#3723 Implementation of a holistic quality improvement framework is associated with lower mortality in hemodialysis patients across 6 countries

Abstract Background and Aims Quality of care for patients receiving hemodialysis has historically centred around the analysis of indicators such as small solute clearance or anemia. Whilst important, reliance on such indicators can overlook the importance of patient safety (the detection and management of adverse incidents) and the role of effective nursing care in the provision of effective hemodialysis. Quality assurance in hemodialysis should consider objective measurements of these areas and consider them as important as traditional indicators. In 2021 a novel quality framework (‘InterStellar’) was introduced across Davita International hemodialysis clinics around the world. The InterStellar framework was designed to assess quality of care provided within clinics using a basket of metrics incorporating patient safety and dialysis nursing care and not limited to traditional ‘medical’ indicators. It was hypothesised that a more holistic quality framework could have a positive impact on high level outcomes such as mortality. Methods 6 countries (Brazil, Colombia, Saudi Arabia, Malaysia, Poland and Portugal) in the Davita International network were evaluated in an observational study between January 2021 (following introduction of the InterStellar framework) and December 2024. InterStellar assessed care of in-centre hemodialysis (ICHD) patients using 35 key performance indicators (KPIs) including (but not limited to) numbers of safety incidents reported, blood stream infection rates, incidence of venous needle dislodgements and intradialytic hypotension, and results of infection control and vascular access care audits. Medical KPIs assessed included adequacy, anemia, use of central venous catheters (CVCs) and phosphorus control. Targets for each KPI were set in advance and performance against target was measured on a quarterly basis. Performance was scored on a sliding scale and aggregated to give a final InterStellar score (0–100). All-cause mortality was used as the primary outcome. Data was extracted from individual country clinical data repositories. Differences in outcomes were assessed with paired t-tests. Results Records from 38,000 ICHD patients across 276 clinics were evaluated. Total InterStellar scores increased by 17% [10%–24%] across all countries over the study period. InterStellar scores stratified by thematic area showed improvement across all countries. Patient safety indicators improved by 20.1% [2%–34%], nursing care audit indicators by 15% [8%–26%] and traditional medical outcomes by 16% [9%–30%]. Patient census also increased by 18% [4%–61%] over the same time due to organic growth of clinic operations. All-cause annualised mortality improved from 17.8% [7.2%–26%] at the beginning of the InterStellar framework to 13.6% [5.1%–19%]. Performed t-tests showed a statistically significant reduction in annualised mortality in all except one country. Conclusion Assuring high quality care across multiple countries with different population demographics, healthcare regulations and cultures of practice, can be challenging. Embedding robust clinical governance, with a focus on patient safety and good nursing care practices, is arguably as important as meeting consensus targets on hemoglobin or Kt/V. The InterStellar framework attempts to combine all of these into a holistic quality improvement system within the in-centre hemodialysis setting. Four years after implementation, InterStellar has been associated with a reduction in all-cause mortality. Further research is required to better characterise confounding and bias as well as identify which specific components within the framework may have contributed to the overall effect observed.