply Cinacalcet/Lanthanum 0.92 0.87

Additional Prescribers 0.97 1

WTE PTX surgeons 0.95 1.06

Guideline 1.14 1.04

Guideline-phosphate binders 1.12 1.02

Guideline-Cinacalcet 1.17 1.07

Guideline-dialysate Ca 1.16 1.27

Guideline-parathyroiectomy referral 1.1 1.06

Measure bloods as per RA 1.17 1.14

Use of low Ca dialysate 1.17 1.14

Page 10: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

Calcium

Variable

OR for calcium 2.2-2.6mmol/L

Unadjusted Adjusted

WTE Nephrologists 0.91 0.9

WTE Dietitians 1.2 1.15

WTE Pharmacists 0.98 1

Intensity of audit 0.9 0.9

System of Care - Consultant 0.82 0.8

System of Care - Centre 0.95 1

QA score - Some MDT 0.87 0.89

QA score - All MDT 0.96 1.02

Proforma 1.01 1

Intensity of nephrology review 1.15 1.03

Intensity of dietitian review 0.65 0.67

Intensity of pharmacist review 0.9 0.96

Intensity of nurse input 0.96 0.97

Intensity of feedback 0.97 0.95

Trigger phosphate 1.3 1.29

Target high risk 0.78 0.81

p<0.01 p<0.05

Variable

OR for calcium 2.2-2.6mmol/L

Unadjusted Adjusted

Policy for Cinacalcet - Protocol 1.44 1.36

Policy for Cinacalcet - Unrestricted 1.02 1.04

Policy for Lanthanum - Protocol 1.5 1.44

Policy for Lanthanum - Unrestricted 1.32 1.32

Hosp supply Al, Ca binders/Vit D 1.04 1.08

Hosp supply Cinacalcet/Lanthanum 1.02 1.09

Additional Prescribers 0.9 0.93

WTE PTX surgeons 1.37 1.31

Guideline 0.85 0.9

Guideline-phosphate binders 0.86 0.93

Guideline-Cinacalcet 1.18 1.15

Guideline-dialysate Ca 1.08 1.05

Guideline-parathyroiectomy referral 0.98 1.02

Measure bloods as per RA 0.98 1.04

Use of low Ca dialysate 0.89 0.94

Page 11: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

PTH

Variable

OR for PTH 16-32mmol/L

Unadjusted Adjusted

WTE Nephrologists 1.02 0.98

WTE Dietitians 1.23 1.2

WTE Pharmacists 1.08 1.09

Intensity of audit 0.93 0.91

System of Care - Consultant 0.98 0.96

System of Care - Centre 1.01 1.01

QA score - Some MDT 1.06 1.04

QA score - All MDT 1.1 1.09

Proforma 1.04 1

Intensity of nephrology review 1.16 1.15

Intensity of dietitian review 0.99 0.98

Intensity of pharmacist review 1.12 1.11

Intensity of nurse input 0.8 0.84

Intensity of feedback 0.83 0.82

Trigger phosphate 1.06 1.07

Target high risk 0.99 0.99

p<0.01 p<0.05

Variable

OR for PTH 16-32mmol/L

Unadjusted Adjusted

Policy for Cinacalcet - Protocol 0.94 0.96

Policy for Cinacalcet - Unrestricted 0.79 0.83

Policy for Lanthanum - Protocol 0.91 0.9

Policy for Lanthanum - Unrestricted 0.99 0.98

Hosp supply Al, Ca binders/Vit D 1.07 1.06

Hosp supply Cinacalcet/Lanthanum 1.13 1.14

Additional Prescribers 0.88 0.9

WTE PTX surgeons 1.14 1.15

Guideline 1.1 1.1

Guideline-phosphate binders 1.1 1.1

Guideline-Cinacalcet 1.04 1.05

Guideline-dialysate Ca 1.03 1.02

Guideline-parathyroiectomy referral 1.04 1.02

Measure bloods as per RA 1.06 1.05

Use of low Ca dialysate 0.9 0.9

Page 12: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

Summary of results

• Better phosphate control in centres is associated with– System of care– Number of MDT attending QA meetings

• Better calcium control in centres is associated with– Policy for prescribing cinacalet and lanthanum– High WTE parathyroidectomy surgeons

Page 13: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

Further analysis

• Multivariable model Multilevel model (MLWin)– Ideal model– % of between centre

variation attributable to:• Patient level/Case mix

• Centre level/Structure and process

– Limited number of exposure variables due to possible interactions

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x

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Fig 5.1a: Simple Regression line

Fig 5.1b: Regression lines with variable intercepts

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Fig 5.1c:Regression lines with variable slopes and intercepts

x

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Fig 5.1d:Multi level model (2 levels) with variable slopes and intercepts

x

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Page 14: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

Further work

• Quality improvement project– Collaborative work to test implementing

practices associated with better outcomes for calcium, phosphate and PTH

• Methodological work– Improve the UKRR methodology to compare

centre performance of quality indicators

Page 15: The effect of organisational factors and processes of care on between centre achievement of audit measures for calcium, phosphate and PTH in UK haemodialysis.

Acknowledgments

• Multidisciplinary teams in UK Dialysis Centres

• UK Renal Registry– Dr J Gilg, Dr A Casula

• PhD Supervisors– Dr C Tomson, Prof P Roderick,

Prof Y BenShlomo


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