***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Low albumin level is a strong predictor of mortality and morbidity among hemodialysis patients , yet few interventions are available to improve albumin levels . Moreover , the relative importance of nutritional barriers versus inflammation in contributing to hypoalbuminemia is unclear . We sought to determine whether targeting specific nutritional barriers will improve albumin levels . METHODS We conducted a r and omized controlled trial involving 180 patients with baseline albumin levels less than 3.7 g/dL ( < 37 g/L ) at 44 long-term hemodialysis facilities . Study coordinators identified and intervened on specific barriers present among intervention patients , whereas control patients continued to receive the usual care . Barriers targeted included poor nutritional knowledge , poor appetite , help needed with shopping or cooking , low fluid intake , inadequate dialysis dose , depression , difficulty chewing , difficulty swallowing , gastrointestinal symptoms , and acidosis . RESULTS At baseline , intervention and control patients had similar albumin levels , dietary intakes , levels of inflammatory markers , and numbers of nutritional barriers . After 12 months , intervention patients had greater increases in albumin levels compared with control patients ( + 0.21 versus + 0.06 g/dL [ + 2.1 versus + 0.6 g/L ] ; P < 0.01 ) , as well as greater increases in energy intake ( + 4.1 versus -0.6 Kcal/d/kg ; P < 0.001 ) and protein intake ( + 0.13 versus -0.06 g/d/kg ; P < 0.001 ) . The intervention appeared most effective for barriers related to poor nutritional knowledge , help needed with shopping or cooking , and difficulty swallowing . About half the subjects had elevated levels of inflammatory markers , but there was no relationship between change in levels of albumin and inflammatory markers . CONCLUSION A nutrition intervention tailored to patient-specific barriers result ed in modest improvements in albumin levels regardless of levels of inflammatory markers BACKGROUND AND OBJECTIVES Annualized mortality rates of chronic hemodialysis ( CHD ) patients in their first 90 d of treatment range from 24 to 50 % . Limited studies also show high hospitalization rates . It was hypothesized that a structured quality improvement program ( RightStart ) , focused on medical needs and patient education and support , would improve outcomes for incident CHD patients . DESIGN , SETTING , PARTICIPANTS , & MEASUREMENTS A total of 918 CHD incident patients were prospect ively enrolled in a multicenter RightStart Program  , and compared with a time-concurrent group of 1020 control patients from non-RightStart clinics . RightStart patients received 3 mo of intervention in management of anemia , dosage of dialysis , nutrition , and dialysis access and a comprehensive educational program . Outcomes were tracked for up to 12 mo . RESULTS At 3 mo , RightStart patients had higher albumin and hematocrit values . Dose of dialysis and permanent access placement were not statistically significantly different from control subjects . Compared with baseline , Mental Composite Score for RightStart patients improved significantly . Mean hospitalization days per patient year were reduced with RightStart versus control subjects . Mortality rates at 3 , 6 , and 12 mo were 20 , 18 , and 17 for RightStart patients versus 39 , 33 , and 30 deaths per 100 patient-years for control subjects , respectively . CONCLUSIONS A structured program of prompt medical and educational strategies in incident CHD patients results in improved morbidity and mortality that last up to 1 yr The present study examined the efficacy of a behavioral intervention design ed to increase adherence to fluid-intake restrictions among hemodialysis patients . Twenty intervention-group patients were compared with 20 matched control patients on an indicator of fluid-intake adherence at 3 time points . The Group x Time interaction was significant , indicating that patients in the 2 groups exhibited a differential pattern of change in fluid-intake adherence across the follow-up period . The intervention and control groups did not differ significantly in terms of adherence at the initial postintervention period but did differ at the 8-week follow-up . The observed group differences were , in part , due to a trend toward increasingly better adherence in the intervention group and poorer adherence in the control group across the follow-up period Background The diversity of quality improvement interventions ( QIIs ) has impeded the use of evidence review to advance quality improvement activities . An agreed-upon framework for identifying QII articles would facilitate evidence review and consensus around best practice s. Aim To adapt and test evidence review methods for identifying empirical QII evaluations that would be suitable for assessing QII effectiveness , impact or success . Design Literature search with measurement of multilevel inter-rater agreement and review of disagreement . Methods Ten journals ( 2005 - 2007 ) were search ed electronically and the output was screened based on title and abstract . Three pairs of review ers then independently rated 22 articles , r and omly selected from the screened list .  Kappa statistics and percentage agreement were assessed . 12 stakeholders in quality improvement , including QII experts and journal editors , rated and discussed publications about which review ers disagreed . Results The level of agreement among review ers for identifying empirical evaluations of QII development , implementation or results was 73 % ( with a paradoxically low kappa of 0.041 ) . Discussion by raters and stakeholders regarding how to improve agreement focused on three controversial article selection issues : no data on patient health , provider behaviour or process of care outcomes ; no evidence for adaptation of an intervention to a local context ; and a design using only observational methods , as correlational analyses , with no comparison group . Conclusion The level of review er agreement was only moderate . Reliable identification of relevant articles is an initial step in assessing published evidence . Advancement in quality improvement will depend on the theory- and consensus-based development and testing of a generalizable framework for identifying QII evaluations BACKGROUND The Dialysis Outcomes and Practice Patterns Study ( DOPPS ) is a prospect i ve , observational study based on data collected from nationally representative sample s of haemodialysis facilities . The burden of anaemia in haemodialysis patients is substantial , leading to considerable morbidity , mortality and reduced quality of life . This study examines anaemia management and outcomes based on data from five European countries participating in the DOPPS : France , Germany , Italy , Spain and the UK . METHODS Baseline data on demographics , co-morbidities and anaemia management in 4591 haemodialysis patients from 101 nephrology facilities were collected in 1998 - 2000 . Using multivariate Cox survival analyses to adjust for patient characteristics , relationships between haemoglobin concentration at study entry and rates of mortality and hospitalization were evaluated . RESULTS For a year 2000 sample of prevalent patients on haemodialysis > 180 days , mean haemoglobin concentration was 11.0 g/dl ; 53 % had a haemoglobin concentration > or = 11 g/dl [ 1998 - 1999 = 44 % ( P < 0.05 ) ] . In 2000 , 84 % of prevalent patients were prescribed recombinant human erythropoietin ( rHuEpo ) . Higher haemoglobin concentrations were associated with decreased relative risk ( RR ) for mortality ( RR = 0.95 for every 1 g/dl higher haemoglobin , P = 0.03 ) and hospitalization ( RR = 0.96 , P = 0.02 ) . Patients with haemoglobin < 10 g/dl were 29 % more likely to be hospitalized than patients with haemoglobin 11 - 12 g/dl ( P < 0.001 ) . CONCLUSION Even after adjustment , lower haemoglobin concentrations were associated with higher morbidity and mortality in European haemodialysis patients . A trend to increased haemoglobin concentrations was observed following publication of the European Best Practice Guidelines ( EBPG ) on anaemia management for chronic kidney disease patients , but efforts must continue to achieve EBPG goals BACKGROUND Starting  hemodialysis therapy with an arteriovenous fistula ( AVF ) is associated with improved patient survival . Clinical audit showed that less than 50 % of our patients started hemodialysis therapy with an AVF . STUDY DESIGN Quality improvement report , prospect i ve before and after study . SETTING & PARTICIPANTS Tertiary referral hospital with 184 patients starting hemodialysis therapy in 2005 and 2006 . QUALITY IMPROVEMENT PLAN Situational analysis showed poor overall coordination of surgical waiting lists . Multifaceted intervention included vascular access nurse coordinator and an algorithm to prioritize surgery . OUTCOMES Vascular access used at first hemodialysis treatment in patients with pre-end-stage renal disease  in the 12 months before and after the intervention . MEASUREMENTS Proportions of patients starting hemodialysis therapy with an AVF .  RESULTS Overall , 65 % of patients started hemodialysis therapy with an AVF ; 2 % , with an arteriovenous graft ; and 33 % , with a catheter . The proportion of patients starting hemodialysis therapy with an AVF  increased from 56 % preimplementation to 75 % postimplementation ( P = 0.007 ) . After adjustment for age , sex , late referral , cause of renal failure , and presentation type , patients starting dialysis therapy in the implementation phase were twice as likely to start treatment with an AVF ( odds ratio , 2.85 ; P = 0.008 ) . The total number of catheter-days in the implementation phase was half that of the preimplementation phase ( 2,833 v 4,685 days ) . LIMITATIONS Nonr and omized study . CONCLUSIONS Implementation of a multifaceted intervention including a vascular access nurse and an algorithm to prioritize surgery significantly increased the proportion of patients starting dialysis therapy with an AVF by improving the overall coordination of the surgical waiting list BACKGROUND : Human recombinant erythropoietin ( rHuEPO ) is administered to patients with end-stage renal disease for treatment of anemia . OBJECTIVE : To assess the impact of a structured team approach to anemia management in rHuEPO-resistant hemodialysis patients . METHODS : This was an 8-month prospect i ve , open-label , quality -improvement initiative . Nineteen patients in a 160-bed hemodialysis unit receiving rHuEPO doses > 300 units/kg/wk were defined as rHuEPO-resistant .  Hemoglobin ( Hb ) , iron indices , parathyroid hormone , folate , B12 , aluminum , and reticulocyte counts were determined at baseline . The former 3 parameters were followed every 6 , 12 , and 26 weeks , respectively . Vascular access flow was regularly assessed via ultrasonic dilution methodology . Target Hb was 12.0–13.5 g/dL. All factors potentially contributing to rHuEPO resistance were assessed and , if possible , treated every 6 weeks by a dedicated anemia team . Downward rHuEPO dosage adjustments of 12.5–25 % to the closest 1000 units were considered if underlying causes of rHuEPO resistance could not be identified or reversed , or if the Hb rose beyond the target level . RESULTS : Dysfunctional vascular access and iron deficiency were the predominant treatable factors associated with rHuEPO resistance . At 8 months , mean rHuEPO dosage decreased significantly from 469 to 319 units/kg/wk ( p < 0.001 ) and mean Hb increased significantly from 10.6 to 11.6 g/dL ( p = 0.023 ) . Eight-month cost savings approximated $ 45 000 ( CDN$ ) . CONCLUSIONS : A structured team approach to the management of  rHuEPO-resistant patients was successful in significantly lowering rHuEPO dosage with improvement in serum Hb at a substantial cost savings The Kidney Disease Outcomes Quality Initiative guidelines for peritoneal dialysis ( PD ) emphasize the need for quality improvement interventions to improve outcomes in PD . Here , we report 17 years experience of initiatives focused on lowering peritonitis rates in a single PD program . This institutional review board-approved retrospective analysis used a PD registry containing prospect ively collected data on patient demographics , initial Charlson comorbidity index ( CCI ) , peritonitis , and clinical outcomes , including reasons for transfer to hemodialysis . Periods were analyzed based on quality initiatives : 1990 - 1991 , baseline ; 1992 - 1995 , r and omized controlled trial of exit-site infection prophylaxis comparing mupirocin cream applied daily to the exit site with oral cyclical ( every 12 weeks ) rifampin ; 1996 - 1999 , compact assist device introduced for spiking on the cycler ; 2000 - 2004 , r and omized controlled trial comparing daily gentamicin cream with mupirocin as exit-site prophylaxis ; and 2005 - 2007 , gentamicin prophylaxis implemented as routine care ( 2005 ) and retraining of all patients ( 2006 ) . Infection rates and technique failure rates in each period were compared with baseline rates using incident rate ratio analysis . A total of 382 PD patients were evaluated [ median age : 50 years ( range : 18 - 90 years ) ; 54 % women ; 19 
    Output:
    
Our results tend to support previous findings that multifaceted strategies are more effective than single strategies .