Minimum staffing ratios fail to improve dialysis outcomes

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A new study published in Hemodialysis International has found that minimum staffing regulations for haemodialysis facilities may not be associated with improved patient outcomes. Led by Allan Jacob (Physicians Dialysis, Miami, USA) and featuring corresponding author Edward Timmons (West Virginia University, Morgantown, USA), the authors have called for research on such regulations at the facility level.  

Jacob and colleagues set out some context for their research by noting that eight US states, as well as Washington, DC, have mandated regulations on staffing numbers in an attempt to improve dialysis treatment. For their study, they used data from the US Renal Data System to analyse the effects of a mandated minimum ratio between treatment staff and dialysis patients. They employed a synthetic difference in differences method of estimation to compare death and hospitalisations for patients with end-stage renal disease (ESRD) in centres with and without mandates. 

“We were unable to find evidence that mandated dialysis staffing ratios are associated with a reduction in mortality or hospitalisations,” Jacob et al aver. They add that they estimate “a slight reduction in deaths per 1,000 patient hours” as well as a “slight increase in hospitalisations” in response to their results, but that neither of these were found to be statistically significant effects. 

The results echo the suggestions of previous analyses of data on minimum staffing ratios. In an editorial published in the Clinical Journal of the American Society of Nephrology (CJASN) in 2018, Anjay Rastogi (University of California Los Angeles, Los Angeles, USA) and Glenn M Chertow (Stanford University School of Medicine, Palo Alto, USA) made the case that “publicly available data from Dialysis Facility Compare and the ESKD Quality Incentive Program” demonstrated that “outcomes, including survival, rates of hospitalisation and infection, and patient satisfaction are not superior in states where mandated staffing ratios are in effect”. 

Conversely, the Identifying Best Practices in Dialysis (IBPiD) study led by Brennan M R Spiegel (VA Greater Los Angeles Health System, Los Angeles, USA), the results of which were published in the American Journal of Kidney Disease (AJKD) in 2010, suggested access to additional staffing was associated with improved outcomes when facilities were compared by haemoglobin outcomes. 

Jacob and colleagues state that their own findings “highlight the need for future work” to clarify the situation on staff mandates. They add that an analysis that examines results at the “facility level”, rather than more broadly, may elucidate their capacity to improve outcomes. 

Speaking exclusively to Renal Interventions, Timmons said: “Our work provides evidence that minimum staffing ratios in haemodialysis clinics may not be serving their intended purpose of improving quality. Policy makers may wish to reconsider these mandates since they impose additional cost on dialysis facilities.”

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