Overpriced? Are Hospital Prices Associated with the Quality of Care?

In most consumer markets, higher prices generally imply increased quality. For example, in the automobile, restaurant, hospitality, and airline industries, higher pricing generally conveys a signal of complexity and superiority of a service or product. However, in the healthcare industry, there is room to challenge the price-quality connection as both health prices and health quality can be difficult to interpret.

Effect of change in vascular access on patient mortality in hemodialysis patients.

Background: Hemodialysis patients using a catheter have a greater mortality risk than those using an arteriovenous (AV) access (fistula or graft). However, catheter-dependent patients also differ from those with an AV access in several clinical features, and these differences may themselves contribute to their excess mortality.

Methods: The current study evaluates whether a change in vascular access affects risk for mortality in patients enrolled in the Hemodialysis Study.

Cerebrovascular disease in maintenance hemodialysis patients: results of the HEMO Study.

Background: Cerebrovascular disease (CBVD) in hemodialysis patients is associated with significant morbidity and mortality. A secondary analysis of CBVD in the Hemodialysis (HEMO) Study was performed. Specific objectives were to: (1) determine risk factors for the presence of CBVD at baseline, (2) assess risk factors for the subsequent occurrence of cerebrovascular deaths, and (3) analyze the effects of dose and flux on cerebrovascular mortality.

Design of the Dialysis Access Consortium (DAC) Clopidogrel Prevention of Early AV Fistula Thrombosis Trial.

Background: The Dialysis Access Consortium (DAC) was developed to investigate interventions to improve hemodialysis vascular access outcomes. The autogenous arteriovenous fistula created by direct connection of native artery to vein is the recommended vascular access for hemodialysis. However, it fails frequently due to clotting after surgery.

Design of the Dialysis Access Consortium (DAC) Aggrenox Prevention Of Access Stenosis Trial.

Background: Surgically created arteriovenous (AV) grafts are the most common type of hemodialysis vascular access in the United States, but fail frequently due to the development of venous stenosis. The Dialysis Access Consortium (DAC) Aggrenox Prevention of Access Stenosis Trial tests the hypothesis that Aggrenox (containing dipyridamole and aspirin) can prevent stenosis and prolong survival of arteriovenous grafts.

Methods: This is a multicenter, randomized, double-blind, placebo-controlled trial that will enroll 1056 subjects over four years with one-half year follow-up.

Vascular access as a determinant of adequacy of dialysis.

Vascular accesses consist of permanent arteriovenous (AV) accesses (autogenous fistulas and synthetic grafts) and venous accesses (central venous catheters [CVCs]). AV accesses have fewer complications than venous accesses, and are therefore the preferred hemodialysis access. An important additional issue is whether the type of access influences adequacy of dialysis (i.

The spectrum of infection-related morbidity in hospitalized haemodialysis patients.

Background: Infection is a common cause of mortality and morbidity in haemodialysis patients. Few prospective studies have examined the clinical consequences of infection-related hospitalizations in haemodialysis patients or the risk factors predictive of clinical outcomes.

Methods: The outcomes of all first infection-related hospitalizations of patients enrolled in the HEMO Study were categorized in terms of mortality, requirement for intensive care unit (ICU) stay and length of hospitalization.

Effects of high-flux hemodialysis on clinical outcomes: results of the HEMO study.

Among the 1846 patients in the HEMO Study, chronic high-flux dialysis did not significantly affect the primary outcome of the all-cause mortality (ACM) rate or the main secondary composite outcomes, including the rates of first cardiac hospitalization or ACM, first infectious hospitalization or ACM, first 15% decrease in serum albumin levels or ACM, or all non-vascular access-related hospitalizations. The high-flux intervention, however, seemed to be associated with reduced risks of specific cardiac-related events. The relative risks (RR) for the high-flux arm, compared with the low-flux arm, were 0.

Chronic kidney disease, mortality, and treatment strategies among patients with clinically significant coronary artery disease.

Cardiovascular disease is an important cause of mortality among patients with chronic kidney disease (CKD). This study describes associations between CKD, cardiac revascularization strategies, and mortality among patients with CKD and cardiovascular disease. All patients undergoing cardiac catheterization at Duke University Medical Center (1995 to 2000) with documented stenosis > or =75% of at least one coronary artery and available creatinine data were included.

Impact of dialysis dose and membrane on infection-related hospitalization and death: results of the HEMO Study.

Infection is the second most common cause of death among hemodialysis patients. A predefined secondary aim of the HEMO study was to determine if dialysis dose or flux reduced infection-related deaths or hospitalizations. The effects of dialysis dose, dialysis membrane, and other clinical parameters on infection-related deaths and first infection-related hospitalizations were analyzed using Cox regression analysis.

Effect of dialysis dose and membrane flux in maintenance hemodialysis.

Background: The effects of the dose of dialysis and the level of flux of the dialyzer membrane on mortality and morbidity among patients undergoing maintenance hemodialysis are uncertain.

Methods: We undertook a randomized clinical trial in 1846 patients undergoing thrice-weekly dialysis, using a two-by-two factorial design to assign patients randomly to a standard or high dose of dialysis and to a low-flux or high-flux dialyzer.

Results: In the standard-dose group, the mean (+/-SD) urea-reduction ratio was 66.

Treatment approaches for infected hemodialysis vascular catheters.

Purpose Of Review: The focus of the review is to delineate protocols for catheter removal, catheter replacement and duration of therapy when a catheter-related infection occurs, and to demonstrate possible means of preventing such infections.

Recent Findings: The evidence supporting these views will be discussed in the light of our current practice.

Summary: Cuffed tunneled hemodialysis catheters have evolved for wide use as both temporary and semi-permanent hemodialysis access.

Coronary steal from a left internal mammary artery coronary bypass graft by a left upper extremity arteriovenous hemodialysis fistula.

In patients with end-stage renal disease undergoing hemodialysis, the upper extremity arteriovenous (AV) fistula is the dialysis access recommended by the DOQI guidelines for patients with appropriate vasculature. Upper extremity AV fistulae have long periods of usefulness, high flow rates, and low associated complication rates. Placement of AV access may result in increased cardiac output and increased cardiac oxygen demand in these patients.

Multicenter clinical trial results with the LifeSite hemodialysis access system.

Background: The LifeSite Hemodialysis Access System is a subcutaneous access device designed to maximize blood flow while minimizing access-related complications. The purpose of this study was to compare the efficacy and safety of the LifeSite System to a similar but transcutaneous access device, the Tesio-Cath Hemodialysis Catheter.

Methods: The study was conducted in two phases.

National profile of practice patterns for hemodialysis vascular access in the United States.

The Centers for Medicare & Medicaid Service's (CMS), national End-Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project is a data collection initiative to identify opportunities for improvement of care to adult, Medicare maintenance dialysis beneficiaries. This analysis of 1999 CPM data characterizes the profile of hemodialysis vascular access in the United States and identifies determinants of vascular access type 2 yr after the translation of vascular access clinical practice guideline statements into national CPMs. CPM data were collected during October to December 1999 and stratified by the 18 regional ESRD networks.