Her father was an expert in statistics and one of the pioneers in the embryonic field of epidemiology. Florence shared his interest in statistics and made extensive use of statistical analysis in the compilation, analysis and presentation of data on medical care and public health. She was also insistent that the knowledge gained from the analyses must then be the basis for effective action. Today, after 150 years, the same motivation is the basis for evidence-based approaches in Medicine, in Public Health, in Nursing, in Nephrology and the ERA Quest initiative.

The international renal community has established many standards that we should achieve in patients under the care of nephrologists. In some countries, governments are legally mandating a requirement to achieve these standards even though practical methods to achieve the standards are poorly documented.

When the UK Renal Registry was set up to collect comparative data relating to quality of care, the consensus in the UK, as in many other countries, was that physicians were all doing the best possible for our patients and there was probably little difference between centres. The UK Renal Registry has been collecting quarterly data on dialysis and transplant patients for almost 8 years and has demonstrated that this may not be the case. The latest Report continues to show statistically significant differences in the achievement of haemoglobin, ferritin, PTH, phosphate, calcium, albumin (BCP or BCG assays), blood pressure, Urea Reduction Ratio, and bicarbonate between centres (X2 p<0.001), which are not readily explained through case-mix and local circumstances. While these differences are no doubt multifactorial the question of how to reduce them and reliably achieve outcomes in line with Clinical Practice Guidelines remains.

Since the 1970s quality control methodology in industry has produced huge improvement in the quality of manufactured goods. Do we have anything to learn from their example, in addition to the lesson that monitoring quality control takes time and carries financial cost?

In the USA. the ‘100,000 Lives’ Campaign, a nationwide initiative of the Institute for Healthcare Improvement  to significantly reduce morbidity and mortality in American health care, has been a considerable success. The campaign was the first national effort to promote saving a specified number of lives by a certain date (June 14, 2006) through engaging US hospitals in a commitment to changes that were known to improve patient care and prevent avoidable deaths.

In Nephrology, much of the data we have is observational and the negative all cause mortality results from recent interventional studies (Hemo, 4D, CARE, ALERT, DCORR ) have not been helpful in indicating the direction we should be taking. If we are achieving the current standards, increasing dialysis dose further, decreasing serum cholesterol or serum phosphate will not be the nephrology ‘100,000 lives’ equivalent. We need to first monitor the standards, to show what is being achieved, and then investigate the methodologies of centres who are doing better than average.
Other targets for the nephrology ‘100,000 lives’ would be improving vascular access (reducing lines and line sepsis) and reducing late referral. In 2005, the UKRR reported nationally on the large variation in provision of vascular access between the centres within the UK. A similar international survey under iDOPPs has highlighted similar large variations between different countries.

The UK has been a leader in the publication of our data analyses, with each centre being clearly identified. This data has also been made openly available on the web for both the patients and general public. In spite of this easy accessibility in comparing data, there has been no systematic use of the data to study the underlying differences in unit management processes or to attempt a reduction in centre variation. This year, the UK renal community has negotiated funding from the Government, to establish Quality Initiative teams to moderate discussion groups and to teach improvement methodology. A much more active quality assurance culture is in prospect, which the figure illustrates (figure1).

As a parallel development the ERA Quest initiative will extend the ERA dataset collection, through development of a European standard for transmission of data between renal IT systems. This will promote quality control activity and the comparison of data between renal units, nationally and internationally. There is  inevitably some apprehension by nephrologists around centre identification in reporting data, and the UK experience should help alleviate some of this concern. And point to ways for effective implementation of the evidence base.