1999 Annual Statistical Report
D. 1999 Quality Improvement Activities
1.The Clinical Performance Measures Project
In March 1999 the Clinical Performance Measures (CPM) Project evolved from the Core Indicators Project. The CPM Project is similar to the Core Indicators Project with the addition of measures for assessing vascular access. This project has a consistent clinical database to assess patient outcomes and support improvement activities at Networks 9/10 and facilities. The elements of the database represent clinical measures indicating key components of ESRD patient care. In 1999, all dialysis facilities participated in the Network-wide improvement project. The goals of the project are to:
(1) increase the knowledge and awareness of the CPM Project to Networks 9/10 ESRD providers,
(2) analyze the applicability of the CPMs on facility and network levels,
(3) implement improvement intervention programs on a Network-wide level, and,
(4) improve patient outcomes.
The Renal Network established a process to collect, analyze, and provide data feedback reports to facilities. In the Network–wide CPM project, facilities collected data on 100% of prevalent patients and electronically submitted this to the Network for analysis. There were three hemodialysis (HD) collections: April, July and fourth quarter 1999. Peritoneal dialysis (PD) data was collected in a six-month time frame, November 1998 through April 1999 (N98-A99) and September-December 1999 (S-D99). The data were analyzed and feedback reports were distributed after each collection. The patient demographics and facility participation rates by state and Networks 9/10 are described in Tables D.1 and D.2.
Comparison of HD Outcomes from 4th Quarter 1998 to 4th Quarter 1999
% patients with average URR ³ 65% increased from 76% to 79%
Average URR increased from 69.3% to 69.8%
% patients with average Kt/V Daugirdis II ³ 1.2 increased from 81% to 84%
Average Kt/V Daugirdis II increased from 1.47 to 1.49
Average hemoglobin increased from 11.0 to 11.4 gm/dL
% patients with average hemoglobin ³ 11 gm/dL increased from 58% to 68%
% patients with average hemoglobin between 11-12 gm/dL increased from 51% to 56%
% patients with average hematocrit between 33-36 vol% decreased from 35% to 32%
Average hematocrit increased from 33.9 to 35 vol%
% of patients with average albumin ³ 3.5 gm/dL decreased from 81% to 79%
Average albumin decreased from 3.77 to 3.75 gm/dL
Comparison of PD Outcomes from N97-A98 to N98-A99
% patients with measurement of weekly Creatinine Clearance(CrCl) remained unchanged at 75%
% patients with measurement of weekly Kt/V remained unchanged at 76%
% patients met weekly Kt/V target by modality increased from 62% to 70%
% patient met weekly CrCl target by modality increased from 59% to 64%
% patients with average hematocrit between 33-36 vol% remained unchanged at 32%
Average hematocrit increased from 33.9 to 34.5 vol%
% patients with albumin ³ 3.5 gm/dL increased from 58% to 59%
Average albumin increased from 3.52 to 3.54 gm/dL
Comparison of PD Outcomes from Nov98-Aug99 to Sept 99 – Dec99
% patients with measurement of weekly Creatinine Clearance(CrCl) decreased from 75% to 65%
% patients with measurement of weekly Kt/V increased from 76% to 81%
% patients met weekly Kt/V target by modality increased from 70% to 73%
% patient met weekly CrCl target by modality increased from 64% to 66%
Average hemoglobin increased from 11.42 to 11.67 gm/dL
% patients with average hemoglobin ³ 11 gm/dL increased from 65% to 68%
% patients with average hemoglobin between 11-12 gm/dL decreased from 52% to 48%
% patients with average hematocrit between 33-36 vol% decreased from 32% to 27%
Average hematocrit increased from 34.5 to 35.3 vol%
% patients with albumin ³ 3.5 gm/dL increased from 59% to 60%
Average albumin increased from 3.54 to 3.55 gm/dL
| Table D.1. 1999 April, July & 4th Quarter Hemodialysis (HD) Patient Demographics & Facility Participation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| *% represents less than one percent. Subgroup total may not add to 100% due to rounding or missing data elements. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| *% represents less
than one percent. ^ U.S. data from HCFA National Core
Indicator Project. Subgroup total may not add to 100% due to rounding or missing data elements. |
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2. CPM Results.
Three clinical areas are addressed in the HD CPM project. The treatment of anemia includes the first monthly pre-dialysis hemoglobin (HGB), hematocrit (HCT), transferrin saturation (TSAT), serum ferritin concentration and weekly Epogen (Epo) dosage. Adequacy of dialysis contains the first monthly-paired pre/post serum urea nitrogen for a urea reduction ratio (URR) and a calculation of Kt/V using the Daugirdis II methodology. The nutritional status is measured by the serum albumin; bromocresol purple (BCP) assay measurements are adjusted by +0.3 for comparison to the bromocresol green (BCG) measurements.
2.a.Treatment of Anemia - Hemodialysis. Figure D.1. shows the percent of patients with average pre-dialysis HGB ³ 11 gm/dL. Networks 9/10 rates had a statistical increase of 10% between the 4th quarter 1998 and 4th quarter 1999 with state rates ranging from 8%-11%. Figure D.2. and Table D.3 show the distribution of HGB values for the states, Networks 9/10 and the United States. The average HCT increased from 33.9 in the 4th quarter 1998 to 35.0 in the 4th quarter 1999. Figure D.3. shows the percent of patients with HCT ³ 31 vol% by state and Networks 9/10. There have been statistical increases each year. Table D.4. shows the distribution of HCT values for states and Networks 9/10. Table D.5. compares average and standard deviation values by state for HGB, HCT, TSAT, Ferritin and Epo dose. The more frequent route of Epogenä administration was reported as intravenous at 75%. This was an increase of 1% from 4th quarter 1998. The average Epogenä dose decreased from 241 units/kilogram/week to 240 units/kilogram/week in 1998. Of the patients who were prescribed iron, 75% were prescribed intravenous iron in the 4th quarter of 1999. Between the 4th quarters of 1997 and 1999, the average TSAT decreased 1% from 29% to 28.0% and the average ferritin increased from 469 ng/mL to 514 ng/mL. Figures D.4. & D.5.compare TSAT and ferritin between states and Networks 9/10 for the 4th quarters of 1998 and 1999. Table D.6. shows the percent of patients with paired TSAT <20% and Ferritin <100 ng/mL from 4th quarter 1997-1999. |
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| Table D.3. Distribution of HD HGB values (gm/dL) by State. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Table D.4. Distribution of HD HCT values (vol%) by States & Networks 9/10. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Table D.5. HD Anemia Management Measures by State and Networks 9/10. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Table D.6. Anemia Management Measures for Percent of Patients in 4th Quarter 1997-1999 with Paired TSAT <20% & Ferritin < 100 ng/mL by State and Networks 9/10 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 2.b.Treatment of Anemia – Peritoneal
Dialysis. Anemia management measures show improvement
in each of the reporting cycles. Figure D.6. shows the percent of patients with average HGB ³ 11 gm/dL for the states and Networks 9/10. Figure D.7. shows the distribution of PD HGB values for Networks 9/10 and the U.S. Table D.7. shows the distribution of HGB values for the states. The distribution is shifting to the right, indicating improvements. Table D.8. shows the distribution of HCT values for the past 4 reporting cycles. The distributions are shifting to the right, indicating improvements. Table D.9. reports averages and standard deviations of the HGB, HCT, TSAT, Ferritin and EPO dose measurements. Figures D.8. and D.9. compare the TSAT and Ferritin values by state and Network 9/10 for the periods N98-A99 and S-D99. Table D.10. shows state comparisons for paired TSAT <20 % and Ferritin <100 ng/mL measures, the Networks 9/10 rate is10%. Iron prescriptions were reported for 2986 patients in N98-A99 and 2118 patients in S-D99, 5% of these patients were reported having an IV iron prescription. |
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| Table D.7. Distribution of PD HGB values (gm/dL) by State. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Table D.8. Distribution of PD HCT values (vol%) by State | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Table D.9. PD Anemia Management Measures by State & Networks 9/10. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Table D.10. Percent of Patient
Measurements in November 1997 – April 1998 with Paired TSAT <20% & Ferritin < 100 ng/mL by State & Networks 9/10. |
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| 2.c. Adequacy of
Hemodialysis. Figure D.10. shows the percent
of patients with an average URR of 65% or greater by
state, Networks 9/10, and by year. There was a 3%
increase from 4Q98 to 4Q99. Figure D.11. shows the percent of patients with an average Kt/V Daugirdis II of 1.2 or greater. There was a 2% increase from one year ago in the Networks 9/10 rate. The 4th quarter 1999 average URR was 69.8% with a standard deviation of 7.6 and the average Kt/V Daugirdis II was 1.49 with a standard deviation of 0.37. The average HD treatment time increased one minute, from 217 to 218. Table D.11. shows URR, Kt/V Daugirdis II and treatment time averages and standard deviations by state and Networks 9/10. Figures D.12. and D.13. show the distribution of URR and Kt/V Daugirdis II values for 4th quarter 1996- 1999. The curves shift to the right, which indicates adequacy outcome improvements over time. |
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| Table D.11. HD Adequacy Performance Measures by State & Networks 9/10. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 2.d. Adequacy of Peritoneal Dialysis. Two collections of PD Clinical Performance Measures were collected in 1999, November 1998 – April 1999 (N98-A99) and September – December 1999 (S-D99). PD adequacy measures were the weekly creatinine clearance (CrCl) and weekly Kt/V. Facilities reported patient measurements in the collection time frames. Measuring CrCl adequacy decreased from 75% to 65% and measuring Kt/V increased from 76% to 81% between the two collections. Figures D.14. and D.15. show the percent of PD patients in Networks 9/10 measured and meeting weekly CrCl and Kt/V DOQIä guidelines for three most current reporting cycles. Approximately 40% of the PD population were either not measured or did not meet DOQIä guidelines. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| In the 1999 HCFA Annual Report, ESRD Clinical
Performance Measures Project, approximately 85%
of PD patients in the October 1998-March 1999 national
sample had an adequacy measurement. The Networks 9/10
Kt/V measurement rate of 81% is below the national rate
for measuring PD patients for adequacy. Improvement areas
continue to be in the areas of measuring and adequacy. Table D.12. shows average CrCl and Kt/V reported by facilities are increasing. |
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| Table D.12. PD Average (avg) and Standard
Deviation (sd) Values for Adequacy Measures by State & Networks 9/10. |
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| Figures D.16., D.17., D.18., and D.19. show the percent of CAPD and CCPD patients by state and Networks 9/10 meeting DOQI™ guidelines for adequacy. The trends show improvements. The 95% confidence intervals indicate no difference in the same reporting period, but do indicate differences between different collection time frames. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 2.e. Nutritional Status.
The serum albumin was measured as a nutritional outcome.
80% of the HD patients had an albumin measured with a
bromocresol green (BCG) assay, 4% bromocresol purple
(BCP) and 16% were reported with no designated assay. 80%
of the PD patients had an albumin measured with a BCG
assay, 18% with a BCP assay and 2% were reported with no
designated assay. An adjustment of +0.3 was made to serum
albumin measured using the BCP assay for comparisons. Hemodialysis - Albumin. Table D.13. outlines the average and standard deviation values by state, Networks 9/10.The average albumin in the 4th quarter 1999 was 3.75 gm/dL, a slight decrease from 3.77 gm/dL in the 4th quarter 1998. The percent of patients with an average albumin ³ 3.5 gm/dL decreased 2%,(81% to 79%) between the two time periods. 33% of the patients had an average albumin ³ 4.0 gm/dL. |
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Table D.13. HD Average (avg)
and Standard Deviation (sd) Values for Albumin by State
& Networks 9&10.
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| Table D.14. shows the distribution of average albumin by state and Networks 9/10 from 4th quarter 1996-1999. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Table D.14. Distribution of Average Albumin Values (gm/dl) by State & Networks 9/10. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| *The percent of patients with average albumins ³ 4.0 gm/dL are noted in parentheses for 4Q99 only. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Figure D.20. compares the percent patients with average albumin ³ 3.5 gm/dL by state, Networks 9/10 from 4th quarter 1996-1999. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Peritoneal Dialysis -
Albumin. The Networks 9/10 average albumin for the
November 1998- April 1999 and September –December
1999 reporting cycles were 3.54 gm/dL and 3.55 gm/dL,
respectively, Table D.15. In these two reporting cycles,
the percent of patients in Networks 9/10 with an average
albumin ³ 3.5 gm/dl was 59% and 60%. Table D.16. shows the distribution of average albumin values by state and Networks 9/10. The data shows statistical changes over time and variation between states. |
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| Table D.15. PD Average (avg) and Standard Deviation (sd) Values for Albumin by State & Networks9/10 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Table D.16. Distribution of Average Albumin Values by State & Networks 9&10 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| *The percent of
patients with average albumin ³ 4.0 gm/dL are noted in parentheses
for N98-A99 and S-D99 only. |
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| Figure D.21. compares the percentage of patients with an average albumin ³ 3.5 gm/dl by state and Networks 9/10 for the 4 most current reporting cycles. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||