1. Annie-Claire Nadeau-Fredette
Examination of Centre Effects using the ANZData registry ANZSN 53rd ASM Darwin 5th September
Carmel Hawley
On behalf of
Annie-Claire Nadeau-Fredette
Htay Htay
David Johnson
Elaine Pascoe
Yeoungjee Cho
PD working group
ANZData Registry team
The AKTN operates within the UQ School of Medicine’s Centre for Kidney Disease Research (CKDR).

2. Peritoneal Dialysis centre effects’ analyses
Significant variation in PD outcomes is known to exist
Identifying centre practices associated with outcomes is important as these practices may be modifiable and be relevant to quality improvement
Aim: To determine the relative contributions of patient characteristics and dialysis centre characteristics
Hypothesis: Centre factors are an important contributor to variation in important PD outcomes

3. Methods PD outcomes of interest examined
Incidence of peritonitis: published
Technique failure : published
Outcome of peritonitis : under review
Statistical method
2 level mixed effects models with random intercept for dialysis centres
Fixed effects were patient and centre characteristics

4. Methods Study populations Australian incident PD patients
ANZData registry
(peritonitis)
(technique failure; cure of peritonitis)
51 centres: 8711 (Peritonitis); (technique failure); (cure of peritonitis)

5. Model building Model 1 Model 2 Model 3
only centre (random effect) intercept only model
obtain estimate for risk each centre & sd (sd1) relating to variation
Model 2
Model 1+ add patient characteristics (fixed effects)
obtain estimate for each centre & sd (sd2) relating to variation
% reduction in variation = (sd1-sd2)/sd1
Model 3
Model add centre characteristics (as fixed effect)
obtain estimate for each centre & sd (sd3) relating to variation
Further % reduction = (sd2-sd3)/sd2

6. Methods Patient characteristics:
Age, gender, race and diabetes + (patient level model)
Centre characteristics:
Centre size, PD %, APD exposure, icodextrin exposure, PET performance, and analysis-specific factors
1st and 4th quartile compared with combined 2nd and 3rd quartile

7. Peritonitis rates

8. Centre Variation in Peritonitis Rates
Unadjusted
Patient-adjusted
Facility-adjusted
16% patient
34% centre
Variation in incidence rate of peritonitis across 51 Australian peritoneal dialysis centers during the period of in unadjusted (green diamond), patient-level adjusted (red triangle) and patient- and center-level adjusted models (blue circle) with standard errors. Dialysis centers are ranked by incidence rate
Nadeau-Fredette et al PDI :

9. Centre characteristics : Peritonitis risk
Center-level characteristics
Variation across centers (n=51)
Center size (total patient-years of follow-up)
220 ( )
Percentage of PD (versus overall dialysis population)
20% (16%-26%)
Transplantation center (n, %)
19 (37%)
APD treatments exposure (% patients in center)
73% (49%-85%)
Icodextrin solution exposure (% patients in center)
46% (30%-56%)
Biocompatible solutions exposure (% patients in center)
2% (0%-10%)
PET performed at PD initiation (% patients in center)
54% (36%-62%)
Anti-fungal prophylaxis tis (% peritonitis in center)
64% (24%-82%)
Hospitalisation for peritonitis (% peritonitis in center)
49% (28%-62%)
Catheter removal with peritonitis (% peritonitis in center)
20% (15%-24%)
Nadeau-Fredette et al PDI :

10. Centre characteristics associated with peritonitis risk
Smaller centre size, higher % of PD, lower rates of PET performance at PD start and lower % of hospitalisation for peritonitis were assocaited with a lower peritonitis count.
In contrast a lower % of APD exposure, greater icodextrin exposure and lower or higher use of antifungal prophylaxis at time of peritonitis were associated with a higher peritonitis risk
Nadeau-Fredette et al PDI :

11. Technique Failure

12. Centre Variation in Technique Failure
7 fold variation
28% patient
53% centre
Unadjusted
Patient-adjusted
Facility-adjusted
Hazard rate
Figure 1. Variation in hazard of technique failure across 51 Australian peritoneal dialysis centers during the period of unadjusted (green diamond), patient-level adjusted (red triangle) and patient- and center-level adjusted models (blue circle) with standard errors. Dialysis centers are ranked by hazard rate of peritonitis
Average technique failure: episodes /pt-yr
Htay…Johnson Clin J Am Soc Nephrol 2017; 12:

13. Center characteristics associated with technique failure Adjusted analyses
% Patients on PD also predictive
Technique failure was significantly less in centres with higher % of PD patients and larger centres; and more likely in centres with lower proportions of patients achieving baseline serum phosphate levels in target
Htay et al ; Clin J Am Soc Nephrol 2017; 12:

14. Peritonitis Cure with antibiotics
Paper under review

15. Conclusions 1
Centre characteristics accounted for important variation in risk of peritonitis, technique failure, and cure of peritonitis with antibiotics
Whether these factors are directly related to the outcomes or relate to surrogate markers for other characteristics of units is uncertain

16. Conclusions 2 More methodological research is required
More information on centre factors that may influence important outcomes is required

17. Acknowledgements
All registry contributors: patients and health professionals
Annie Claire Nadeau-Fredette: Baxter Healthcare Clinical Evidence Council (CEC) research grant
Htay Htay : Health Manpower Development Plan fellowship award co-sponsored by MOH and Singhealth (Singapore)
BEAT CKD NHMRC program grant
ANZData registry staff
PD working group of ANZData
NHMRC fellowships: Johnson and Cho