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The State Of E In Sexas

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ESRD Network of Texas, Inc. Annual Educational Collaborative for ESRD professionals.



Presentations from the 2009 Annual Meeting

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The State Of E In Sexas

  1. 1. 2009 ESRD Network of Texas, Inc. Network Coordinating Council Meeting
  2. 2. CHAIRMAN’S REPORT Richard Gibney, MD Gibney Network Elections Quality Improvement A Pause to Reflect Supporting Quality Care
  3. 3. NOMINATING COMMITTEE 09-10 09- Melvin Laski, Lubbock Richard Gibney MD Waco Gibney, MD, Robert Hootkins, MD, Austin Cleve Collins, MD, San Antonio Tom Lowery MD Tyler Lowery, MD,
  4. 4. Slate of Officers Melvin Laski, MD, Chairman Manny Alvarez, MD, Vice Chairman Larry McGowan, Treasurer Amy Hackney, Secretary Richard Gibney, MD Immediate Past Chairman Ruben Velez, MD MRB Chair Velez MD, Laura Yates, RN, At Large Charles Orji, MD, At Large Leigh Anne Tanzenburger, At Large 09- 09-10 EXECUTIVE COMMITTEE
  5. 5. Network Coordinating Co ncil Net o k Coo dinating Council Election
  6. 6. Words on Quality
  7. 7. Q QUALITY IMPROVEMENT URGENCY TO CHANGE: Improve quality of care (↓harm) (↓harm). All / Patients & family benefit Win Staff (RN, PCT, SW, Dietitian, Physician ↓ Mortality, improve quality indicators. Evidence based medicine, best practices, more efficient time, , p , , patient flow. ↓Chance of liability. Our reputation (not national average or less). Transparency good! It i noble & uplifting to be the best at helping our fellow man. is bl lifti t b th b t t h l i f ll
  8. 8. Q QUALITY IMPROVEMENT “The problem with life is, p , there is no SCARY music.” -- Robin Williams ↓Mortality, ↓Patients Harmed.
  9. 9. Q QUALITY IMPROVEMENT DATA USE: Right things easy BIG GOALS! Bad things hard / Simple & visual. No denominator. N d i t “Hope is not a strategy.” “Complexity is the enemy of reliability.” Protocols, processes, Protocols processes systems flow (orders diagnosis (orders, diagnosis, & treatment.)
  10. 10. WE HAVE BEEN CALLED TO A MINISTRY, WHERE WE ENTER SACRED & HOLY MOMENTS OF A PERSON’S LIFE LIFE; A REAL AND TREASURED PRIVILEGE. -- James Reinertsen, M.D. September, 2008
  11. 11. LOAVES AND FISHES This is not the age of information. This is not the age of information. Forget the news, g , and the radio, and the blurred screen. This is the time of loaves and fishes. People are hungry, and one good word is bread g for a thousand. --David Whyte
  12. 12. Report from the Executive Director Glenda Harbert, RN, CNN, CPHQ
  13. 13. MISSION Statement The ESRD Network of Texas, Inc. supports quality dialysis & kidney transplant healthcare th t l t h lth through patient h ti t services, education, quality q y improvement & data exchange. 2003
  14. 14. Topics DSHS Referrals & Rules Network Growth Network Activities
  15. 15. DSHS ESRD Licensure Rules Revision 3 Stakeholder meetings October & December 08, January 09 April 1 Submit rule packet to Office of General Counsel by June 25 ESRD rules will be proposed at the DSHS C Council meeting on il ti 30 day comment period after the proposed rules are published l bli h d No decision yet if a public comment hearing will be held during the 30 day comment period
  16. 16. DSHS responds to each comment submitted during the comment period – the comment is either accepted and the suggested change made, made or it is not and why After Aft comment period, fi l rule preamble t i d final l bl and final rules go to HHSC for final approval After approval, the final rules are published and become effective 30 days after publication www.dshs.tx.us/hfp/rules.shtm www dshs tx us/hfp/rules shtm
  17. 17. DSHS Referral Update
  18. 18. Number of Cases & Levels
  19. 19. Common Themes Unsafe Infection Control Practices Poor hand washing practices Inappropriate use of Personal Protective Equipment (PPE) Not disinfecting surfaces Failure to implement Quality Assessment and Performance Improvement (QAPI) Patient Safety Concerns Lack of patient assessments (pre, during & post) Disabling machine alarms
  20. 20. Common Themes Vascular Access Outliers High Catheter Rate Low AVF Rate Unsafe Physical Environment Dirty floors Broken Tiles, etc. Water Treatment Practices Not testing properly Lack of staff knowledge Unsafe Reuse practices
  21. 21. Communication Issues PCT’s not reporting critical treatment data/events to nurses: Failure to report Hyper & Hypo tension pre, during, and post dialysis treatments Initiating Sodium Profiling with ↑ BP Failure to: obtain accurate weights identify wet transducers communicate “Reportable Parameters” to physician or nurse
  22. 22. Serious Situations Patient deaths attributed to nursing practice issues Phlebotomy of 1 liter of blood every treatment X 3 treatments Hep H B positive (+) conversion then converted ii ( ) i h d to negative (-) with pt. left in Isolation Room for extended period Initiating dialysis when water treatment out of parameters
  23. 23. Serious Situations Use non-standard dialysate without appropriate monitoring pp p g Failure to recognize, report and track Adverse Events
  24. 24. 2008 Network #14 Growth & Trends •CMS Certified Facilities • Facility Ownership • Growth in Patient Census • Patients Transplanted
  25. 25. Network Growth Total Number of Texas Dialysis Facilities CMS Annual Facility Survey Data The ESRD Network of Texas, Inc.
  26. 26. Facility Ownership in Texas 26
  27. 27. 2008 Texas Facility Ownership (%) 27
  28. 28. Total Number of Texas Patients (Includes Home & In-Center HD and PD Patients) In-
  29. 29. Total Transplants by Donor Type 29
  30. 30. 2004- 2004-2007 Standardized Transplantation Ratio a da d d a p a a o a o (STR) UM KECC DFR report
  31. 31. 2007 Percent Patients (<70 years old) on a ( 0 y a o d) o Transplant Waitlist UM KECC DFR report
  32. 32. 2007 Percent Patients on the Waitlist by Subgroup Pe S aitlist ercent of Subgroup on the Wa
  33. 33. Distribution of Percent of Texas Facility Patients on Waitlist 2007 UM KECC DFR report
  34. 34. Paired donation Matches one incompatible donor/recipient pair to another pair with a complimentary incompatibility, incompatibility so that the donor of the first pair gives to p g the recipient of the second, and vice versa.
  35. 35. Potential Donations 5000 anges 4000 Number of Possible Excha •100 donor - recipient pairs generates 4,950 potential paired exchanges 3000 2000 r 1000 0 1 11 21 31 41 51 61 71 81 91 101 Number of Pairs
  36. 36. Alliance for Paired Donation Composed of 63 transplant centers in 22 states. 1st year APD facilitated 19 paired exchanges List of Texas Participating Centers (18) www.paireddonation.org
  37. 37. Paired Donation Network Includes over 80 kidney transplant programs in i 23 states that are organized in five regional t t th t i d i fi i l consortia. 14 p i ed donor transplants have been done paired dono t n pl nt h e within the PDN system since October 08. Texas – 2 centers North Austin Medical Center Memorial Hermann Renal Transplant Center http://www.paireddonationnetwork.org/
  38. 38. Activities of the Network Quality Improvement Outreach TEEC & Disaster preparedness Patient & Provider Technical Assistance & Education Involuntary Discharge Information Management
  39. 39. Quality Improvement Lab data Collection Quality Improvement Projects Home Sweet Home Quality of Care Concerns & CPM’s CPM s Vascular Access Improvement Projects Severe Anemia 2 year outliers for clinical labs
  40. 40. Patient Services and Outreach
  41. 41. What is Wh t i TEEC? The mission of TEEC is to ensure a coordinated preparedness, plan, response and p recovery to emergency events affecting th T ff ti the Texas ESRD community.
  42. 42. Important Lessons Learned Independent facilities must pre-plan for backup dialysis with another provider Patients should be encouraged to evacuate Any patient with limited mobility, support mobility systems and or transportation MUST be registered for evacuation with 211 Telling patients to go the hospital for dialysis is NOT a disaster plan!
  43. 43. Involuntary Discharge 54 46 44 40 32 31 < 0.15% of total patients
  44. 44. Monitoring & Profiling Complaints by Facility
  45. 45. Percent of total Facilities with Complaints 1 Complaint 14.7%  2 Complaints 1.5%  3 Complaints 0.02%  3 Complaints 0 02%  None 83.78%  >3 Complaints 0.0% 
  46. 46. Booklet Test Fall 2008 6 facilities- El Paso facilities- Paso, Angleton, Houston, Tyler, Lubbock Tyler Lubbock, McAllen 55 patients ti t In English and Spanish http://www.esrdnetwork.org/patients/education/resources.asp
  47. 47. Test Method 9 volunteer RD’s were asked to participate – 6 completed the test RD’s were asked to select 9 patients (if possible) with the following characteristics to be representative of NW 14 patient g p p population – 43% Hispanic ethnicity n= 3 – 57% Non-Hispanic White= 4 including 1 other race, such as Asian if possible – 30.5% Black= 2 Of the 9 patients include at least 2 Non–readers 1 English speaking 1 Spanish speaking
  48. 48. Ask Me Three Methodology* Selected readers were given the booklet to readd Non readers had the booklet read to them in either English or Spanish After the patient read the booklet (or had it p ( read to them) RD’s were asked to explain to patient : p * National Patient Safety Foundation
  49. 49. Non Blaming, Non Shaming Blaming “We are testing how well we did We writing this booklet so patients can understand what it says. I would d t d h t ld like to ask you a few questions to see how well we did.” Not: Do you understand? Do D you hhave any questions? ti ?
  50. 50. The RD then asked 3 simple questions and recorded the answers awarding 1 point for each correct answer accepting multiple answers A other category was i l d d for th t included f answers the RD deemed correct that were not one of th pre-selected t f the l t d answers
  51. 51. Patient Scores Total score of > 4 considered booklet effective 50 of 55 > 4 (91%) Of the 5 that did not score at least 4 – 1 Hispanic white spanish speaking non- non- reader – 3 Non Hispanic white English reader* – 1 African American English reader reader* *Although it is not known, it is possible these patients were g , p p marginal readers. It is common for adult poor readers or non- non-readers to deny their literacy status.
  52. 52. Average Score by Group Hispanic Hispanic Non Non Hispanic White Hispanic White Hispanic Hispanic Black A/A White ENG. White Spanish White White Black A/A ENG. non ENG. non Spanish non ENG. Spanish ENG. reader reader reader reader reader reader reader reader N=10 N=1 N=10 N=2 N=5 N=7 N=15 N=3 5.5 9 6.3 5 5.6 4.9 4.8 8.3
  53. 53. Question #1: What is the main problem? Correct answer= thi t C t thirst
  54. 54. What are things I can do about it? (strategies to control thirst) Percent responding Percent responding Other  approved by RD  Use smaller  as correct, 38% glass , 45% if Diabetic:  Control blood  sugar , 22% Use  Suck on  S k hard candy or  ice, 51% gum , 44% Don't  eat processed  eat processed meats , 25%
  55. 55. Why is this important for me? Percent responding   Percent responding other , 9 less swelling, 35 not as thirsty, 29 less sob, 40 less fluid gain,  64 better for my  heart, 60
  56. 56. Conclusions The booklet effectively educated patients of several demographics regarding: f ld hi di – The main topic- with 95% answering thirst correctly – Strategies to control thirst 22 51% 22-51% cited >1 of 5 answers determined in advance to be correct 38% cited another answer that the RD approved as correct Suck on ice was the strategy scoring the highest (51%)
  57. 57. Conclusions, continued – Importance to them personally 29 64% 29-64% cited >1 of 5 answers determined in advance to be correct Less fluid gain was the reason scoring the g g highest (64%) Better for my heart second highest (60%) y g ( ) 9% cited another answer that the RD approved as correct
  58. 58. Why do all that for a booklet y everyone likes & uses? Need to show effectiveness of outreach to CMS Learning new methods to address Health Literacy issues Demonstrating effectiveness
  59. 59. Health Literacy: A Prescription to End Confusion. 90 million US adults: literacy skills below high school level Adults with limited literacy: less knowledge of disease management & health promoting behaviors i b h i report poorer health status less likely to use preventive services y p higher hospitalization rates & emergency service use less adherence >300 studies show health-related materials far exceed average reading ability of US adults Institute of Medicine, 2004 Medicine
  60. 60. Health Literacy of American Adults National Assessment of Adult Literacy (NAAL): National Center for Educational Statistics, U.S. Department of Education, 2003.
  61. 61. Health Literacy “The degree to which individuals have the capacity to; p y ; obtain, process, and understand basic health information and services needed to make appropriate health decisions. decisions ” Healthy People 2010
  62. 62. Improves Patient Safety A 2006 study examined patients’ abilities to understand five common instructions on prescription medications. Both patients with adequate and low literacy had difficulty understanding at least one of the five instructions.
  63. 63. “What Did the Doctor Say?”* y Recommends making plain language a “universal precaution” in all patient encounters *Improving Health Literacy to Protect Patient Safety- Joint Commission
  64. 64. What is plain language? • Plain language is communication that an audience can understand the first time they read or hear it. it What • The concept of using plain language is closely related to the concept of health literacy. Why y • Clear communication is critical to successful health care. care How
  65. 65. Watch for more information on Health Literacy and Patient Education
  66. 66. What happened to Crown Web? •Phase I- Pilot Project with 4 Networks & 8 Facilities F iliti •Phase II ? Spring or Summer 09 •Full Implementation ?? F ll I l t ti •For more Information- Special Session Saturday Aft S t d Afternoon
  67. 67. Thank you for all that you do gharbert@nw14.esrd.net 469-916- 469-916-3801
  68. 68. Report from Medical Review Board (MRB) Chairman Robert Hootkins MD, PhD, FACP, FASN R b t H tki MD PhD FACP
  69. 69. My Assignment Today! y g y Review geographic representation and functions of MRB Share current NW #14 clinical indicator data Closing thoughts as outgoing “lame duck Chairman lame duck”
  70. 70. MRB Functions Evaluate quality and appropriateness of care delivered to ESRD patients in Texas Propose Corrective Action Plans (CAP) for dialysis units with Level 2-3 deficiencies to Texas 2- Department of State Health Services (DSHS) Analyze NW #14 data and recommend clinical outcome profiling cut-points cut- Serve as primary advisory panel to Network to promote improved patient care and safety through QI activities Utilize NW #14 data to identify Network-wide y Network- improvement opportunities
  71. 71. Current Geographic Representation of MRB Ruben Velez, MD Camille May, RN Ingemar Davidson, MD I D id Jennie Lang House, RD Trish White, RN Mary Beth Callahan, SW Dianne Morgan a e o ga James Cotton, MD Mohan Narayan, MD Stuart Goldstein ,MD Robert Hootkins, MD Donald Molony, MD Deborah Heinrich, RN Jane Louis, RD Jacqueline Lappin, MD J li L i Denise Hart, MD Mazeen Arar, MD Arar, Joyce Hernandez, SW y , Clyde Rutherford, MD Rutherford Anna Gonzalez Navid Saigal, MD Saigal, Kaylenne Duran, RN The ESRD Network of Texas, Inc.
  72. 72. Information on Data & Projects ESRD Network of Texas, Inc.
  73. 73. Comparative Clinical Indicator Data used by NW #14 Mandating Comparative Data Collection Sample Size Use Organization Data Level Network Clinical Random Identify and U.S. Performance CMS Sample NW QI (No Facility Measures (CPM) Patients Projects Specific Data) Quality of 100% of Facility, Identify Care(QOC) Network #14 eligible Network and outlier Indicator Project patients U.S. facilities Facility, Identify 100% of Fistula First CMS Network and VA outlier patients U.S. facilities Data All facility Facility, posted on patients with Network and Annual Dialysis DFC and CMS URR and ESA U.S. Facility Report used by Medicare State Billing Claims SMR, SHR, STR Surveyors
  74. 74. Hemodialysis Adequacy
  75. 75. Percent of Patients with URR > 65% - CPM 94 90% 89% 92 90 90 90 90 90 90 90 90 89 89 89 89 89 89 % of Patients 88 88 88 88 87 86 85 P 84 83 82 80 78 76 14 4 6 8 12 1 16 3 9 11 13 15 US 2 7 18 10 5 17 Network The ESRD Network of Texas, Inc.
  76. 76. Percent of Patients with Kt/V > 1.2 - CPM 93% 94 91% 93 93 93 93 93 93 93 92 92 92 92 92 92 91 91 91 91 % of Patients 90 90 90 90 89 89 P 88 87 87 86 85 84 14 4 8 9 1 16 3 6 7 12 18 13 15 US 2 10 11 5 17 Network The ESRD Network of Texas, Inc.
  77. 77. MRB Quality of Care Cut-Point for HD Adequacy (2007 data) More than 80% of facility patients have a URR of > 65% 95% of TX HD facilities (N= 391) met or exceeded th MRB quality cut-point! d d the lit cut- i t! t What about the 5% of TX facilities (N=19) that didn’t did ’ meet the cut point? h i 14 facilities 71- 71-80% of patients had a URR > 65% 3 facilities 61- 61-70% of patients had a URR > 65% 1 facility 51- 51-60% of patients had a URR > 65% 1 facility 0-10% of patients had a URR > 65%
  78. 78. Hemodialysis Anemia Management
  79. 79. Percent of Patients with HGB < 10.0 - CPM 9 8 8 5% 5% 7 7 7 7 6 6 6 % of Patients 6 5 5 5 5 5 5 5 5 5 4 4 4 P 4 3 3 2 1 0 17 1 15 18 14 4 6 7 US 3 16 10 5 12 13 8 9 11 2 Network The ESRD Network of Texas, Inc.
  80. 80. Percent of Patients with HGB > 11.0 - CPM 86% 88 86 82% 86 85 84 84 84 83 83 83 % of Patients 82 82 82 82 82 81 81 81 80 80 80 80 80 P 78 77 76 74 72 14 1 17 18 3 7 15 11 US 16 12 5 6 10 4 8 9 13 2 Network The ESRD Network of Texas, Inc.
  81. 81. Percent of Patients with HGB 11.0-12.0 - CPM 11.0- 44% 50 39% 45 44 45 42 42 42 42 41 41 40 39 39 40 38 37 37 37 36 36 % of Patients 35 33 32 30 25 P 20 15 10 5 0 1 14 3 4 16 17 15 18 2 US 10 5 9 11 12 7 8 6 13 Network The ESRD Network of Texas, Inc.
  82. 82. MRB Quality of Care Cut Point Cut-Point for HD Severe Anemia Management (2007 data) Less than 11% of facility patients have a Hemoglobin < 10.0 94% of TX HD facilities (N=413) met or exceeded the MRB quality cut-point! cut- What about the 6% of TX facilities (N=26) that didn’t meet the cut point for this Hgb range? 23 facilities 11- 11-20 % of patients with Hemoglobin < 10.0 1 facility 21-30% 21-30% of patients with Hemoglobin < 10.0 1 facility 41-50% of patients with Hemoglobin < 10.00 41- 1 facility 91-100% 91-100% of patients with Hemoglobin < 10.0 10 0
  83. 83. MRB Quality of Care Cut-Point for HD Anemia Management (2007 data) More than 70% of facility patients have a Hemoglobin between > 10 0 and < 13 0 gm/dl H l bi b 10.0 d 13.0 /dl 90% of TX HD facilities (N 370) met or exceeded (N= the MRB quality cut-point! cut- What about the 10% of TX facilities (N=43) that didn’t meet the cut point for this Hgb range? 30 facilities 60.1- 60.1-70% of patients > 10.0 and < 13.0 gm/dl 8 facilities 50.1 50.1-60% of patients > 10.0 and < 13.0 gm/dl 4 facility 40.1- 40.1-50% of patients > 10.0 and < 13.0 gm/dl 1 facility 0-10% of patients > 10.0 and < 13.0 gm/dl
  84. 84. Hemodialysis Bone and Mineral Metabolism
  85. 85. Percent of Patients with Phosphorus 3.5-5.5 - CPM 3.5- 58% 70 52% 60 57 58 54 55 55 56 51 51 52 52 52 53 53 54 50 51 48 49 50 % of Patients 45 40 P 30 20 10 0 6 7 16 6 5 8 13 17 3 9 11 US 3 15 10 12 5 0 1 18 2 8 4 14 Network The ESRD Network of Texas, Inc.
  86. 86. Peritoneal Dialysis Adequacy
  87. 87. Percent of PD Patients with Kt/V ≥ 1.7 - QOC 2006 2007 100 95 91.1 89.9 90 85 ents 80 75 % of Patie 70 65 60 55 50 45 40 The ESRD Network of Texas, Inc.
  88. 88. MRB Quality of Care Cut-Point for PD Adequacy (2007 data) More than 80% of facility patients have a Kt/V > 1.7 75% of TX PD facilities (N= 84) met or exceeded the MRB quality cut-point! th lit cut- i t! t What about the 25% of TX facilities (N=28) that didn’t did ’ meet the cut point? h i 18 facilities 71- 71-80% of patients met Kt/V > 1.7 2 facilities 61- 61-70% of patients met Kt/V > 1 7 1.7 1 facility 51- 51-60% of patients met Kt/V > 1.7 7 facilities 0-50% of patients met Kt/V > 1.7
  89. 89. Peritoneal Dialysis Anemia Management
  90. 90. Percent of PD Patients with HGB < 10 0 - QOC 10.0 The ESRD Network of Texas, Inc.
  91. 91. Percent of PD Patients with HGB ≥ 11 0 - QOC ith 11.0 90 2000 2001 2002 2003 85 2004 2005 2006 2007 81.9 80.4 80 79.1 78.3 tients 77.1 % of Pat 75 73.8 73 8 69.2 70 65 60 The ESRD Network of Texas, Inc.
  92. 92. Percent of PD Patients with TSAT ≥ 20% - QOC ith The ESRD Network of Texas, Inc.
  93. 93. MRB Quality of Care Cut Point Cut-Point for PD Severe Anemia Management (2007 data) Less than 11% of facility patients have a Hemoglobin < 10.0 77% of TX PD f iliti (N=77) met or exceeded the f facilities (N 77) t d d th MRB quality cut-point! cut- What b t th Wh t about the 23% of TX facilities (N=26) that f f iliti (N 26) th t didn’t meet the cut point for this Hgb range? 14 facilities 11- 11-20 % of patients with Hemoglobin < 10.0 6 facilities 21-30% 21-30% of patients with Hemoglobin < 10.0 6 facilities 41- 41-50% of patients with Hemoglobin < 10.0
  94. 94. MRB Quality of Care Cut-Point for PD Anemia Management (2007 data) More than 70% of facility patients have a Hemoglobin between > 10 0 and < 13 0 gm/dl H l bi b 10.0 d 13.0 /dl 66% of TX PD facilities (N=77) met or exceeded the MRB quality cut-point! cut- What about the 34% of TX facilities (N=40) that didn’t meet the cut point for this Hgb range? 19 facilities 60.1- 60.1-70% of patients > 10.0 and < 13.0 gm/dl 6 facilities 50.1 50.1-60% of patients > 10.0 and < 13.0 gm/dl 9 facilities 40.1- 40.1-50% of patients > 10.0 and < 13.0 gm/dl 6 facilities 0-40% of patients > 10 0 and < 13 0 gm/dl 10.0 13.0
  95. 95. Peritoneal Dialysis Albumin
  96. 96. Percent of PD Patients with ALB ≥ 4 0/3 7 - QOC ith 4.0/3.7 36 2000 2001 2002 2003 32 2004 2005 2006 2007 27.4 28 24.8 24 8 23.0 atients 24 21.3 20.3 20.6 20 % of Pa 16 12 8 4 0 The ESRD Network of Texas, Inc.
  97. 97. Vascular Access Management
  98. 98. AVF Utilization in the U.S. November 2008 70 64 51.4% 50.5% 60 57 57 56 55 55 52 51 51 51 51 50 50 50 49 48 48 47 50 47 Percent AVF 40 30 20 10 0 16 15 17 1 2 18 3 7 US 12 14 4 11 13 10 5 8 9 6 Network The ESRD Network of Texas, Inc.
  99. 99. Improvement Needed to Meet CMS Contract Year Goal of 4% 2008-2009 AVF Gap Analysis Trending - Network #14 Where we are now and where we NEED TO BE to meet our CMS goal of 4% increase in prevalent AVFs Assuming Equal Growth each Month 52.8% Where we need to be Where we are/were 52.0% 52.0% 51.8% 51.5% 50.9% 51.2% 51.2% 50.6% 50.3% AVF Rate R 50.4% 50.0% 49.7% 50.5% 50.4% 49.6% 49.4% 49.9% 49.1% 49.6% 49.8% 9 6% 50.0% 48.8% 48.8% 48.5% 48.8% 48.5% 48.6% 48.0% Mar-08 Apr-08 May-08 Jun-08 M 08 A 08 M 08 J 08 Jul-08 Aug-08 S J l 08 A 08 Sep-08 O t 08 N 08 D 08 J 08 Oct-08 Nov-08 Dec-08 Jan-09 F b 09 M 09 09 Feb-09 Mar-09 Month
  100. 100. Percent of Prevalent Patients with Catheter (with/without AVF or AVG, regardless of duration of use) - CPM use) 40 27% 34 35 31 31 31 32 32 32 21% 30 27 27 27 28 28 28 % of Patients 24 24 25 25 23 21 21 20 P 15 10 5 0 14 18 16 1 6 8 15 17 US 2 3 4 11 12 13 7 9 10 5 Network The ESRD Network of Texas, Inc.
  101. 101. Percent of Prevalent Patients with Catheter - CPM 30 25 24 23 21 21 % of Patients 20 19 17 15 10 5 0 2002 2003 2004 2005 2006 2007 Network 14 The ESRD Network of Texas, Inc.
  102. 102. September 2008 Chart 2: Prevalent Texas Patients With Catheter Only Oct 2003 Oct 2004 Sep 2005 Sep 2006 Sep 2007 Mar 2008 Sep 2008 12 ents 9.3 valent Patie 10 8.9 8.4 8.3 8.1 8.0 7.9 8 6.2 5.6 5.6 5.6 cent of Prev 6 5.2 52 5.1 51 5.2 52 4 2 Perc 0 Utilizing Catheter Utilizing Catheter < 90 Days > 90 Days
  103. 103. Percent of Prevalent Patients with AV Graft - CPM 31% 35 31 22% 30 30 26 25 23 23 23 23 atients 22 22 22 20 21 19 20 17 18 16 16 6 6 % of Pa 14 15 15 10 5 0 16 15 1 12 7 10 2 17 3 5 13 US 4 9 11 18 8 6 14 Network The ESRD Network of Texas, Inc.
  104. 104. Percent of Prevalent Patients with AV Graft - CPM 60 56 52 50 44 atients 40 32 32 31 30 % of Pa 20 10 0 2002 2003 2004 2005 2006 2007 Network 14 The ESRD Network of Texas, Inc.
  105. 105. Percent of Prevalent Patients with AVG and S d Stenosis M i i i Monitoring - CPM 120 99 71% 100 69% 87 84 80 % of Patients 80 72 72 72 71 71 71 71 69 67 67 64 62 62 61 58 60 P 40 20 0 16 13 6 4 3 8 11 1 10 18 US 14 12 17 2 9 15 7 5 Network The ESRD Network of Texas, Inc.
  106. 106. Percent of Prevalent Patients with AVG and S d Stenosis M i i i Monitoring - CPM 100 90 84 atients 80 78 % of Pa 72 72 68 69 70 60 50 2002 2003 2004 2005 2006 2007 The ESRD Network of Texas, Inc. Network 14
  107. 107. Fistula First Focus Nephrologist awareness and early referral p patterns Regional areas with system barriers AVG conversion to Secondary AVF Focus on Assessing Failing AVG for conversion to Secondary AVF Pilot Project Ongoing- 6 Texas Facilities with historically high AVG rates (> 30% AVG x 3 years)
  108. 108. Nephrologist Profile Report: Cath + AVF or AVG AVF AVF Cath + AVF or AVG Physician Texas AVG Physician Texas Catheter Only Catheter Only Physician N % Texas N % AVF 2 12.5 AVF 419 24.2 AVG 0 0.0 AVG 153 8.9 Catheter ith C th t with Catheter ith C th t with 2 12.5 431 24.9 AVF or AVG AVF or AVG Catheter Only 12 75.0 Catheter Only 726 42.0 Total 16 100.0 Total 1729 100.0 VA Used for First Chronic Dialysis Patients with > 12 Months Nephrologist Pre-ESRD Care Pre- The ESRD Network of Texas, Inc.
  109. 109. AVF Prevalent AVF in Texas 03-08 03- Distributiion of Percent AVF Rate 140 120 acilities 100 N ber of Fac 80 60 Num 40 Sep '08 20 Sep '07 Sep '06 Sep '05 05 0 10 20 30 40 50 60 70 80 90 Sep '04 Oct '03 Pe rcent AVF Rate
  110. 110. Other NW data & QI Projects
  111. 111. 2004- 2004-2007 Standardized Mortality Ratio (SMR)
  112. 112. Statistically Si ifi St ti ti ll Significant SMR 2004-2007 t 2004- High Low 28 Facilities 41 Facilities SMR range 1.22- 2.13 1.22- SMR range 0.00-0.74 0.00- P value range 0.000-0.26 0.000- P value range 0.00-0.049 0.00- Patient Census 38-312 38- Patient Census 29-372 29- MRB follow up in progress
  113. 113. 2004- 2004-2008 Patients on Incenter & Home Dialysis ents Numbe of Patie er
  114. 114.     Increasing Home Dialysis Quality Improvement Project Benchmark facility results
  115. 115. Important practices in educating, referring, & referring, recruiting patients for home dialysis Staff member(s) assigned to role of home dialysis patient education specialist or coordinator. Facility has a strong physician advocate for home dialysis. Facility has a separate Home Dialysis Program with separate staff from the in-center program. Facility has processes that empower nurses & SWs to educate patients & encourage home dialysis. Facility has formal home dialysis patient education protocol initiated on all new patients.
  116. 116. Important practices in educating, referring, & referring, recruiting patients for home dialysis New staff receive education on home dialysis during orientation & regularly. Reassess new patients' suitability for home dialysis 3 and 6 months after dialysis is initiated & then annually. Home Dialysis “awareness days” done for in-center HD New patients re-educated on home dialysis options 3 and 6 months after dialysis is initiated. Referral assessment tool with specific criteria utilized to determine suitability for home dialysis.
  117. 117. Change in facilities with Home Patients P ti t Baseline 2006 After Project 2008
  118. 118. Improving Management of Phosphorus Outcomes
  119. 119. Rationale and Goals Phosphorus is important Mortality Quality of Life There is variability across facilities Project Goals Increase percent of patients in target range
  120. 120. Distribution of Facilities By Percent of PD Patients with Serum Phosphorus 5.5 mg/dl or Lower 55 Opportunity QOC Concern to Improve Benchmarks Mean = 62.8 St Dev = 25.71 2007 Quality of Care Project (4th Quarter 2006 data)
  121. 121. Observational Data Have Shown Elevated Serum Phosphorus Levels Are Associated With Increased Mortality Study Data Population N PO4 Increased (mg/dL) Relative Risk Slinin Y t l Sli i Y, et al. 1993- 1993-1996 DMMS 14,829 14 829 5.4-6.3 5.4 5 4 -6 3 2% 6.4- 6.4-7.5 10% > 7.5 19% Melamed EW, et EW 1995- 1995-1998 CHOICE 593 5.1-6.0* 5.1 5 1-6 0* 1- 8% al. > 6.0* 57% Block GA, et al. 1997 FMC 40,538 5.0-5.5 5.0- 10% Database 5.5- 5.5-6.0 25% Young EW, et al. 1996-2001 1996- DOPPS 17,236 Per 1 4% mg/dL Kalantar- Kalantar-Zadeh, 2001-2003 2001- DaVita 58,058 > 6.0* Increased† Increased† et al. Database *Adjusted for vitamin D administration. †Exact number not specified.
  122. 122. Continuing Opportunities for g pp Improvement in Texas Barriers: Funding & NW Resources Potential Projects: P t ti l P j t K+ Baths / Protocols Abx/Cult Practices – Protocols? Catheter Management
  123. 123. Closing thoughts Safety / Risks Staff Oversight / Vigilance DSHS Collaboration Medical Director Commitment M di l Di t C it t “We Can Do Better”
  124. 124. “The medical direction of dialysis facilities has been … sometimes absent, feckless* or absent uninspired” *lacking purpose without skill ineffective, incompetent , p lacking the courage to act in any meaningful way Gutman, 2007 G t
  125. 125.         CMS 2744 (2004-2006) Annual Facility Survey Data Regional g Fistula First Collaborative & Secondary S d Dashboard Data AVF VAIP VA Workshops Quality of Care Quality of Care “Concern” Facilities Indicator Data CMS 2728 (2007) Access in Use at Medical Evidence Report Form Initiation of Dialysis y         Improving Clinical Performance Phosphorous Measures (CPM) Data Management
  126. 126. Recognitions g

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