REFERENCES
BACKGROUND
The Renal Network, Inc. collects dialysis patient information from Medicare-approved ESRD providers when permitted to do so by The Centers of Medicare and Medicaid Services (CMS). Patient information is aggregated into various data profiles and displayed with comparisons to geographical locations, i.e. dialysis facility, health service areas (HSAs), state, network region and corporation. The Renal Network, Inc. analyzes these data profiles and targets providers for quality improvement and community outreach.
Quality improvement activities on core indicator/clinical performance measure (CPM) data are under the direction of the Medical Review Board (MRB). The MRB reviews CPM data at the second regularly scheduled meeting each year and as necessary throughout the year. The MRB identifies trends within the CPM data that is collected and develops quality improvement proposals to assist facilities in improving patient outcomes.
Since 1996, Network 9/10 has collected CPM data on all ESRD patients in the network during the fourth quarter of every year. In 1997, the MRB approved the dissemination of facility feedback reports to each dialysis facility and provided regional educational workshops targeting dialysis providers in each state. In 1998, HD CPMs began being collected during April, July, and the fourth quarter of the year and peritoneal dialysis (PD) CPMs were collected three times per year using a four-month reporting period in order to facilitate adequacy measurement and improvement. The MRB also targeted low-performing health service areas and began to provide physician-specific feedback reports to renal physicians. 1,2,3
In 2004, CMS approved a one-time fourth quarter 2003 CPM data collection for all chronic HD and PD patients.
Network 9/10 also participates in the yearly National CPM Data Collection that collects data on a sample of HD and PD patients in the US.
METHODS
1. Subjects and Facilities
Facility samples consist of all Medicare approved ESRD dialysis facilities in the Network 9/10 area. Approved data elements on all patients within these facilities will be collected.
2. Data Collection
Data collected on each patient will include:
- Pre and post BUN to calculate URR for adequacy management of HD
- Reported weekly CrCl and reported weekly Kt/V for adequacy management of PD
- Hemoglobin for anemia management
- Serum Albumin for nutrition management
- Monthly facility incident and prevalent access rates for vascular access management
3. Non-LDO data submission
The data for fourth quarter 2004 will be collected from Non-LDO facilities by utilizing an Excel spreadsheet data collection tool to be developed by CMS. Facilities will be able to submit information to the network via data disc or paper reporting method. The vascular access management data is being collected monthly and faxed to the network for entry into the CMS database. Vascular access data is reported monthly to networks through CMS.
4. LDO data submission
The data for fourth quarter 2004 will be collected from LDO facilities by CMS for data download directly from the LDO corporate offices. LDO facility data will then be distributed to networks from CMS. The vascular access management data is being submitted directly to CMS from the LDO corporate offices for data download into the CMS database. Vascular access data is reported monthly to networks through CMS.
5. Statistical Analysis
Analysis is done comparing states to Network 9/10 and the top performing network as identified through the national CPM project each year. Ninety-five percent confidence intervals are calculated for each State and the State�s upper confidence interval value is compared to the Network rate. The data are also displayed to demonstrate trends over time in each area.
The MRB reviews each core indicator and CPM to identify opportunities for improvement within the Network, states and dialysis facilities. The analysis of this information:
- Justifies the need for quality improvement projects and other quality assurance activities
- Supports the creation of educational material
- Supports the application of the Intervention Profiling System
REPORTING
The MRB designed and approved feedback reports displaying facility data to be distributed to dialysis facility medical directors, administrators, and nurse managers. These reports will be continued with CMS approval until the National Core Data Set has been fully developed and a time frame for collection and reporting is approved.
The reports display outcomes by facility, HSAs, states, and network in the following areas:
- URR
- PD Adequacy Measures
- Hemoglobin
- Albumin
- Vascular Access Rates
With the 2003 fourth quarter data collection we provided reports that compared same type dialysis environments to their counterparts in the network region, i.e. LDO, Hospital, Independent. We also reported incident patient information using the data that is available to us. Aggregate information was placed on the Network 9/10 Web site. These reports will continue with the 2004 fourth quarter CPM data collection with CMS approval.
Also in 2003, the MRB identified those facilities that were two standard deviations below the mean compared to Network 9/10 as a whole in either anemia management, adequacy of dialysis, or AV fistula rates. These facilities were sent a collection of resources designed to assist them in improving outcomes in their specific areas of need. The MRB also encouraged these facilities to investigate these areas during quality improvement meetings and/or initiatives and make assessments for opportunities of improvement. Network 9/10 also offered technical support in tailoring the resources to the facilities� specific requests. The resource materials have been placed on the Web site so that all facilities within Network 9/10 can utilize this information for quality improvement.
Vascular access management reports that have been developed by CMS are being sent to facility medical directors and nurse managers on a quarterly basis. Those nephrology professionals are being asked to review the data, incorporate the information into their quality improvement programs and consider requesting technical assistance from the network where needed. The network is also reviewing this data regularly to identify facilities and HSAs in need of educational assistance and to identify those facilities with good outcomes that can assist in mentoring through educational offerings and sharing of policies, protocols, and programs.
With a 2004 CPM data collection, Network 9/10 will continue to provide educational materials to those facilities that have a significant variance from the top performing dialysis facilities in the network. We will also provide reports to facilities as allowed by CMS.
As stated earlier, Network 9/10 also participates in the yearly National CPM Data Collection. The National CPM sample is analyzed by CMS and distributed to networks in or around December of every year. This information is placed on the Network 9/10 Web site, www.therenalnetwork.org, and featured in the network�s professional newsletter. The ESRD Clinical Performance Measures Project Annual Report that displays and discusses this CPM data is also sent to every facility medical director and nurse manager within the Network in the spring of each year.
GOALS
1. Anemia Management
a. Hemodialysis �
- ≥ 85% of hemodialysis patient population achieve Hemoglobin ≥ 11 gm/dL
b. Peritoneal Dialysis �
- All patients measured every month of PD clinic visit
- ≥85% of patient population achieve Hemoglobin ≥ 11 gm/dL
2. Adequacy of Dialysis
a. Hemodialysis �
- All patients measured for adequacy every month
- ≥ 95% of patient population achieve URR ≥ 65%
- ≥ 95% of patient population achieve Kt/V Daugirdas II ≥ 1.2
b. Peritoneal Dialysis �
- All patients measured for adequacy every 4 months
- CAPD ≥ 85% of patient population achieve weekly Creatinine Clearance ≥ 60 L/bsa or weekly Kt/V ≥ 2.0
- CCPD ≥ 85% of patient population achieve weekly Creatinine Clearance ≥ 63 L/bsa or weekly Kt/V ≥ 2.1
c. Nutrition � a stabilized serum albumin equal to or greater than the lower limit of the normal range (approximately 3.5 g/dl for the bromcresol green method) is the outcome goal.
d. Vascular Access �
- ≥ 40% prevalent fistula use
- ≤ 10% catheter use
REFERENCES
- 1997 Annual Statistical Report for End-Stage Renal Disease Networks 9&10, The Renal Network, Inc., Indianapolis, IN., 1998.
- 1998 Annual Statistical Report for End-Stage Renal Disease Networks 9&10, The Renal Network, Inc., Indianapolis, IN., 1999.
- 1999 Annual Statistical Report for End-Stage Renal Disease Networks 9&10, The Renal Network, Inc., Indianapolis, IN., 2000.
- 2003 Annual Statistical Report for End-Stage Renal Disease Networks 9&10, The Renal Network, Inc., Indianapolis, IN., 2004.
MRB Approved - 11/2000
BOT Approved � 1/2001
Revised � 1/2005
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