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Wingard RL, Chan KE, Lazarus JM, Hakim RM: The "right" of passage: surviving the first year of dialysis. Clin J Am Soc Nephrol. 2009 Dec;4 Suppl 1:S114-20.
Mortality risk for dialysis patients is highest in the first year. We previously showed a 41% mortality benefit associated with a pilot case management program for incident hemodialysis patients (n = 918). The RightStart Program (RSP) provided prompt medical management and self-management education and was recently expanded to more facilities. We conducted a matched cohort analysis to validate the expanded program's continued effectiveness. Death risk was reduced for RS patients (n = 4308) versus matched controls (C; n = 4308) by 34% (hazard ratio = 0.66, P < 0.0001) at 120 d and 22% at 1 yr (hazard ratio = 0.78, P < 0.0001). RS patients had lower hospitalization during the first year (RS = 15.5 days per patient year versus C = 16.9, P < 0.01). At 120 d, more RS patients achieved hemoglobin 11 to 12 g/dl (RS = 22.4% versus C = 19.7%, P < 0.01), eKt/V > or = 1.2 (RS = 66% versus C = 53.5%, P < 0.01), albumin > or = 4.0 g/dl (RS = 26% versus C = 22%, P < 0.01), and phosphorus 3.5 to 5.5 mg/dl (RS = 52.4% versus C = 45.4%). At 120 d, RS patients had a greater reduction in catheter use (RS = 32% versus C = 25%, P < 0.01) and more vitamin D orders (RS = 60% versus C = 55%, P < 0.01). Expansion of RS to a larger incident patient population results in significant reduction of morbidity and mortality associated with improvement of intermediate outcomes. |
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