Sit down rounds improve outcomes for kidney dialysis patients

"Sit-down" medical rounds, during which a health care team meets to review a patient's medical record and discuss short- and long-term needs, are associated with better outcomes for kidney dialysis patients, a Johns Hopkins-directed study has found.

Patients treated at clinics that conducted sit-down rounds at least once a month were more likely to have healthy levels of the blood proteins albumin and hemoglobin than those seen at clinics that performed only walking rounds, in which a nephrologist typically assessed more immediate needs of patients as they received dialysis.

They also were 32 percent less likely to be admitted to the hospital, and 29 percent less likely to die.

These results are published in the December issue of the Journal of the American Society of Nephrology and available online Nov. 19.

Sit-down rounds provide an opportunity for the patient care team to thoroughly assess progress, address problems and tailor strategies, says Neil R. Powe, M.D., M.P.H., M.B.A., senior author of the study and director of Hopkins' Welch Center for Prevention, Epidemiology and Clinical Research. They are meant to complement a nephrologist's "walk-rounds" from patient to patient. The latter are brief and often focus on urgent issues, he says.

"Our results provide evidence that time spent meeting to discuss each patient's progress is as important as direct patient care in chronic disease management, in that this rounding practice is associated with better outcomes," Powe says. "Previous studies have shown that sit-down rounds also make sense for acute-care settings, like intensive care units. In addition, sit-down rounds may be warranted for patients with multiple chronic illnesses - a growing concern among the aging baby boomer population."

Powe and colleagues recruited and collected data on 644 dialysis patients being treated at 75 dialysis clinics in 17 states. The patients all had participated in a national kidney disease study called CHOICE (Choices for Healthy Outcomes in Caring for End-stage Renal Disease). As part of a small study within CHOICE on dialysis clinic process measures and quality of care, called the EQUAL (ESRD Quality) Study, the researchers surveyed medical directors or head nurses at the clinics on how they did medical rounds.

Thirty-five clinics (47 percent) reported no sit-down rounds, while 31 (41 percent) conducted sit-down rounds monthly. The remaining facilities conducted sit-down rounds more than once a month (6 percent) or less than once a month (5 percent).

Researchers then compared the outcomes of 357 patients being treated at the 39 clinics conducting sit-down rounds less than monthly or not at all, versus 287 patients being treated at the 36 clinics conducting sit-down rounds at least once a month.

Overall, 84 percent of patients had healthy levels of albumin and 60 percent had healthy levels of hemoglobin six months after enrolling in the CHOICE study, but patients treated at clinics with regular sit-down rounds had significantly greater odds of achieving these targets. They also had significantly lower hospitalization and mortality rates than patients treated at clinics that did not conduct regular sit-down rounds.

The study also found that significantly higher proportions of patients treated at clinics with more frequent sit-down rounds were white, married or high school graduates. In addition, there was evidence that larger clinics were more likely to have less frequent or no rounds.

Frequency of walk-rounds by a nephrologist did not differ by the frequency of sit-down rounds.

"Sit-down rounds do require dedicated time when team members can meet," Powe acknowledges. "In busy dialysis units that are short-staffed or under financial constraints, this may be difficult.

Such rounds must then be scheduled outside regular shifts, or when there is a low volume of patients."

The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases, the Agency for Health Care Research and Quality, and the National Heart, Lung and Blood Institute. Co-authors were Laura C. Plantinga, Nancy E. Fink, Bernard. G. Jaar, Josef Coresh and Michael J. Klag of Hopkins; John H. Sadler of the Independent Dialysis Foundation; and Andrew S. Levey of Tufts-New England Medical Center in Boston.

Plantinga, Laura et al, "Frequency of Sit-down Patient Care Rounds, Attainment of Clinical Performance Targets, Hospitalization, and Mortality in Hemodialysis Patients," Journal of the American Society of Nephrology, December 2004, Vol. 15.

Johns Hopkins' Welch Center for Prevention, Epidemiology and Clinical Research || American Society of Nephrology