You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Mortality in end-stage renal disease is associated with facility-to-facility differences in adequacy of hemodialysis.
Abstract 1:
Death rates of end-stage renal disease ( ESRD ) patients treated with hemodialysis vary substantially among treatment centers . The association between facility-to-facility differences in delivered hemodialysis dose and facility-specific mortality rates was examined among 5817 r and omly selected patients treated with hemodialysis on October 1 , 1994 , from all 213 hemodialysis treatment centers reporting to ESRD Network 6 . The mean urea reduction ratio ( URR ) for each treatment center , a measure of hemodialysis adequacy , was calculated for each facility , using measurements made by center staff members during one treatment for each of the r and omly selected patients . During 7 mo of follow-up ( ending April 30 , 1995 ) , 441 ( 7.6 % ) patients died . The average URR among the treatment centers was 64.9 % . There was a strong , inverse association between increasing treatment center URR and adjusted mortality count ( P = 0.009 ) . Other treatment center characteristics associated with increased mortality included free-st and ing status ( P = 0.009 ) and decreasing frequency of reported physician supervision of care ( P = 0.01 ) . It was concluded that lower average levels of dialysis adequacy in treatment centers are associated with higher rates of death , and this association persists after controlling for facility-to-facility differences in patient and nonpatient characteristics


Title 2:
Improving the quality of hemodialysis treatment: a community-based randomized controlled trial to overcome patient-specific barriers.
Abstract 2:
CONTEXT Mortality rates among US hemodialysis patients are the highest in the industrialized world at 23 % per year . Measures of dialysis dose ( Kt/V ) correspond strongly with survival and are inadequate in one sixth of patients . Inadequate dialysis is also associated with increased hospitalizations and high inpatient costs . Our previous work identified 3 barriers to adequate hemodialysis : dialysis underprescription , catheter use , and shortened treatment time . OBJECTIVE To determine the effect of a tailored intervention on adequacy of hemodialysis . DESIGN AND SETTING Community-based r and omized controlled trial with recruitment from April 1999 to June 2000 at 29 hemodialysis facilities in northeast Ohio . PARTICIPANTS Forty-four nephrologists and their 169 r and omly selected adult patients receiving inadequate hemodialysis . INTERVENTION Nephrologists were r and omly assigned to an intervention ( n = 21 ) or control ( n = 23 ) group . For patients in the intervention group ( n = 85 ) , depending on the barrier(s ) present , a study coordinator gave nephrologists recommendations about optimizing dialysis prescriptions , expedited conversion of catheters to surgically created grafts or fistulas , and educated patients about the importance of compliance with treatment time . Patients in the control group ( n = 84 ) continued to receive usual care . MAIN OUTCOME MEASURES Changes in Kt/V and specific barriers after 6 months . RESULTS At baseline , intervention and control patients had similar Kt/V measurements , specific barriers , and demographic and medical characteristics . After 6 months , intervention patients had 2-fold larger increases in Kt/V compared with control patients ( + 0.20 vs + 0.10 ; P<.001 ) and were more likely to achieve their facility Kt/V goal ( 62 % vs 42 % ; P = .01 ) . Intervention patients also had nearly 3-fold larger increases in dialysis prescription ( + 0.16 vs + 0.06 ; P<.001 ) and were 4 times more likely to change from use of catheters to use of fistulas/grafts ( 28 % vs 7 % ; P = .04 ) . CONCLUSIONS An intervention tailored to patient-specific barriers result ed in increased hemodialysis dose . Extending this approach to the 33 000 persons in the United States receiving inadequate hemodialysis may substantially enhance patient survival , diminish hospitalizations , and decrease inpatient expenditures


Title 3:
Attainment of clinical performance targets and improvement in clinical outcomes and resource use in hemodialysis care: a prospective cohort study
Abstract 3:
Background Clinical performance targets are intended to improve patient outcomes in chronic disease through quality improvement , but evidence of an association between multiple target attainment and patient outcomes in routine clinical practice is often lacking . Methods In a national prospect i ve cohort study ( ESRD Quality , or EQUAL ) , we examined whether attainment of multiple targets in 668 incident hemodialysis patients from 74 U.S. not-for-profit dialysis clinics was associated with better outcomes . We measured whether the following accepted clinical performance targets were met at 6 months after study enrollment : albumin ( ≥4.0 g/dl ) , hemoglobin ( ≥11 g/dl ) , calcium-phosphate product ( < 55 mg2/dl2 ) , dialysis dose ( Kt/V≥1.2 ) , and vascular access type ( fistula ) . Outcomes included mortality , hospital admissions , hospital days , and hospital costs . Results Attainment of each of the five targets was associated individually with better outcomes ; e.g. , patients who attained the albumin target had decreased mortality [ relative hazard ( RH ) = 0.55 , 95 % confidence interval ( CI ) , 0.41–0.75 ] , hospital admissions [ incidence rate ratio ( IRR ) = 0.67 , 95 % CI , 0.62–0.73 ] , hospital days ( IRR = 0.61 , 95 % CI , 0.58–0.63 ) , and hospital costs ( average annual cost reduction = $ 3,282 , P = 0.002 ) , relative to those who did not . Increasing numbers of targets attained were also associated , in a grade d fashion , with decreased mortality ( P = 0.030 ) , fewer hospital admissions and days ( P < 0.001 for both ) , and lower costs ( P = 0.029 ) ; these trends remained statistically significant for all outcomes after adjustment ( P < 0.001 ) , except cost , which was marginally significant ( P = 0.052 ) . Conclusion Attainment of more clinical performance targets , regardless of which targets , was strongly associated with decreased mortality , hospital admissions , and re source use in hemodialysis patients


Title 4:
DOPPS Estimates of Patient Life Years Attributable to Modifiable Hemodialysis Practices in the United States
Abstract 4:
Data from the Dialysis Outcomes and Practice Patterns Study ( DOPPS ) allow estimation of the percentage of patients outside published hemodialysis guidelines and their associated mortality risk . We estimated the number of life years that could be gained from adherence to four of these guidelines and two other modifiable practice s , i.e. dialysis dose , phosphate control , improved anemia , partial correction of serum albumin , reduced interdialytic weight gain and less use of catheters for vascular access . We extrapolated DOPPS data on these practice s and guidelines to the US hemodialysis population for a 5-year projected period . Of the practice s we examined , the highest relative risk of mortality was associated with having albumin < 3.5 g/dl ( relative risk = 1.38 , p < 0.0001 ) ; 20.5 % of the patients in the study fell outside the target range . The adjusted sum of the patient years attributable to all six practice patterns was 143,617 ; a more conservative estimate , modeling life years potentially gained by bringing half of all patients outside targets within them , is 69,367 . The magnitude of potential savings in life years should encourage greater adherence to guidelines and practice s that are significantly associated with better survival


Title 5:
Center effects in anemia management of dialysis patients.
Abstract 5:
This study set out to determine whether there is a center effect on anemia management in hemodialysis patients . The US Renal Data System and Medicare st and ard analysis files were analyzed . Between-center variation and within-facility correlations in hematocrit values were examined in two separate data sets ( years 2000 and 2001 ) and compared with simulated sample s that were composed of r and om values that assumed no center effect . Mixed-effect models were used to adjust for multiple factors and quantify the within-facility correlation in hematocrit values . Expected hematocrit values were compared in patients who underwent dialysis at poor and superior performing facilities with fixed characteristics including epoetin alpha dosing . There was a wider center variation in hematocrit for the actual versus simulated data and a coefficient of variation of 4.1 % for the former versus 1.7 % for the latter , in both years . The within-facility correlation for hematocrit was 0.053 ( 95 % confidence interval 0.050 to 0.056 ; P < 0.001 ) in 2000 with similar values in 2001 but no within-facility correlation in the simulated data . The impact of these findings was demonstrated with a difference in expected hematocrit for a patient who was treated with fixed-dosage epoetin alpha in the poorest versus best performing units ( mean difference in expected hematocrit 3.06 ; 95 % confidence interval 3.03 to 3.09 ; P < 0.001 ) . Key attributes of a center effect on anemia management in hemodialysis have been identified . The presence of a center effect suggests that there are facility-specific processes that influence performance in dialysis anemia management and are independent of commonly titrated inputs , such as dosing of erythropoietic agents
In contrast , there was wide disagreement about the importance of facility-based health maintenance practice s , optimal staffing ratios , frequency of dialysis-based physician visits , and optimal frequency of multidisciplinary care .