Impact of quality improvement efforts on race and sex disparities in hemodialysis

Context By improving the process of care, quality improvement efforts have the potential to reduce race and sex disparities. However, little is known about whether reductions actually occur. National quality improvement activities targeting hemodialysis patients provide an opportunity to examine this issue. Objective To determine the effect of quality improvement efforts on race and sex disparities among hemodialysis patients. Design, Setting, and Subjects Longitudinal study of 58700 randomly selected hemodialysis patients from throughout the United States in 1993 through 2000. Intervention Medicare-funded quality improvement project involving monitoring of patient outcomes, feedback of performance data, and education of clinicians at dialysis centers. Main Outcome Measures Changes in hemodialysis dose (Kt/V), anemia management (hemoglobin level), and nutritional status (albumin level). Results The proportion of all patients with an adequate hemodialysis dose increased 2-fold. In 1993, 46% of white patients and 36% of black patients received an adequate hemodialysis dose compared with 2000 when the proportions were 87% and 84%, respectively. Thus, the gap between white and black patients decreased from 10% to 3% (P<.001). The gap between female and male patients decreased from 23% to 9% over the same period (P=.008). The proportion of all patients with adequate hemoglobin levels increased 3-fold. The proportion of all patients with adequate albumin levels remained unchanged. Race and sex disparities in anemia management and nutritional status did not change significantly. Conclusions Quality improvement efforts have a variable impact on race and sex disparities in health outcomes. Further work is needed to determine how quality improvement methods can be targeted to reduce health disparities.