Implementation of a structured quality improvement framework is associated with lower mortality in hemodialysis patients in 6 countries

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 score 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 would have a positive impact on high level outcomes such as mortality.

6 countries (Brazil, Colombia, Saudi Arabia, Malaysia, Poland and Portugal) in the Davita International network were evaluated in an observational study between 2022 (following introduction of the InterStellar framework) and December 2025. 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. Interstellar KPIs were grouped into three thematic domains: patient safety, nursing quality and medical outcomes.  Targets for each KPI were set in advance and performance against target was measured on a quarterly basis. All patients >=18 years of age with >=3 months of dialysis vintage were included. Overall approximately 45,000 patients, 910,000 reported safety events and 170,000 nursing quality audits across 313 dialysis centres were included in this analysis.

All-cause mortality was used as the primary outcome. Data was extracted from individual country clinical data repositores. T-tests were conducted for each InterStellar domain to assess percentage improvements over time. A Poisson regression analysis was performed to determine the presence of a statistically significant trend in mortality rates. Additionally, Pearson’s correlation coefficients were calculated to evaluate the relationship between average InterStellar outcomes (aggregated across the three domains) and mortality rates, measured on a quarterly basis.

In the 3-year period analysed the total patients cared for at DaVita centres in these 6 countries increased from 30,101 to 38,135 (27% increase). 83.3% of patients were on conventional HD with 10.8% on HDF and 5.9% on PD.

Countries showed a significant improvement in year-on-year results in all three thematic areas of InterStellar. Patient Safety composite score improved from 75% to 92%, (p < 0.001) , Nursing Quality score improved from 74% to 90%, (p < 0.001), and Medical Outcomes score improved from 55% to 72% (p = <=0.001). Average monthly mortality reduced from 1.36% to 1.27%. The Poisson regression showed that our time unit (years) offset by the average total patients per year, was statistically significant (p < 0.001) with a 4.7% reduction of the underlying mortality year on year. The Pearson’s correlation (R) between the average InterStellar results and quarterly mortality was -0.49 (p = 0.02)

InterStellar scores showed a statistically significant improvement over time, with balanced progress across all three InterStellar domains. Across the six participating countries, there was an overall reduction in all-cause mortality from 2022 to 2025 after controlling for average yearly patient counts. A statistically significant, moderate negative correlation was observed between mortality and mean InterStellar scores across all countries. Poisson regression analysis indicated an average 2.2% year-on-year decrease in mortality since 2022.

Ensuring consistent, high-quality care across multiple countries with distinct population demographics, healthcare regulations, and clinical cultures presents considerable challenges. Embedding robust clinical governance, emphasising patient safety and high standards of nursing practice, is arguably as critical as achieving consensus targets for hemoglobin or Kt/V. The InterStellar framework has integrated these elements into a holistic, data-driven quality improvement system for in-centre hemodialysis.

Four years after implementation, the framework has been associated with a reduction in all-cause mortality. Further research is warranted to better characterize potential confounding factors and sources of bias, and to identify which specific components of the framework may have contributed most to the observed improvements.