***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: Death rates of end-stage renal disease ( ESRD ) patients treated with hemodialysis vary substantially among treatment centers . The association between facility-to-facility differences in delivered hemodialysis dose and facility-specific mortality rates was examined among 5817 r and omly selected patients treated with hemodialysis on October 1 , 1994 , from all 213 hemodialysis treatment centers reporting to ESRD Network 6 . The mean urea reduction ratio ( URR ) for each treatment center , a measure of hemodialysis adequacy , was calculated for each facility , using measurements made by center staff members during one treatment for each of the r and omly selected patients . During 7 mo of follow-up ( ending April 30 , 1995 ) , 441 ( 7.6 % ) patients died . The average URR among the treatment centers was 64.9 % . There was a strong , inverse association between increasing treatment center URR and adjusted mortality count ( P = 0.009 ) . Other treatment center characteristics associated with increased mortality included free-st and ing status ( P = 0.009 ) and decreasing frequency of reported physician supervision of care ( P = 0.01 ) . It was concluded that lower average levels of dialysis adequacy in treatment centers are associated with higher rates of death , and this association persists after controlling for facility-to-facility differences in patient and nonpatient characteristics CONTEXT Mortality rates among US hemodialysis patients are the highest in the industrialized world at 23 % per year . Measures of dialysis dose ( Kt/V ) correspond strongly with survival and are inadequate in one sixth of patients . Inadequate dialysis is also associated with increased hospitalizations and high inpatient costs . Our previous work identified 3 barriers to adequate hemodialysis : dialysis underprescription , catheter use , and shortened treatment time . OBJECTIVE To determine the effect of a tailored intervention on adequacy of hemodialysis . DESIGN AND SETTING Community-based r and omized controlled trial with recruitment from April 1999 to June 2000 at 29 hemodialysis facilities in northeast Ohio . PARTICIPANTS Forty-four nephrologists and their 169 r and omly selected adult patients receiving inadequate hemodialysis . INTERVENTION Nephrologists were r and omly assigned to an intervention ( n = 21 ) or control ( n = 23 ) group . For patients in the intervention group ( n = 85 ) , depending on the barrier(s ) present , a study coordinator gave nephrologists recommendations about optimizing dialysis prescriptions , expedited conversion of catheters to surgically created grafts or fistulas , and educated patients about the importance of compliance with treatment time . Patients in the control group ( n = 84 ) continued to receive usual care . MAIN OUTCOME MEASURES Changes in Kt/V and specific barriers after 6 months . RESULTS At baseline , intervention and control patients had similar Kt/V measurements , specific barriers , and demographic and medical characteristics . After 6 months , intervention patients had 2-fold larger increases in Kt/V compared with control patients ( + 0.20 vs + 0.10 ; P<.001 ) and were more likely to achieve their facility Kt/V goal ( 62 % vs 42 % ; P = .01 ) . Intervention patients also had nearly 3-fold larger increases in dialysis prescription ( + 0.16 vs + 0.06 ; P<.001 ) and were 4 times more likely to change from use of catheters to use of fistulas/grafts ( 28 % vs 7 % ; P = .04 ) . CONCLUSIONS An intervention tailored to patient-specific barriers result ed in increased hemodialysis dose . Extending this approach to the 33 000 persons in the United States receiving inadequate hemodialysis may substantially enhance patient survival , diminish hospitalizations , and decrease inpatient expenditures Background Clinical performance targets are intended to improve patient outcomes in chronic disease through quality improvement , but evidence of an association between multiple target attainment and patient outcomes in routine clinical practice is often lacking . Methods In a national prospect i ve cohort study ( ESRD Quality , or EQUAL ) , we examined whether attainment of multiple targets in 668 incident hemodialysis patients from 74 U.S. not-for-profit dialysis clinics was associated with better outcomes . We measured whether the following accepted clinical performance targets were met at 6 months after study enrollment : albumin ( ≥4.0 g/dl ) , hemoglobin ( ≥11 g/dl ) , calcium-phosphate product ( < 55 mg2/dl2 ) , dialysis dose ( Kt/V≥1.2 ) , and vascular access type ( fistula ) . Outcomes included mortality , hospital admissions , hospital days , and hospital costs . Results Attainment of each of the five targets was associated individually with better outcomes ; e.g. , patients who attained the albumin target had decreased mortality [ relative hazard ( RH ) = 0.55 , 95 % confidence interval ( CI ) , 0.41–0.75 ] , hospital admissions [ incidence rate ratio ( IRR ) = 0.67 , 95 % CI , 0.62–0.73 ] , hospital days ( IRR = 0.61 , 95 % CI , 0.58–0.63 ) , and hospital costs ( average annual cost reduction = $ 3,282 , P = 0.002 ) , relative to those who did not . Increasing numbers of targets attained were also associated , in a grade d fashion , with decreased mortality ( P = 0.030 ) , fewer hospital admissions and days ( P < 0.001 for both ) , and lower costs ( P = 0.029 ) ; these trends remained statistically significant for all outcomes after adjustment ( P < 0.001 ) , except cost , which was marginally significant ( P = 0.052 ) . Conclusion Attainment of more clinical performance targets , regardless of which targets , was strongly associated with decreased mortality , hospital admissions , and re source use in hemodialysis patients Data from the Dialysis Outcomes and Practice Patterns Study ( DOPPS ) allow estimation of the percentage of patients outside published hemodialysis guidelines and their associated mortality risk . We estimated the number of life years that could be gained from adherence to four of these guidelines and two other modifiable practice s , i.e. dialysis dose , phosphate control , improved anemia , partial correction of serum albumin , reduced interdialytic weight gain and less use of catheters for vascular access . We extrapolated DOPPS data on these practice s and guidelines to the US hemodialysis population for a 5-year projected period . Of the practice s we examined , the highest relative risk of mortality was associated with having albumin < 3.5 g/dl ( relative risk = 1.38 , p < 0.0001 ) ; 20.5 % of the patients in the study fell outside the target range . The adjusted sum of the patient years attributable to all six practice patterns was 143,617 ; a more conservative estimate , modeling life years potentially gained by bringing half of all patients outside targets within them , is 69,367 . The magnitude of potential savings in life years should encourage greater adherence to guidelines and practice s that are significantly associated with better survival This study set out to determine whether there is a center effect on anemia management in hemodialysis patients . The US Renal Data System and Medicare st and ard analysis files were analyzed . Between-center variation and within-facility correlations in hematocrit values were examined in two separate data sets ( years 2000 and 2001 ) and compared with simulated sample s that were composed of r and om values that assumed no center effect . Mixed-effect models were used to adjust for multiple factors and quantify the within-facility correlation in hematocrit values . Expected hematocrit values were compared in patients who underwent dialysis at poor and superior performing facilities with fixed characteristics including epoetin alpha dosing . There was a wider center variation in hematocrit for the actual versus simulated data and a coefficient of variation of 4.1 % for the former versus 1.7 % for the latter , in both years . The within-facility correlation for hematocrit was 0.053 ( 95 % confidence interval 0.050 to 0.056 ; P < 0.001 ) in 2000 with similar values in 2001 but no within-facility correlation in the simulated data . The impact of these findings was demonstrated with a difference in expected hematocrit for a patient who was treated with fixed-dosage epoetin alpha in the poorest versus best performing units ( mean difference in expected hematocrit 3.06 ; 95 % confidence interval 3.03 to 3.09 ; P < 0.001 ) . Key attributes of a center effect on anemia management in hemodialysis have been identified . The presence of a center effect suggests that there are facility-specific processes that influence performance in dialysis anemia management and are independent of commonly titrated inputs , such as dosing of erythropoietic agents 
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In contrast , there was wide disagreement about the importance of facility-based health maintenance practice s , optimal staffing ratios , frequency of dialysis-based physician visits , and optimal frequency of multidisciplinary care .