1999 Annual Statistical Report


E. Network Special Projects/Studies.

Quality Improvement Projects.

The development of Quality Improvement Projects (QIP) is mandated in the Networks 9/10 contract with HCFA. The QIPs are developed and directed by the Medical Review Board (MRB).

1.a. Peritoneal Adequacy of Dialysis Prescription QIP. The core indicator data from November 1996-April 1997 indicated that 33% of the PD patients were not measured for adequacy. Only 45% of the PD patients with reported measurements met DOQI™ recommendations for adequacy. The MRB targeted PD adequacy with increased focus on prescription for improvement.

Improvement was observed in the PD core indicator data for measurement and adequacy outcomes (Table E.1). At the end of the second year 80% of the PD patients were measured for Kt/V and 75% were measured for CrCl, an increase of 13% and 8% respectively. Improvements in percent meeting DOQI were also attained. Percentages went from 54% meeting DOQI Kt/V to 70% (+16%) and 52% meeting DOQI CrCl to 63% (+11%).

Table E.1. Number and Percent of Patients Measured for PD Adequacy and the Percent of Patients Meeting DOQI™





% Measured


% Met DOQI CrCl

% Met DOQI Kt/V








Year 1







Year 2








Two sets of data were collected between November 1997 and April 1998: the core indicator data and the Adequacy of Dialysis Prescription data. The Adequacy of Dialysis Prescription data included 3776 prevalent PD patients from 199 facilities as of 1/1/98. Facility PD nurses completed individual patient forms and a facility survey. The facility survey addressed adequacy measurement policies and procedures.

Key findings from the prescription data and facility survey data showed a positive correlation between measurement frequency and outcomes. This data showed no correlation between facility adequacy policy or procedure and outcomes.

After review of the project’s data, i.e. core indicator, the national CPM data, and the PD QIP, the MRB approved revisions to the collection forms and reporting cycles. The reporting cycles changed from three times in six months (two-month cycles) to three times in one year (four-month cycle). These changes are consistent with Networks 9/10 data findings and the DOQI recommendations for adequacy measurements of every 4 months.

This quality improvement project will conclude in June 2000. Networks 9/10 will continue to monitor PD adequacy indicators and report to facilities through feedback reports generated by CPM data collections.

1.b. Hemodialysis Central Venous Catheter QIP. The central venous catheter rate in Networks 9/10 has been one of the highest in the nation according to the Centers for Disease Control & Prevention data, 1995-97. The MRB identified this process of care as an opportunity for improvement. The goal of the QIP is to lower the catheter rate in Networks 9/10. The main interventions are (1) facility data feedback reports that adjust for the patient demographics and (2) educational resources.

Baseline data was collected in December of 1997. Patient vascular access data, i.e., access type, catheter type, location and reason for catheter, were entered for each facility prevalent patient sample. These data established baseline rates for all HD accesses for Networks 9/10, state, health service area and facility.

The type of vascular access in Networks 9/10 has changed from the baseline year. Catheters and fistulas have increased 3% from baseline rates for patients >90 days ESRD. Figure E.1. shows these changes.

Information on reasons for catheter placement was collected in this project in order to define care process areas that could be targeted for improvement. There are five categories:

(1) no vascular sites,

(2) no fistula/graft created,

(3) temporary interruption,

(4) fistula/graft maturing, and,

(5) other reasons.



Figure E.2. shows reported reasons for catheters from baseline to December 1999 for patients >90 days ESRD. The percent of patients with no fistula/graft created at >90 ESRD has increased 7% from baseline. There was a 3% increase in the number of fistula/graft maturing in patients with catheters >90 days ESRD.


The methodology to adjust for patient demographics, i.e., age, race, sex, height/weight, cause of ESRD, and number of years on dialysis, was approved by the MRB. Facility access rates were calculated. The standardized ratio methodology includes patients who had been on dialysis greater than 90 days. Facilities were included in the analysis if the number of total patients was 30 or greater.

The standardized ratios for catheters (SCR), fistula (SFR) and grafts (SGR) are analogous to the standardized mortality ratio (SMR) or the standardized hospitalization ratio (SHR). The ratio is the actual number of patients with a specific access divided by the expected number of patients with the specific access. The SCR, SFR, and SGR for a facility are compared to the Networks 9/10 ratios.

Table E.1. reports the number and percent of facilities with standardized access scores for each type of vascular access in baseline (December 1997) and first year (December 1998). Improvements were reported in the standardized vascular access facility ratios. The percent of facilities having an SCR statistically less than 1.0 decreased form 18% to 10% from baseline to first year. The percent of facilities having an SFR statistically >1.0 increased from 13% to 18% in the same time frame.

In 1999, the MRB developed a facility survey to examine facility processes of care. 30 facilities, 17 statistically high SCR and 13 statistically low SCR facilities were sent the survey. Analysis of this data will be done in 2000.

Table E.2.Number and percent of facilities with standardized access scores

statistically different than 1.0 in baseline and Year 1.

# facilities with:

Baseline December 1997

# %

First Year December 1998

# %

SCR> 1.0*

SCR < 1.0*

SCR not different from 1.0













SFR> 1.0*

SFR < 1.0*

SFR not different from 1.0













SGR> 1.0*

SGR < 1.0*

SGR not different from 1.0


















* Statistically different than 1.0

May not add to 100% due to rounding

Facility Access Reports were distributed in December. These reports compared the standardized facility catheter rate to state and Networks 9/10. These reports were distributed to facility medical directors, administrators and nurse managers.

The "Vascular Access Tool Kit" was distributed in December. It included the "Improving Outcomes: Vascular Access" bulletin, a model form for recording patient vascular accesses, a model tracking log for recording facility vascular access events, NKF DOQI Guideline 10 reference and a form for ordering the patient brochure, "Access Care: Your Lifeline."

This quality improvement project will continue through 2000. Networks 9/10 will continue to monitor vascular access indicators and report to facilities through feedback reports generated by CPM data collections.

Focused Quality Assurance Activities

The MRB developed a methodology to profile facilities for more intensive, proactive review. The Intervention Profiling System incorporates seven areas. The seven areas are:

(1) clinical performance measures outcomes,


(3.)standardized scores for mortality (SMR),

(4.)hospitalization (SHR),

(5.) catheters (SCR),

(6.) participation in Networks 9/10 activities, and,

(7.) patient data reporting.

The profiling methodology weights the criteria by importance, statistical significance, and comparison to Networks 9/10 rates. These quality indicators combine to form a comprehensive facility profile.

The Network conducted reviews of two facilities in 1999. The initial reviews were conducted in August by a seven-member team. The reason for the site visits were based on statistically low core indicator outcome data for anemia and adequacy, statistically high SMRs, and consumer grievances. The facilities were given areas where improvement was necessary. The MRB approved action plans and continued to monitor progress. A follow-up review of documentation was conducted by Networks 9/10 staff in October. The facilities were still being followed at year-end.

3. United States Renal Data Systems, USRDS

3.a. Networks 9/10 distributed unit specific reports for the USRDS in July 1999 to facility medical directors and administrators. This report included standardized mortality ratios (SMR), standardized hospitalization ratios (SHR), and standardized transplant ration (STR) for Medicare-only patients for 1995-1997.

# Facilities

Network 9: 178

Network 10: 104

3.b. The USRDS and Networks 9/10 cooperated to collect the national surveillance of dialysis associated diseases. A total of 330 forms were collected from facilities in Networks 9/10 (227 Network 9 and 106 Network 10) for a response rate of 98%.

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