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

2. 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

3. The centre effect and the UKRR Proportion of HD patients with phosphate <1.8mmol/L in each dialysis centre in England, Wales and Northern Ireland

4. Change in mean phosphate before and after case mix adjustment using multi level analysis (MLWin) Unadjusted Adjusted for age, gender, ethnicity, predialysis creatinine, transplant WL status Poster 0097, Wednesday 22 nd 1pm

5. 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

6. 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

7. 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

8. 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)

9. Phosphate Variable OR for Phosphate <1.8mmol/L UnadjustedAdjusted WTE Nephrologists 1.161.14 WTE Dietitians 1.121.08 WTE Pharmacists 1.111.05 Intensity of audit 0.920.83 System of Care - Consultant 1.131.09 System of Care - Centre 1.271.23 QA score - Some MDT 1.341.17 QA score - All MDT 1.471.27 Proforma 1.231.12 Intensity of nephrology review 1.14 Intensity of dietitian review 1.11 Intensity of pharmacist review 1.120.92 Intensity of nurse input 0.880.96 Intensity of feedback 1.041.06 Trigger phosphate 1.071.12 Target high risk 10.9 p<0.01p<0.05 Variable OR for Phosphate <1.8mmol/L UnadjustedAdjusted Policy for Cinacalcet - Protocol 0.831.05 Policy for Cinacalcet - Unrestricted 0.881 Policy for Lanthanum - Protocol 0.971.09 Policy for Lanthanum - Unrestricted 0.870.89 Hosp supply Al, Ca binders/Vit D 0.960.83 Hosp supply Cinacalcet/Lanthanum 0.920.87 Additional Prescribers 0.971 WTE PTX surgeons 0.951.06 Guideline 1.141.04 Guideline-phosphate binders 1.121.02 Guideline-Cinacalcet 1.171.07 Guideline-dialysate Ca 1.161.27 Guideline-parathyroiectomy referral 1.11.06 Measure bloods as per RA 1.171.14 Use of low Ca dialysate 1.171.14

10. Calcium Variable OR for calcium 2.2- 2.6mmol/L UnadjustedAdjusted WTE Nephrologists 0.910.9 WTE Dietitians 1.21.15 WTE Pharmacists 0.981 Intensity of audit 0.9 System of Care - Consultant 0.820.8 System of Care - Centre 0.951 QA score - Some MDT 0.870.89 QA score - All MDT 0.961.02 Proforma 1.011 Intensity of nephrology review 1.151.03 Intensity of dietitian review 0.650.67 Intensity of pharmacist review 0.90.96 Intensity of nurse input 0.960.97 Intensity of feedback 0.970.95 Trigger phosphate 1.31.29 Target high risk 0.780.81 p<0.01p<0.05 Variable OR for calcium 2.2- 2.6mmol/L UnadjustedAdjusted Policy for Cinacalcet - Protocol 1.441.36 Policy for Cinacalcet - Unrestricted 1.021.04 Policy for Lanthanum - Protocol 1.51.44 Policy for Lanthanum - Unrestricted 1.32 Hosp supply Al, Ca binders/Vit D 1.041.08 Hosp supply Cinacalcet/Lanthanum 1.021.09 Additional Prescribers 0.90.93 WTE PTX surgeons 1.371.31 Guideline 0.850.9 Guideline-phosphate binders 0.860.93 Guideline-Cinacalcet 1.181.15 Guideline-dialysate Ca 1.081.05 Guideline-parathyroiectomy referral 0.981.02 Measure bloods as per RA 0.981.04 Use of low Ca dialysate 0.890.94

11. PTH Variable OR for PTH 16-32mmol/L UnadjustedAdjusted WTE Nephrologists 1.020.98 WTE Dietitians 1.231.2 WTE Pharmacists 1.081.09 Intensity of audit 0.930.91 System of Care - Consultant 0.980.96 System of Care - Centre 1.01 QA score - Some MDT 1.061.04 QA score - All MDT 1.11.09 Proforma 1.041 Intensity of nephrology review 1.161.15 Intensity of dietitian review 0.990.98 Intensity of pharmacist review 1.121.11 Intensity of nurse input 0.80.84 Intensity of feedback 0.830.82 Trigger phosphate 1.061.07 Target high risk 0.99 p<0.01p<0.05 Variable OR for PTH 16-32mmol/L UnadjustedAdjusted Policy for Cinacalcet - Protocol 0.940.96 Policy for Cinacalcet - Unrestricted 0.790.83 Policy for Lanthanum - Protocol 0.910.9 Policy for Lanthanum - Unrestricted 0.990.98 Hosp supply Al, Ca binders/Vit D 1.071.06 Hosp supply Cinacalcet/Lanthanum 1.131.14 Additional Prescribers 0.880.9 WTE PTX surgeons 1.141.15 Guideline 1.1 Guideline-phosphate binders 1.1 Guideline-Cinacalcet 1.041.05 Guideline-dialysate Ca 1.031.02 Guideline-parathyroiectomy referral 1.041.02 Measure bloods as per RA 1.061.05 Use of low Ca dialysate 0.9

12. 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

13. 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

14. 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

15. 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