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Identifying Best Practices in Dialysis Care: Results of Cognitive Interviews and a National Survey of Dialysis Providers

Amar A. Desai^*,, Roger Bolus^,, Allen Nissenson, Sally Bolus, Matthew D. Solomon^,||, Osman Khawar, Matthew Gitlin^¶, Jennifer Talley^,**, and Brennan M. R. Spiegel^,,**

^* Department of Medicine, University of California–San Francisco, San Francisco, California; Center for Health Policy and Primary Care Outcomes Research and ^|| Department of Medicine, Stanford University, Palo Alto, California; Department of Medicine, David Geffen School of Medicine, University of California–Los Angeles, Los Angeles, California; UCLA/VA Center for Outcomes Research and Education, Los Angeles, California; ^¶ Amgen, Inc; and ^** Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California

Correspondence: Dr. Brennan M. R. Spiegel, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, UCLA/VA Center for Outcomes Research and Education, 11301 Wilshire Boulevard, Building 115, Room 215, Los Angeles, CA 90073. Phone: 310-268-3256; Fax: 310-268-4510; E-mail: bspiegel{at}mednet.ucla.edu

Background and objectives: Because there is wide variation in case-mix adjusted outcomes across dialysis facilities, it is possible that top-performing facilities use practices not shared by others. We sought to catalogue "best practices" that may account for interfacility variations in outcomes.

Design, setting, participants, & measurements: This multidisciplinary study identified candidate best practices in dialysis through a staged process, including systematic review, cognitive interviews, and a national "virtual focus group" of dialysis providers. The resulting candidate practices were rank-ordered by perceived importance as determined by mean RAND Appropriateness Scores from a national survey of nephrologists, nurses, and opinion leaders.

Results: A total of 155 candidate best practices were identified. Among these, respondents believed dialysis outcomes are most strongly related to 1) characteristics of multidisciplinary care conferences, 2) technician proficiency in protecting vascular access, 3) training of nurses to provide education in fluid management, vascular access, and nutrition, 4) use of random and blinded audits of staff performance, and 5) communication and teamwork among staff. In contrast, there was wide disagreement about the importance of facility-based health maintenance practices, optimal staffing ratios, frequency of dialysis-based physician visits, and optimal frequency of multidisciplinary care.

Conclusions: This study provides a "conceptual map" of candidate dialysis best practices and highlights areas of general agreement and disagreement. These findings can help the dialysis community think critically about what may define "best practice" and provide targets for future research in quality improvement.