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Biomedical subjects

W M McClellan

Publications and source records attributed to W M McClellan.

At least 37 records · Page 2Linked to original sources
PubMed1998

Improving the care of patients treated with hemodialysis: a report from the Health Care Financing Administration's ESRD Core Indicators Project.

To determine the impact of a quality improvement intervention on dialysis care delivered to hemodialysis patients, we studied 213 hemodialysis facilities in North Carolina, South Carolina, and Georgia. Dialysis adequacy measurements made on two random samples of 30 patients per treatment center, or all patients if fewer than 30 were treated, selected in October 1994 (preintervention) and October 1995 (postintervention) were used to estimate the facility mean urea reduction ratio (URR) and the proportion of patients with a mean URR less than 50%. The 10% of facilities (n = 22) with the highest proportion of patients with a mean URR less than 50% in the facility at preintervention were selected for an intervention that included feedback of facility-specific mean URR, educational programs, a quality improvement workshop, and monitoring until improvement was attained. Changes between preintervention and postintervention facility mean URR and proportions of patients with a URR less than 60% and 65% were used to assess the impact of the intervention. After 1 year, the mean URR had increased an average of 7% in intervention centers compared with an increase of 1.4% (P < 0.001) in the remainder of the treatment centers in the Network. There was an average reduction of 17.2% in the proportion of patients with a URR less than 65% in intervention centers compared with 4.8% in the other facilities (P < 0.001). Comparable reductions in the proportion of patients with a mean URR of less than 60% were 16.2% in intervention centers and 2.0% in comparison facilities (P < 0.001). After controlling for facility case mix and other characteristics, the intervention was independently associated with an absolute 2.4% increase in facility-specific mean URR. We conclude that the intervention was associated with improvement in hemodialysis care.

Ambulatory Care Facilities↗
PubMed1998

Mortality in end-stage renal disease is associated with facility-to-facility differences in adequacy of hemodialysis.

Death rates of end-stage renal disease (ESRD) patients treated with hemodialysis vary substantially among treatment centers. The association between facility-to-facility differences in delivered hemodialysis dose and facility-specific mortality rates was examined among 5817 randomly selected patients treated with hemodialysis on October 1, 1994, from all 213 hemodialysis treatment centers reporting to ESRD Network 6. The mean urea reduction ratio (URR) for each treatment center, a measure of hemodialysis adequacy, was calculated for each facility, using measurements made by center staff members during one treatment for each of the randomly selected patients. During 7 mo of follow-up (ending April 30, 1995), 441 (7.6%) patients died. The average URR among the treatment centers was 64.9%. There was a strong, inverse association between increasing treatment center URR and adjusted mortality count (P = 0.009). Other treatment center characteristics associated with increased mortality included free-standing status (P = 0.009) and decreasing frequency of reported physician supervision of care (P = 0.01). It was concluded that lower average levels of dialysis adequacy in treatment centers are associated with higher rates of death, and this association persists after controlling for facility-to-facility differences in patient and nonpatient characteristics.

Adolescent↗
PubMed1997

Report from the 1995 Core Indicators for Peritoneal Dialysis Study Group.

The 1995 Peritoneal Dialysis Core Indicators Study was conducted by the Health Care Financing Administration to ascertain standard practices and outcomes in chronic peritoneal dialysis patients. Data from 1,202 patients who did not receive hemodialysis but who were on chronic ambulatory peritoneal dialysis (CAPD) for at least part of the 6-month period between November 1, 1994, and April 30, 1995, are reported. The mean serum albumin level for this cohort was 3.5 g/dL by the bromcresol green method and 3.2 g/dL by the bromcresol purple method. Data sufficient to calculate a weekly Kt/V(urea) or weekly creatinine clearance were available for only 34% of patient submissions. In these patients, the median weekly Kt/V(urea) was 1.7 using a fixed value for V of 0.58 x body weight and was 2.0 using the Watson equation to calculate V; the median weekly creatinine clearance was 60.7 L/wk/1.73 m2. The mean hematocrit for this cohort was 32% and the average weekly recombinant human erythropoietin (rHmEPO) dose was 115 u/kg. Hematocrit values < or = 30% were found in 50% of black patients and 31% of white patients. The average blood pressure among peritoneal dialysis patients was 139/80 mm Hg, with 29% of patients having a systolic blood pressure exceeding 150 mm Hg and 18% a diastolic blood pressure greater than 90 mm Hg. In summary, serum albumin levels were significantly lower in peritoneal dialysis patients than in hemodialysis patients. Approximately one third of peritoneal dialysis patients did not have an adequacy measure obtained during the 6-month observation period. A significant minority of patients had either inadequately treated anemia of chronic renal disease or hypertension. There is an opportunity to substantially improve the medical care provided to chronic peritoneal dialysis patients.

Adolescent↗
PubMed1997

Early detection and treatment of renal disease in hospitalized diabetic and hypertensive patients: important differences between practice and published guidelines.

This study was performed to ascertain the degree to which the care of hospitalized diabetic and hypertensive patients conforms to published guidelines for the detection and management of early renal disease. It was designed as a retrospective chart audit. Six hospitals, four nonurban referral centers, and two urban teaching institutions provided the data. Patients were a random sample of Medicare beneficiaries, with a mean age (SD) of 65.6 (9.1) years, admitted during 1994 with a primary or secondary diagnosis of either diabetes (n = 260) or hypertension (n = 327). A urinalysis was obtained for 163 (62.7%) of the diabetic patients. Among diabetics who had their urine tested, 31.3% had 1+ or greater dipstick proteinuria. A serum creatinine was obtained for 298 (91%) of the hypertensive patients, and 11.8% had a value of 1.5 mg/dL or greater. Abnormal renal function tests were recorded in the discharge summaries of 7.8% of the diabetic and 11.4% of the hypertensive patients. Patients with abnormal renal function were no more likely to be treated with angiotensin-converting enzyme inhibitors (ACEIs). Nonsteroidal antiinflammatory drugs (NSAIDs) were prescribed for 6% of diabetic and 8.8% of hypertensive patients with abnormal renal function at discharge. Despite the high prevalence of renal functional abnormalities detected by routine laboratory tests administered to elderly hospitalized diabetic and hypertensive patients, the medical records of these patients did not document awareness or appropriate management of the potential underlying kidney disease.

Aged↗
PubMed1997

Improvement in adequacy of delivered dialysis for adult in-center hemodialysis patients in the United States, 1993 to 1995.

The objective of this review is to describe the adequacy of delivered dialysis provided to in-center hemodialysis patients in the United States and to compare the findings with published guidelines. The medical records of random samples of 6,138, 6,919, and 6,861 patients in hemodialysis facilities were studied from all Medicare-eligible adult in-center hemodialysis patients alive on December 31, 1993, 1994, and 1995, respectively. The main clinical measure used was the urea reduction ratio (URR), the mean of which was 0.63 in 1993, 0.64 in 1994, and 0.66 in 1995. The proportion of patients with URR > or = 0.65, as recommended by the Renal Physicians Association and a National Institutes of Health Consensus Development Conference Statement, increased from 43% in 1993 to 49% in 1994 and 59% in 1995. In each of these 3 years, women were more likely than men to have a URR > or = 0.65 (1993: 54% v 31%, odds ratio 2.6; 1994: 61% v 38%, odds ratio 2.5; and 1995: 70% v 50%, odds ratio 24), as were older patients (65+ years) compared with younger patients (18 to 44 years) (1993: 47% v 37%, odds ratio 1.4; 1994: 54% v 45%, odds ratio 1.5; and 1995: 65% v 53%, odds ratio 1.6) and white patients compared with black patients (1993: 46% v 36%, odds ratio 1.5; 1994: 53% v 43%, odds ratio 1.5; and 1995: 63% v 54%, odds ratio 1.4). There was also substantial geographic variation in the proportion of patients receiving hemodialysis with a URR > or = 0.65. In conclusion, marked differences existed in 1993, 1994, and 1995 between observed practice and consensus guidelines for the delivery of adequate dialysis. Nevertheless, notable improvement occurred during this time period. A system to monitor further improvements in hemodialysis care in the United States is in place.

Adult↗
PubMed1997

Family history of end-stage renal disease among incident dialysis patients.

As part of a larger study of genetic risk factors for the occurrence of renal failure, the prevalence of a family history of end-stage renal disease (ESRD) in first- and second-degree relatives of all incident dialysis patients treated in Georgia, North Carolina, and South Carolina (ESRD Network 6) in 1994 was ascertained. Family histories were obtained from 4365 dialysis patients (83% of those eligible), and 856 (20%) reported having a family history of ESRD. Among race-sex groups, 14.1% of Caucasian men, 14.6% of Caucasian women, 22.9% of African-American men, and 23.9% of African-American women reported a first- or second-degree relative with ESRD (P = 0.001). The prevalence of relatives with ESRD varied by the reported etiology: 22.2% in diabetes mellitus; 18.9% in hypertension, 22.7% in glomerulonephritis; and 13.0% of other etiologies (P = 0.001). Patient characteristics independently associated with family history of ESRD included race, younger age, higher levels of education, and etiology of ESRD. In this report, it is concluded that a large proportion of incident ESRD cases have close relatives with ESRD in whom preventive actions might be directed. Genetic analyses in multiply affected families may identify the inherited factors contributing to progressive renal failure.

Adult↗
PubMed1996

Quality of patient care in the Medicare End-Stage Renal Disease Program: the basis and implementation of the 1994-1997 End-Stage Renal Disease Health Care Quality Improvement Program.

Substantial changes have occurred in the quality assurance and improvement programs conducted by the Health Care Financing Administration in the Medicare End-Stage Renal Disease Program. This review is a brief description of these changes and an introduction to the health policy, epidemiology, health services research, clinical nephrology, and statistical process control literature that is the basis for this initiative.

Humans↗
PubMed1996

Early death in dialysis patients: risk factors and impact on incidence and mortality rates.

Patients who die within the first 90 days after beginning dialysis are not included in mortality rates and may be absent from incidence counts. To identify factors associated with mortality within 3 months of the initiation of dialysis for ESRD and to estimate the impact of early deaths on ESRD incidence and mortality rates, this study investigated 15,245 patients who began dialysis in Georgia, North Carolina, and South Carolina over a 5-yr period. Data were collected by dialysis facility staff and reported to an ESRD registry. Six percent of all new patients died within 90 days of dialysis initiation (32% of all deaths occurring in the first year of treatment). Characteristics independently associated with increased risk of early death included older age, white race, male gender, physical and nutritional impairment, smoking, and the presence of cancer, congestive heart failure, clinical depression, and history of myocardial infarction. Depending on race-gender group, age-adjusted mortality rates based on this cohort were underestimated by 3 to 12% when patients who died early were excluded. These results suggest that certain patient characteristics-some potentially modifiable-confer increased risk of early death, and that the systematic exclusion of patients who die early from the U.S. national registry substantially influences ESRD mortality rates.

Adult↗
PubMed1996

Risk factors for hospital utilization in chronic dialysis patients. Southeastern Kidney Council (Network 6).

It is not known if the risk factors for hospital utilization are similar to the risk factors for mortality in chronic dialysis patients. The risk factors associated with hospital days per year of patient risk were identified in a subset of patients in Network 6 (the states of North Carolina, South Carolina, and Georgia) who began dialysis in 1989. The demographic characteristics of this cohort of 1572 patients included a mean (+/- SD) age of 57.4 +/- 15.0 yr; 63.7% of the patients were African American, 52.4% were female, and 33.0% had diabetes mellitus as the primary cause of ESRD. The median number of hospital days per year of patient risk was 8.8, with 25th and 75th quartiles of 3.9 and 20.1, respectively. By using multiple regression analysis, the strongest predictors of the number of hospital days per year of patient risk included low serum albumin level (P = 0.0001), decreased activity level (P = 0.0006), diabetes mellitus as the primary cause of ESRD (P = 0.002), peripheral vascular disease (P = 0.004), white race (P = 0.01), increasing age (P = 0.03), the absence of hypertension (P = 0.03), and the presence of angina (P = 0.03), smoking (P = 0.03), and congestive heart failure (P = 0.045). These risk factors are similar to those reported for an increased risk of mortality in dialysis patients and some of them, such as smoking, are modifiable and may be amenable to interventional strategies.

Adult↗
PubMed1995

Implementing the Health Care Quality Improvement Program in the Medicare ESRD Program: a new era of quality improvement in ESRD.

Improving the quality of health care is a central challenge for America's health care system. The mission of the End-Stage Renal Disease (ESRD) program is to promote the quality, effectiveness, and efficiency of ESRD patient care and program administration. The program provides an ideal opportunity to demonstrate the use of information to help clinicians analyze and improve the care they deliver to patients in an ambulatory setting. This is possible because the program has established regional surveillance systems, called ESRD Networks, that gather information on the occurrence and outcomes of treatment of Medicare beneficiaries with ESRD. The Health Care Financing Administration, which is responsible for the administration of the program, and the renal community have worked together since 1990 to identify ways of incorporating new methods of quality improvement into the program. These methods include statistical evaluation of the processes and outcomes of care in dialysis populations; communicating recommended practices with clinical guidelines and algorithms; regional peer review and feedback (ie, technical assistance and/or collaborations for quality improvement); interventions that focus on the provision of assistance for quality improvement efforts; continuing collection and active feedback of data to providers; and a commitment to continue to evaluate and revise quality improvement activities to reflect lessons learned and newly identified needs. These ideas have been included in the 1994-1997 scope of work for the ESRD Networks and is called the ESRD Health Care Quality Improvement Program (HCQIP). This article describes the background for the ESRD HCQIP and the program's elements.

Humans↗
PubMed1995

A data-driven approach to improving the care of in-center hemodialysis patients.

Health care providers, patients, the end stage renal disease (ESRD) networks, and HCFA have developed the ESRD Health Care Quality Improvement Program (HCQIP) in an effort to assess and improve care provided to ESRD patients. Currently, the ESRD HCQIP focuses on collecting information on quality indicators (QIs) for treatment of anemia, delivery of adequate dialysis, nutritional status, and blood pressure control for adult in-center hemodialysis patients. QIs were measured in a national probability sample of ESRD patients, and interventions and evaluations of the interventions are beginning. The ESRD HCQIP illustrates a way to mobilize the strengths of the public and private sectors to achieve improved care for special populations.

Adult↗
PubMed1993

Social support and subsequent mortality among patients with end-stage renal disease.

The association between social support in newly entered dialysis patients and their subsequent risk of mortality was investigated. Two hundred forty-nine dialysis patients were enrolled from dialysis facilities in two southeastern states. A score was calculated for the amount of social support a patient reported giving and receiving from spouse, family, friends, nurses, physicians, staff, and fellow patients. Patients were monitored for 12 months after enrollment into the cohort: 43 (17.6%) died. Mean (SD) scores for giving support to the family were higher among survivors, 3.59 (0.92), than among those who died, 3.17 (1.32) (P = 0.022). Mean scores for giving support to friends were also higher among survivors, 3.38 (1.13), than among nonsurvivors, 2.94 (1.33) (P = 0.044). After other factors associated with increased risk of dying, including age, sex, race, diabetic renal disease, angina pectoris, and functional status, were controlled for, individuals in the lowest quartile of giving social support to friends continued to have a greater risk of dying, with adjusted relative risk (95% confidence interval) = 2.02 (1.01, 4.07). In contrast, there were no differences in risk of death found for differing levels of receiving social support. It was concluded that social support is an independent risk factor for mortality among new dialysis patients.

Cohort Studies↗
PubMed1992

Variable mortality rates among dialysis treatment centers.

OBJECTIVE: To examine the variation in the risk for mortality among patients treated at renal dialysis facilities within a defined geographic area. SETTING: All free-standing and hospital-based dialysis facilities in a single southeastern state reported to the registry. DESIGN: Cohort of dialysis patients followed for 1 year by an end-stage renal disease registry. PATIENTS: Patients (n = 3612) aged 20 years and older receiving treatment at the dialysis facilities reporting to the registry during 1987. MEASUREMENTS: Demographic, comorbid, and severity of illness indicators were abstracted from patient records. Facility-specific risk estimates were derived from a Cox proportional hazards model. RESULTS: Facility-specific mortality rates ranged between 2.0 and 10.5 deaths per 10,000 patient days. Mortality rates were higher among older persons; whites; those with a history of diabetic nephropathy, angina, or congestive heart failure; and patients with either nutritional or functional status impairment. Facility-specific prevalence of each mortality risk factor varied widely. The unadjusted risk for death in a facility at the 75th percentile of risk was 1.3 times that of a facility at the median, whereas at the 25th percentile, it was 0.68 times as likely--a twofold range of risk. Controlling for differences in the prevalence of patient characteristics did not change the interquartile range in risks, and a facility's adjusted risk estimate showed a strong correlation with its unadjusted estimate (R2, 0.566; P less than 0.0001). CONCLUSIONS: Patient attributes associated with increased risk for mortality vary widely among dialysis facilities. Adjustment for these differences did not, however, substantially change either the degree of variation in mortality risks or the relative ranking of a facility's mortality.

Adult↗
PubMed1991

Functional status and quality of life: predictors of early mortality among patients entering treatment for end stage renal disease.

We investigated the association between functional status and quality of life in newly-entered dialysis patients and the subsequent risk of mortality. We enrolled the patients from 37 dialysis facilities in two southeastern states (n = 294). Functional status was assessed by the Karnofsky Performance Scale (KPS) and quality of life by the Spitzer Quality of Life Index (SQLI). During a mean (SE) follow-up of 479.6 (109.4) days 49 patients (16.4%) of the cohort died. The mean KPS score (SE) for survivors was 7.31 (0.11) and for non-survivors was 5.89 (0.26), P less than 0.0001. The mean SQLI score (SE) for survivors was 6.74 (0.15) and non-survivors was 4.95 (0.28), P less than 0.0001. Strong gradients of the risk of mortality were found for both measurements. After controlling for other covariates including age, race, sex, primary cause of renal failure and the presence of comorbidity, both the KPS and SQLI scores were independently correlated with risk of mortality. We conclude that functional status and quality of life are strong independent risk factors for subsequent mortality in new dialysis patients. These are easily measured indicators which may serve to predict subsequent risk of mortality or adjust case-mix estimates for comparisons between dialysis populations.

Comorbidity↗
PubMed1988

Continuity of care in hypertension. An important correlate of blood pressure control among aware hypertensives.

Hypertensive patients frequently discontinue follow-up care. In a population-based survey of 4688 adults, we examined the impact of nonattendance on blood pressure control in aware hypertensives. Nonattendance was defined as a failure to visit a physician for hypertensive care within a six-month interval and was reported by 29% of 907 aware hypertensives. Nonattenders had a higher prevalence of diastolic blood pressure above 90 mm Hg (67% vs 30% for attenders). The nonattender profile was male, young, active in the work force, and without coexisting chronic diseases. Poor blood pressure control among nonattenders was associated with a lower treatment rate. Uncontrolled diastolic hypertension and less adherence to medications in nonattenders warrants concern by clinicians.

Adult↗
PubMed1985

Improved follow-up care of hypertensive patients by a nurse practitioner in a rural clinic.

The usefulness of nurse practitioners in the care of hypertension has been demonstrated in a variety of settings. In a randomized prospective comparison between physicians and nurse practitioner care, observations are extended to rural ambulatory hypertensives. Data indicate that for patients who remain actively in follow-up, blood pressure control was the same when treated by either physicians or the nurse practitioner. However, patients treated by the nurse practitioner had a significantly better follow-up adherence rate than did those treated by physicians. The data presented support the use of nurse practitioners in the care of hypertension, particularly in rural populations where a need for intermediate level practitioners is likely to persist despite an expanding supply of physicians.

Community Health Centers↗