1—Preface...1—Preface Statement from the Chairman In June 2006, the Centers for Medicare and Medicaid Services (CMS) awarded the End Stage Renal Disease (ESRD) Network 2 contract

1—Preface

Statement from the Chairman

In June 2006, the Centers for Medicare and Medicaid Services (CMS) awarded the End Stage Renal Disease (ESRD) Network 2 contract to IPRO, the Medicare QIO for the State of New York. It has been a successful partnership and the fit has been a natural one. Both Network 2 and IPRO are highly committed to assessing and improving the quality of health care services delivered to the residents of New York State.

There have been challenges and successes during this period. A primary focus of Network 2 activities in 2006 was the Fistula First project, which looks to improve both the fistula rates and the reporting of these data by providers. The facility-reporting project was a great success and has resulted in enhanced communication between the Network and providers. Vascular access reporting in July 2006 was at 63.9%. With process changes, this improved to 100% by February 2007. Between the third quarter of 2005 and March 2007, fistula rates improved by 2.6%, from 47.3% to 49.9%.

The IPRO End Stage Renal Disease Network has also provided patients and facilities with educational opportunities and materials. Network 2 established a Coalition for Disaster Preparedness in the five boroughs of New York City, to be used as a template for how the ESRD community will prepare for emergencies in the future. This coalition has brought together over 60 renal community leaders who are committed to ensuring a state of readiness.

IPRO and the ESRD Network would like to thank the ESRD providers for their support this year and for their commitment to meeting the challenges that lie ahead. From this promising beginning, IPRO will continue to cultivate its partnership with the renal provider community. IPRO is proudly and fully committed to supporting the ESRD program in New York State and in improving the lives of our patients.

John Wagner, MD Chairman of Network Council End Stage Renal Disease Network of NY

IPRO End Stage Renal Disease Network of New York Annual Report 2006

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2—Table of Contents

1—Preface.......................................................................... i Statement from the Chairman..................................................................... i

2—Table of Contents............................................................. i

3—Introduction................................................................... 1 Network Description...................................................................................1

Geography and General Population .................................................................... 2

ESRD Population ................................................................................................... 3 Network Structure...................................................................................... 5

Network Staff .......................................................................................................... 6

Governance and Committees ............................................................................... 7

4—CMS National Goals and Network Activities ............................12 Goal 1: Improve the quality and safety of dialysis-related services provided for individuals with ESRD..............................................................................12

1. Vascular Access (Fistula First)........................................................................ 13

2. Clinical Performance Measures ...................................................................... 20

3. Network 2 Quality Improvement .................................................................. 22

4. Facility-specific Quality Assessment and Improvement ............................ 24 Goal 2: Improve the independence, quality of life, and rehabilitation (to the extent possible) of individuals with ESRD through transplantation, use of self-care modalities and in-center self-care, as medically appropriate, through the end of life............................................................................................ 25

1. Newsletters ........................................................................................................ 25

2. Web Site ............................................................................................................. 26

3. Vocational Rehabilitation ................................................................................ 26

4. Employer Recognition Awards ...................................................................... 27 Goal 3: To improve the collection, reliability, timeliness, and use of data to measure processes of ESRD care and outcomes, maintain the ESRD Patient Registry, and support the national ESRD Network Program Data Reporting, Reliability and Validity............................................................................. 28

1. CMS Forms Processed..................................................................................... 28

2. Patient Events ................................................................................................... 29

3. Provider and Personnel Database.................................................................. 30

4. Quality Assurance of Patient Data................................................................. 30

5. Annual Compliance Reports........................................................................... 31


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6. Other Data Management Activities ............................................................... 32 Goal 4: Improve collaboration with providers and facilities to ensure achievement of goals 1 through 3 through the most efficient and effective means possible, with recognition of the differences among providers (independent, hospital-based, member of a group, affiliate of an organization, etc.) and the associated possibilities/capabilities............. 36

1. Coalition............................................................................................................. 36

2. Centers for Medicare and Medicaid Services ............................................... 36

3. Quality Improvement Organization .............................................................. 37

4. NY State Department of Health .................................................................... 37

5. ESRD Networks ............................................................................................... 38

6. Professional Organizations ............................................................................. 38

7. Spring Network Council Meeting/Provider Session .................................. 38

8. Fall Annual Network Meeting Scientific Program ...................................... 38 Goal 5: To improve patient perception of care and experience of care, and resolve patients’ complaints and grievances regarding ESRD facilities and providers................................................................................................... 39

1. Patient Advisory Committee Activities ......................................................... 39

2. Dealing with the Challenging Patient ............................................................ 40

3. Technical Assistance ........................................................................................ 41

4—Sanction Recommendations ...............................................42

5—Recommendations for Additional Facilities ............................43

6—Data Tables ...................................................................44


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The mission of the End Stage Renal

Disease Network of New York is to

promote health care for all ESRD

patients that is safe, effective,

efficient, patient-centered, timely

and equitable.


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3—Introduction

Network Description

The End Stage Renal Disease (ESRD) Network of New York was incorporated in 1979 as a not-for-profit organization dedicated to assisting dialysis and renal transplantation centers in establishing and maintaining high standards of care for ESRD patients. The organization operated as one of 18 ESRD Network Organizations under contract to CMS until July 2006, when CMS awarded the Network 2 contract to IPRO, an independent, not-for-profit corporation and the Medicare Quality Improvement Organization (QIO) for New York. IPRO assumed full responsibility for Network 2 operations from the previous contractor shortly thereafter. IPRO is fully committed to promoting and achieving the goals and vision of the ESRD Network Program and to providing support to the patients and providers within the Network 2 area.

In 2006, 7,319 patients within Network 2 began treatment for ESRD, for an increase of 11% over 2000 (Figure 3). Of the new patients, 56% were male and 44% were female; 60.5% were white and 30% were African-American. For primary cause of renal failure, 41% was diabetes and 22% was hypertension. In 2006, 63% of the incident population were between 50 and 79 years of age.

As specified in the Statement of Work, each Network is responsible for conducting activities in the following areas:

Quality Improvement,

Community Information and Resources,

Administration, and

Information Management.

Network activities, which are framed by the national program goals of improving the quality of health care services and quality of life for ESRD beneficiaries, are tailored to meet local needs, and include:

Assuring the effective and efficient administration of benefits,

Improving quality of care for ESRD patients,

Collecting data to measure quality of care,

Providing assistance to ESRD patients and providers, and

Evaluating and resolving patient grievances.


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The impetus for the ESRD Network Program came largely from landmark reports produced by the Institute of Medicine (IOM) on the Quality of Health Care in the United States. Of particular significance is Crossing the Quality Chasm: A New Health System for the 20th Century, published in 2001, which identified the gap between the quality of health care currently being delivered versus that which we know is achievable. The gap is also evident in the quality of care of ESRD patients today. Network 2 is committed to closing the gap by working closely with consumers, providers, and stakeholders to deliver the right care for every patient every time.

Geography and General Population

Network 2 has the fifth largest ESRD network population in the country. Fifty percent of these patients reside within the five boroughs of New York City; the remainder live in both rural and urban settings. This high concentration of patients in the metropolitan area presents challenges relative to ESRD education, preparedness and treatment modalities.

The state of New York is 54,471 square miles, with 47,234 square miles of land, and 7,247 square miles of inland water. The state includes one of the most highly populated cities in the nation, New York City, and the nation’s largest state forest preserve, the Adirondacks. The boundaries of Network 2 coincide with those of New York State, which is comprised of 62 counties and 12 Standard Metropolitan Statistical Areas. New York State is the third most populated state in the country with over 19 million residents

and a population density of over 400 persons per square mile. 42% of the population resides in New York City and nearly two-thirds are concentrated in the City and its immediate suburbs in Long Island and the Hudson Valley. The

Figure 1. US Population Estimates Per Square Mile - 2006

Figure 1. US Population Estimates Per Square Mile - 2006


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US Census map above illustrates the variation in general population density across states (Figure 1.).

Forty-eight percent of New York State’s residents are male and 52% are female. Approximately 12.7% is aged 65 and older, as shown in Figure 2. Sixteen percent of the population is between 35 and 44 years of age. New York has seen a recent increase in the population ages 45-54, consistent with the 49% increase in the national population of residents in this age group. Both New York State and the nation saw a slower rate of increase in population ages 65 and over.

New York’s population is 34% non-white, with African-Americans comprising 12%, Latinos, 15% and Asians, 7%. This has grown from 1990, when only 26% of the state was non-white. New York State has the fifth largest proportion of Hispanic and Latino residents in the country and its Asian population ranks fourth, behind only Hawaii, California and New Jersey.

The Median Household income in New York for 2005 was the 15th highest in the country at $49,480, with large variation by county. The highest household incomes are in the downstate area.

ESRD Population

Both the ESRD incident (newly diagnosed) and prevalent (chronic) patient populations in Network 2 have grown steadily since 2000. In planning for the continued growth, Network 2 works collaboratively with the New York renal community and key stakeholders to assure the quality and adequacy of care. From 2005 to 2006 the patient prevalent census increased by 1.3% to 23,073 (Figure 3). Of this number, 56.1% is male, 51.7 % is white, and 40.3% is African-

Figure 2. Percent of Total Population 65 Yrs and Over - 2005Figure 2. Percent of Total Population 65 Yrs and Over - 2005


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American. For primary cause of renal failure, 39% have diabetes and 24% have hypertension.

In 2006, 7,319 patients within Network 2 began treatment for ESRD, for an increase of 11% over 2000 (Figure 3). Of the new patients, 56% were male and 44% were female; 60.5% were white and 30% were African-American. For primary cause of renal failure, 41% was diabetes and 22% was hypertension. In 2006, 63% of the incident population were between 50 and 79 years of age.

In 2006, 1,357 renal transplants were performed in New York, 10% more than in 2005. Transplant recipients were 58% male and 43% female. Recipients were also 57% white and 32% African-American. New York currently has 15 transplant centers.

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Incidence Prevalence

Figure 3. Annual Incident and Prevalent Patients - 2006

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Figure 3. Annual Incident and Prevalent Patients - 2006


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Network Structure

Network 2 has an efficient and effective organizational structure that meets the needs of the ESRD contract and the New York renal community. Network 2 staff includes both qualified employees and volunteers from the renal community who sit on IPRO’s Board of Directors and Network advisory committees. The ESRD organizational structure is depicted graphically in Figure 4.

IPRO BOARD OF DIRECTORS

Theodore WillIPRO CEO

Clare Bradley, MDChief Medical

Officer

Finance Committee

Laura WrightSecretary

Network Council

Patient Advisory Committee

Medical Review Board

Grievance Committee

Susan CaponiESRD Network

Executive Director

Dawn EdwardsCommunity Outreach

Coordinator

Nephrology Nurse

John CocchieriData Coordinator

Sharon LambData Coordinator

Flora MartinezData Coordinator

Marc RodriguezData Analyst

Marie MerendaPatient Services

Manager

Carol Lyden, RNQuality Improvement

Coordinator

Figure 4. ESRD Network of NY Organizational ChartMay 2007

IPRO BOARD OF DIRECTORS

Theodore WillIPRO CEO

Clare Bradley, MDChief Medical

Officer

Finance Committee

Laura WrightSecretary

Network Council



Grievance Committee

Susan CaponiESRD Network

Executive Director


Coordinator

Nephrology Nurse






Manager


Coordinator


Coordinator

Nephrology Nurse






Manager


Coordinator

Figure 4. ESRD Network of NY Organizational ChartMay 2007


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Network Staff

Network 2 employs an Executive Director and nine full time staff. The names and key responsibilities of the staff are provided below.

Susan Caponi, RN,BSN, Executive Director

Provides expert recommendations to Network 2 governing bodies on goals, objectives, work plans, and operational policies for the ESRD Program,

Establishes and maintains relationships with ESRD providers and other organizations,

Manages operational and financial aspects of the program,

Assures quality and timely completion of contract deliverables, and

Manages staff and daily office operations.

Dawn Edwards, Community Outreach Coordinator

Leads community information and resource activities,

Provides technical assistance and conducts community outreach to patients and providers relative to disaster preparedness and vocational rehabilitation, and

Directs the activities of the Patient Advisory Committee (PAC).

Marc Rodriguez, MSW, Data Manager

Coordinates activities required to fulfill Network 2’s data responsibilities,

Ensures the integrity of Network 2 data and continuous operation of the computer network, and

Supervises Data Coordinators.

Carol Lyden, RN, BSN, MS, CNN Quality Improvement Coordinator1

Leads and coordinates all Network 2 quality improvement activities,

Develops, implements and evaluates educational content, for applicability to program goals, coordinating with staff, the Medical Review Board (MRB) and Network Council, and

Promotes quality improvement initiatives.

1 In 2006, Marie Merenda also served as Quality Improvement Coordinator.


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Marie Merenda, Patient Services Manager2

Leads social services, community information and resource activities including the grievance system,

Directs the activities of the Patient Advisory Committee (PAC), and

Provides technical assistance and conducts community outreach to patients and providers.

Sharon Lamb, Data Coordinator

Processes all CMS and Network forms for dialysis and transplant providers, and

Maintains patient and facility-specific databases.

Flora Martinez, Data Coordinator



John Cocchieri, Data Coordinator



Laura Wright, Secretary

Provides administrative support for the entire Network contract, and

Assists in the completion of data deliverables.

Governance and Committees

The IPRO Board of Directors, Network Council and several committees support and facilitate Network 2 operations. The role and purpose of these committees are periodically reassessed to ensure that they continue to meet current needs. Committee and board members include representatives from dialysis and transplant facilities, and other strategic organizations within the Network 2 area. Each committee has at least one consumer representative. Their involvement is vital to the success of Network 2 activities and to improving the quality of care and life for ESRD patients.

2 In 2006, the position of Patient Services Manager was held by Rick Russo.


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IPRO Board of Directors

IPRO's Board of Directors, which includes physicians and community stakeholder representatives, sets corporate policies and assures the orderly and efficient operation of IPRO, which includes Network 2. The Board has fiduciary oversight responsibility for Network 2 and sets the course for its activities, as reported by ESRD Executive Director, Susan Caponi. In 2006, two representatives from the renal community joined IPRO's Board of Directors—ESRD beneficiary Larry Wilson and nephrologist Dr. John Wagner. The Board considers and acts on recommendations from the Network Council, which is chaired by Dr. Wagner. The names, primary professional affiliations and locations of IPRO's Board members are listed below.

Chairman Thomas Sheehy, Jr., MD Physician Huntington, NY Members Lois Aronstein NYS Director of AARP New York, NY Anne Barash, MD Physician Syracuse, NY Warren R. Betty, MD Physician Cape May, NJ Randall Bloomfield, MD Physician Brooklyn, NY Thomas Casey, MD Physician Pittsford, NY Sister Bernadette Devlin Catholic Charities Bayside, NY William Dolan, MD Physician Rochester, NY Paul Finkelstein, MD Physician New York, NY John Friedman, MD Physician Syracuse, NY Tina Gerardi, RN, MS CEO, NYS Nurses Assn. Latham, NY Mervyn L. Goldstein, MD Physician White Plains, NY Douglas T. Greaves, MD Physician Bellport, NY Stephen L. Hermele, MD Physician Kingston, NY Victor R. Hrehorovich, MD Physician Lutherville, MD Louis Irmisch, MD Physician Williamsville, NY

Robert Lerner, MD Physician/Vice Chairman, New York Medical College Eastchester, NY

Bruce R. MacDonald, MD Physician Cooperstown, NY

Paul Macielak, Esq. President & CEO, NY Health Plan Assn. Albany, NY

Harry T. Oliver, MD Physician Lockport, NY Stuart I. Orsher, MD Physician New York, NY

Robert Panzer, MD Physician and VP/Chief Quality Officer, University of Rochester Medical Center

Rochester, NY


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Ronald A. Paynter, MD Physician Long Beach, NY

Paul Rowland Sr. VP/CEO, Nassau Healthcare Corp. East Meadow, NY

John Wagner, MD ESRD Representative/Nephrology New Hyde Park, NY Michael Walsh, MD Physician New Rochelle, NY Frederic Weinbaum, MD Physician Sea Cliff, NY Larry Wilson Consumer/ESRD Beneficiary New York, NY Donald A. Winikoff, MD Physician West Nyack, NY Joel Yohai, MD Physician Syosset, NY

Network Council

The Network Council is a subcommittee of the IPRO Board of Directors. It serves as a liaison between Network 2 and the provider members of the renal community. The Council collaborates on, oversees and analyzes Network activities and advises the Board on quality improvement, policies and procedures for the ESRD Program.

Chairman John Wagner, MD Nephrologist New Hyde Park, NY Members Jocelyn Alleyne, RN Administrator Brooklyn, NY Kathy Andersen, RN Director Glens Falls, NY Maria Argentina, LCW Social Worker Bronx, NY Syed Asad, MD Nephrologist Huntington Sta., NY Chaim Charytan, MD Nephrologist Flushing, NY Sue Cobb, RN Nurse Manager Ogdensburg, NY Ellen Demarco, RN Administrator Brooklyn, NY Satya Dogra, RN Nurse Manager Bronx, NY Ann Eldred, MD Nephrologist Cooperstown, NY Mark Finger, MD Nephrologist St. James, NY Paul Frymoyer, MD Nephrologist Syracuse, NY Madelyn Hoffman, RN Regional Director Orchard Park, NY Vilay Jain, MD Nephrologist Rochester, NY Darlena James, RN Dietician Bayside, NY Robert Lynn, MD Nephrologist Bronx, NY David Martinez, MD Nephrologist Binghamton, NY Agricola Medosa, RN Registered Nurse Syracuse, NY Hazel Parker Consumer/PAC Representative Syracuse, NY Andrew Porter Administrator Cooperstown, NY Barbara Richter, RN Nurse Manager Flushing, NY


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Lionel Sannon, RN Nurse Manager Westbury, NY Michael Sloma Administrator Niagara Falls, NY Reynaldo Tan, MD Nephrologist Brooklyn, NY Lisa Vanderbeek, RN, NP Transplant Coordinator New York, NY Rocco Venuto, MD Nephrologist Buffalo, NY


The Network 2 Medical Review Board (MRB) is a subcommittee of the Network Council and functions in an expert capacity on the quality and appropriateness of care delivered to ESRD patients. The MRB also advises on quality improvement activities, including analysis of local data such as clinical performance measures, and develops, implements and evaluates Network 2 quality improvement program. The MRB consists of prominent and dedicated members of the renal community who volunteer their time. Several MRB members have served on the board for multiple years.

Chairman

Robert Lynn, MD Nephrologist Bronx, NY Members

Maria Argentina, LCW Social Worker Bronx, NY Syed Asad, MD Nephrologist Huntington Sta., NY Chaim Charytan, MD Nephrologist Flushing, NY Ellen Demarco, RN Administrator Brooklyn, NY Paul Frymoyer, MD Nephrologist Syracuse, NY Vilay Jain, MD Nephrologist Rochester, NY Helen Joe, RD Dietician Bayside, NY Brian Murray, MD Nephrologist Buffalo, NY Siram Nasipar, MD Pediatric Nephrologist Syracuse, NY Hazel Parker Consumer/ESRD Beneficiary Syracuse, NY Barbara Richter, RN Nurse Manager Flushing, NY Michael Sloma Administrator Niagara Falls, NY


The Patient Advisory Committee (PAC) assists in identifying and addressing barriers to obtaining quality health care from the perspective of ESRD beneficiaries. The PAC supports Network 2 activities by assisting with the development of educational materials for patients via Web sites, newsletters and teleconferences; reviewing and making recommendations regarding beneficiary-related health care messages, materials and activities; providing feedback on the effectiveness of beneficiary-related activities; and assisting in recruiting other beneficiaries to obtain their perspective.


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Chairman Larry H. Wilson Consumer/ BOD Member Bronx, NY Members Aaron Battle Consumer/ESRD Beneficiary Weehawken, NJ Vivian Davis Consumer/ESRD Beneficiary Bronx, NY Laura Joseph* Consumer/ESRD Beneficiary Middle Island, NY Lorraine Langdon Consumer/ESRD Beneficiary Bronx, NY Hazel Parker Consumer/ESRD Beneficiary Syracuse, NY Ad Hoc Member

Dawn Edwards Consumer/ ESRD Community Outreach Coordinator Queens, NY

*Ms. Joseph passed away in 2007 after serving many years as a PAC member.

Grievance Committee

The Network 2 Grievance Committee, an advisory panel to the Network Council, includes nephrology physicians, nurses, social workers and consumer representatives. The committee investigates and resolves patient complaints and grievances in accordance with CMS procedures and Network 2 policy.

Chairman Godfrey C. Burns, MD Physician New York, NY Members Aaron Battle Consumer/ESRD Beneficiary Weehawken, NJ Lynn Cahill, CSW Social Worker New York, NY

Michael Daniel, RN CMS Survey and Certification/Nurse Queens, NY

Vivian Davis Consumer/ESRD Beneficiary Bronx, NY Marilyn Galler, MD Nephrologist New York, NY Patricia Hansen, RN Administrator New York, NY Ira Meisels, MD Physician New York, NY Larry H. Wilson Consumer/ESRD Beneficiary Bronx, NY


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4—CMS National Goals and Network Activities

In accordance with the legislative mandate for the ESRD Network Program, to assist CMS in meeting its goals to ensure the right care for every person every time, and in keeping with sound medical practice, the strategic goals of the ESRD Network Program and Network 2 are to:

Improve the quality and safety of dialysis-related services provided for individuals with ESRD;

Improve the independence, quality of life, and rehabilitation (to the extent possible) of individuals with ESRD through support for transplantation, use of self-care modalities (e.g., peritoneal dialysis, home hemodialysis), and in-center self-care, as medically appropriate, through the end of life;

Improve the collection, reliability, timeliness, and use of data to measure processes of care and outcomes; to maintain a patient registry; and to support the goals of the ESRD Network Program;

Improve collaboration with providers and facilities to ensure achievement of goals 1 through 3 through the most efficient and effective means possible, with recognition of the differences among providers (independent, hospital-based, member of a group, affiliate of an organization, etc.) and the associated possibilities/capabilities; and

Improve patient perception of care and experience of care, and resolve patients’ complaints and grievances.

The following sections of this report describe the activities Network 2 has completed in meeting these goals.

Goal 1: Improve the quality and safety of dialysis-related services provided for individuals with ESRD

As defined in the ESRD Statement of Work, the mission of the CMS Health Care Quality Improvement Program is to promote the quality, effectiveness and efficiency of services to Medicare beneficiaries by strengthening the community of those committed to monitoring and improving care. During 2006, Network 2 developed quality improvement projects, and through the partnership of the MRB and renal providers, has directed and participated in the following projects.

The CMS contract for ESRD Networks for the period of July 1, 2006 through June 30, 2009 requires all Networks to assist ESRD providers in assessing and improving care to all ESRD patients. To guide these efforts, Network 2, working


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closely with the MRB, has developed a comprehensive Quality Improvement Work Plan (QIWP) incorporating the four major activities listed below.

1. Vascular Access (Fistula First) Access Reporting Access Project – Barriers to early AV fistula placement in Incident

Patients

2. Clinical Performance Measures Anemia Management

3. Network-specific Quality Improvement Network 2/QIO Collaboration Project – Vascular access education for

nephrologists and surgeons

4. Facility-specific Quality Assessment and Improvement QAPI Project – Standard Mortality Ratio (SMR)

1. Vascular Access (Fistula First)

CMS, in collaboration with key stakeholders in the renal community, launched the Fistula First Initiative to improve vascular access for dialysis patients with the specific goal of increasing AV fistula use. In a press release published April 14, 2004, CMS Administrator Mark B. McClellan, M.D., PhD. stated: “The Fistula First Initiative aims at having fistulas placed in at least half of new dialysis

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patients with a long-range goal of maintaining fistulas in 40% of eligible patients who remain on dialysis.”

CMS set a target date of June 2006 for reaching the goal of 40% of prevalent hemodialysis patients having an AV fistula. While Network 2 had already surpassed this goal in 2003, as indicated in Figure 5., the national rate reached 40% in August 2005.

For the current contract period, CMS set a new goal of 66% of prevalent hemodialysis patients with AV fistulas, to be achieved by June 2009. Each Network must demonstrate an annual decrease of 20% in its AV fistula quality deficit (the difference between the goal of 66% and the Network's baseline rate measured in the 3rd quarter of 2005, which was 47.3% for Network 2). The resulting goal for Network 2 was 51%, to be achieved by March 2007 (Figure 6.). By that date, Network 2 had achieved an AV fistula rate of 49.9%, slightly shy of our goal. This rate is the fifth highest in the country.

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Figure 6. Fistula Rate 2006-2007 Contract Year

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Figure 6. Fistula Rate 2006-2007 Contract Year


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Access Reporting

Network 2 continues to collect facility specific data and enter it into the CMS Standard Information Management System (SIMS), The data entered are compiled and reported via the Fistula First Dashboard, a public document residing at www.esource.net, which shows the prevalent rate of AVF use by Network and the percent of eligible facilities reporting. Each generation of the dashboard includes data entered since the last dashboard was updated and thus is a fluid document.

The SIMS Vascular Access Utility also produces three Core Standard Reports:

Network and National comparative data for prevalent AVF use,

Facility specific vascular access use (all access types), and

AVF placement in incident patients.

These reports, which illustrate the percent of prevalent patients with AV fistulas, catheter use, AV fistulas placed (used or not) and graft use, were generated and sent to Network 2 medical directors and nurse managers in March and October 2006. A sample report is shown in Figure 7.

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Figure 7. Vascular Access Used in Prevalent Patients

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Figure 7. Vascular Access Used in Prevalent Patients

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Access Provider Education Activities

To assist Network 2 providers in understanding the implications of their reported data on patient outcomes, Network 2 featured author and nationally known vascular access expert Jeffrey Sands, MD at its annual scientific meeting in September 2006. Dr. Sands, Vice President of Medical Technologies for Fresenius Medical Care NA, was provided with Network 2 data in advance of the meeting, and demonstrated the correlation between Network 2 access rates and patient mortality, hospitalization, and anemia rates. He also discussed vascular access processes to consider in efforts to increase vascular access rates.

Network 2 also provides a link to Fistula First information from the IPRO Web site http://esrd.ipro.org/. The site includes the 11-step Change Package, quality improvement tools and other information aimed at helping providers and patients. This information can also be accessed at www.ipro.org, “Information for Patients or Information for Professionals.”

Additional provider and patient information on the Vascular Access initiative is provided through Network 2's newsletters. Specifically, the March 2006 issue of Network Notes, which is distributed to Network 2's renal care professionals, contained an article entitled Update: Fistula First, which discussed the national breakthrough initiative and the collection of Network vascular access data from the providers. The Fall/Winter issue of Network Notes featured an article describing strategies to improve AV fistula rates, based on best practices of two champion facilities within Network 2.

The Fall 2006 issue of PAC Notes, which is published in English and Spanish and sent to providers for distribution to ESRD patients, contained an article that explained the various access types available for hemodialysis and the pros and cons of each.

Network Access Project: Barriers to Early AV Fistula Placement

The objective of the Fistula First National Vascular Access Improvement Initiative is for CMS, the ESRD Networks, and the renal community to reach or surpass the CMS Clinical Performance Measures (CPM) Project goal of AV fistula rate of 50% in incident patients. The 2005 CPM Project, which is based on 2004 national data, shows that 14% of incident patients had an AV fistula at initiation of hemodialysis, whereas after 90 days, 25% of incident patients have an AV fistula. The Fistula First Outcomes Dashboard indicates, as of December 2006, that between 22.6% and 39.5% (Network Ranges) of incident patients had started hemodialysis with an AV fistula placed (present, used or not), as shown in Figure 8. Network 2's rate at that time was 31.7% of incident patients start treatment with an AV fistula placed.


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Figure 8. National Vascular Access Data from 2005 CPM Project

National Data for Type of Vascular Access2005 CPM Project (2004 data)

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According to the results of the 2005 CPM Project (Figure 10.), the main reasons for catheter placement in adult in-center hemodialysis patients (which includes prevalent and incident patients) were: no fistula or graft surgically planned (27%), fistula maturing (21%), no fistula or graft surgically created at this time (21%), and all fistula or graft sites have been exhausted (11%).

To improve the rate of AV fistula placement in incident patients, we also need to understand the major barriers to AV fistula placement at initiation of treatment and how these obstacles differ from prevalent patients. In 2006, Network 2

initiated a quality improvement project to address this need.

The CMS 2728 form was used to identify the incident patients who started treatment in the third quarter of 2006 with a catheter and who had been under the care of a nephrologist for at least six months. Network 2 staff developed a questionnaire, and sent it to the 268 nephrologists who signed the 2728

AV Fistulas Placed in Incident PatientsFistula First Outcomes Dashboard

2006 Data

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forms for the 485 patients who met the study criteria. 65% of the questionnaires were completed and returned. 29% of responses indicated that the respondent was not the nephrologist who saw the patient prior to the beginning of treatment.

As shown in Figure 10., 42% of the responses cited other as the cause of a permanent access not being placed, with the most common reasons being peritoneal dialysis, acute renal failure, coronary artery disease, and financial. The main barriers to early fistula placement in incident patients cited were patient preference (21%), AV fistula maturing (15%), peritoneal dialysis (11%), acute renal disease (6%), and peripheral vascular disease (5%). Not referred to surgeon was indicated 2% of the time. Five of these responses indicated the reason was patient preference or acute renal failure.

Figure 10. Reasons for Catheter Placement

Total Responses Prevalent Pt CPM Data

Incident Pt Network 2 Scan

Reason # % # % Total Responses 2,229 100 351 100 No fistula or graph surgically planned 614 27 * * Patient preference 350 15 75 21 Peripheral vascular disease 140 6 19 5 Physician/surgeon preference 98 4 9 3 Patient size too small for AVF/graft 33 1 7 2 Renal transplantation scheduled 16 .7 9 3 Fistula maturing, not ready to cannulate 480 21 51 15 Graft maturing, not ready to cannulate 104 5 8 2

No fistula or graft surgically created at this time 475 21 NA NA

All fistula or graft sites have been exhausted 261 11 NA NA Temporary interruption of fistula use due to clotting/revision 128 6 14 4

Temporary interruption of graft use due to clotting/revision 106 5 5 1

Not referred for access NA NA 7 2 Other 130 6 147 42 PD planned NA NA 39 11 Acute renal failure NA NA 22 6 CAD NA NA 9 3 Financial NA NA 3 1 *NA=Not asked **Did not ask if access was planned


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When comparing the CPM data of prevalent patients to Network 2's questionnaire responses of incident patients, there were some differences in the causes of catheters being used for hemodialysis treatment. In the prevalent patient population, fistula or graft maturing and fistula or graft complications were indicated as the reason for catheter use. In the incident patient population, patient preference, renal transplantation scheduled and other (peritoneal dialysis, acute renal failure, coronary artery disease and financial) were indicated as the reasons for catheter use. Peripheral vascular disease, physician/surgeon preference, and patient size had similar response in both populations. This project will be reviewed with the Medical Review Board to develop a quality improvement project based on this data for the 2007-2008 contract year.

The Networks are also required to collect aggregate vascular access data from each eligible facility on a monthly basis. Network 2 had the lowest vascular access reporting rates of the 18 Networks in the country in the first half of 2006. Nationally, the reporting rates exceed 95%. As of January 2006 (March dashboard), Network 2 had a reporting rate of 78.2%. This decreased to 64.1% in July (September dashboard). A quality improvement project was developed to improve the reporting rates. The goal of the project was to improve vascular access reporting rates to greater than 85% by March 2007.

NY State has the fifth largest patient population in the country and has the highest number of independent facilities. 67% of hemodialysis facilities are independently owned. Generally, these facilities lack a centralized reporting structure that large dialysis organizations (LDOs) possess. The LDOs do a national electronic data submission for all their facilities once a month and this data is downloaded to the Network via the Central Repository. The independent facilities submit their data individually to the Network directly and Network staff enters the data into the SIMS database. This data gets uploaded from the Network to the Central Repository. The Fistula First Outcomes Dashboard is generated from this data. During the month of July 2006 (September dashboard), 88% of the LDO facilities had submitted data compared to 67% of independent facilities.

The Network identified the facilities that were not reporting vascular access data or sporadically reporting data by generating the SIMS Vascular Access Data Exceptions Report. It was determined that 29 facilities had not reported data during 2006. Of these facilities, 8 facilities had never reported. All 29 facilities were contacted by phone to determine the reasons for non-reporting. Seventeen facilities started to report after contact was made.

The facilities that had reported vascular access data inconsistently were notified. Letters were mailed to all facilities that were missing monthly reports for 2006.


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Facilities that do not submit the vascular access report to the Network by the 20th of the month are sent a fax reminder. A second fax reminder is sent on the 30th of the month, and a phone call is placed after the 5th of the next month if the data has not been received. The Network improved from 64.1% of facilities reporting in July (September dashboard) to 95.5% of facilities reporting in December (February dashboard).

Figure 11. shows the vascular access reporting rates based on the first dashboard after the data collection period and highlights the improvement in vascular access reporting following the quality improvement intervention. The Network reporting improvement interventions were effective retrospectively as well as prospectively. Network 2 will focus on sustaining this improvement in the 2007-2008 contract year.

2. Clinical Performance Measures

Network 2 participates in the national CMS ESRD Clinical Performance Measures Project, under which clinical information on dialysis patients is collected to measure and track the quality of care received by these patients in dialysis facilities. These measures are based on the National Kidney Foundation’s (NKF) Dialysis Outcome Quality Initiative (DOQI) Clinical Practice Guidelines. A 5% statistical sample of hemodialysis and peritoneal dialysis patients across networks is selected for clinical data profiling. The data is collected during the

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last quarter of each year. Although facility specific data is not available, Networks receive reporting on their performance compared to other Networks and the nation as a whole (Figure 12.).

To support the project, Network 2 sent a total of 934 CPM data collection forms to 186 facilities in May 2006. 881 forms were completed and returned. Returned forms were reviewed for completeness and, if necessary, facilities were called for missing data before being entered into Standard Information Management System (SIMS). Approximately 66% of the forms submitted necessitated follow-up for accuracy and completeness. Network 2 quality improvement staff conducted a reliability study of ten forms by chart review, and information was entered into the SIMS database.

Figure 12. Clinical Performance Measures Results 2005-2006 (CPM)

National Results Network 2 Results

CPM 2005 2006 2005 2006 Mean URR > 65% 87% 88% 82% 89%

Mean Kt/V > 1.2 91% 91% 86% 93%

Mean Hb > 11.0 gm/dL 83% 84% 79% 82%

Mean Tsat % > 20 79% 78% 77% 79%

Mean Serum Ferritin % > 100 ng/mL 94% 95% 93% 92%

Mean Serum Albumin >4.0/3.7 g/dL 36% 33% 31% 31%

Mean Serum Albumin >3.5/3.2 g/dL 82% 80% 77% 80%

Prevalent Patients Catheters > 90 Days 21% 21% 19% 21%

Prevalent Patients AV Fistulas 39% 44% 49% 48%

Incident Patients AV Fistulas 37% 54% 43% 53%

Network 2 also participates in the National CPM Laboratory Data Collection project, which provides patient level data for patients cared for in large dialysis organization (LDO) managed/owned facilities, and some independently owned facilities (participation in the project is voluntary). With this facility level data, the MRB and Network 2 are able to focus interventions in the areas, and with the facilities, that demonstrate opportunities for improvement.

For this year, preliminary 2005 CPM data (based on care provided during the fourth quarter 2004) was reviewed with the MRB and it was determined that Network 2 would focus on anemia management since, although we met the CMS


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goal to have 70% of patients with hemoglobin equal to or greater than 11 gm/dl, Network 2 had the lowest nationwide percentage at 79%.

The goal of this project was to improve the percentage of patients with a mean hemoglobin > 11 gm/dl by 5%. The lab data collected during the last quarter of 2005 was used to identify high- and low-performing facilities within Network 2. The champions (high performing facilities) were asked to share their protocols and procedures with facilities having problems with anemia management. Network 2 worked with the nine facilities that had the greatest number of patients with hemoglobin <11gm/dl. These facilities were invited to attend a workshop, held in April 2007, that included speakers on anemia and iron management; presentation of suggested protocols from champions; and quality improvement tools. Network 2 continues to work with these facilities via bi-monthly conference calls and to monitor progress through its quality improvement work plan.

3. Network 2 Quality Improvement

Quality Improvement (QI) initiatives are most successful when the concerns of involved stakeholders and the needs of the local community are taken into consideration. In terms of demographics and location and distribution of patients and providers, Network 2 is a heterogeneous community and has an annual census of over 23,000 ESRD patients, the majority of whom reside within the five boroughs of New York City—the smallest geographic area in the state.

A chief QI project for CMS and Network 2 is increasing AV Fistula access rates. IPRO and other stakeholders within the boundaries of Network 2 have the same goal. Network 2 is collaborating with IPRO on the planning, coordination and implementation of a Network Specific QI project called Fistula First. The goals of this quality improvement project are to educate nephrologists in strategies to improve AVF rates, to educate surgeons in strategies for difficult placement and complications of AVF, and to develop networking between surgeons and nephrologists.

Using the methodology described below, Network 2 was able to determine that the project should begin in the five boroughs of New York City. Based on the success of the initial phase, the project will be modified where necessary and rolled out statewide.

Facilities and their AV fistula rates were gathered and entered into Map Point software by the data staff (Figures 13A and 13B). Counties are delineated in the state and the average AVF rate was calculated for each county. The flags on the maps indicate the percent of prevalent patients with AV fistulas by facility. The


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green flag = 67-100%, yellow flag =52-66%, red flag =40-51%, and white flag =0-39%.

Network 2 held its initial Fistula First educational conference, entitled The Nephrologist/Surgeon Dinner Conference, on March 29, 2007 at the New Yorker Hotel in New York City. The site was selected due to the high concentration of facilities and patients in the area and ease of access by public transportation.

Presentations included the Fistula First Breakthrough Initiative (FFBI) Goals, Techniques to Maximize Successful Native AV Fistula Creation, and Improving Patient Outcomes in the Dialysis Facility. The program was approved for 2.3 credit hours of AMA PRA Category 1 Credits. The conference was video taped and is posted on our Web site.

Figure 13A. Map of NY State Facility AV Fistula Rates

Figure 13B. Map of NY Metro Area Facility AV Fistula Rates

Figure 13A. Map of NY State Facility AV Fistula RatesFigure 13A. Map of NY State Facility AV Fistula Rates

Figure 13B. Map of NY Metro Area Facility AV Fistula RatesFigure 13B. Map of NY Metro Area Facility AV Fistula Rates


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4. Facility-specific Quality Assessment and Improvement

ESRD patients have a permanent and complete loss of renal function requiring renal replacement therapy for survival. Dialysis is the dominant form of ESRD therapy in the United States, sustaining the lives of over 330,000 individuals in 2005. Interest in dialysis outcomes has increased in recent years, driven in part by the recognition of disparities in patient survival rates between individual dialysis units, across regions in the United States and internationally.3

Since 1995, a standardized mortality ratio (SMR) has been calculated for each dialysis facility on a yearly basis and reported in Dialysis Facility Compare. The SMR compares the observed death rate in a facility to the rate that would be expected based on national death rates. Time at risk and deaths within 60 days after transfer out of a facility are compared. Time at risk and deaths after transplantation are excluded from the SMR calculation. The SMR is then adjusted for patient age, gender, race, ethnicity, diabetes as a cause of ESRD, duration of ESRD, BMI at incidence, comorbidities at incidence, as well as state population death rates.

The Dialysis Facility Report indicates that Network 2 has more facilities with a “worse than expected” SMR compared to the other Networks in the country. Despite this, the Network 2 average SMR (.97) is better than the national average (1.0). A goal for Network 2 is therefore to decrease the number of facilities with “worse than expected” SMR. The Network will investigate these disparities by looking at the facilities that are in this group and comparing them to other facilities in the Network for type of facility (hospital based, nursing home based, or free standing), ownership (LDO or independent), and comorbidity conditions (anemia and adequacy). In addition, Network 2 will be compared to other Networks for type of facility and ownership. Comorbid conditions at incidence and causes of renal failure can have an impact on the SMR. An educational offering to improve the accuracy and completeness of reporting was held May 15, 2007 at the Network 2 office in Lake Success, NY.

3 USRDS 1998; McClellan, Flanders, and Gutman 1992.


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Goal 2: Improve the independence, quality of life, and rehabilitation (to the extent possible) of individuals with ESRD through transplantation, use of self-care modalities and in-center self-care, as medically appropriate, through the end of life

Network 2 continues to promote independence, quality of life and rehabilitation through various activities as outlined below. The Network has encouraged participation in the vocational rehabilitation program and has instituted the community service outreach position to champion this program by visiting facilities and attending work programs. One of the many ways Network 2 promotes this goal is by providing education via our newsletters, Web site and our various provider meetings throughout the year.

1. Newsletters

Network 2 produces two newsletters, one for patients, PAC Notes, and one for facilities/providers, Network Notes. Topics of this year’s newsletters included a description of the patient advisory committee (PAC) and articles about disaster preparedness, vocational rehabilitation and transplantation.

The Winter 2006-2007 issue of PAC Notes included an announcement highlighting Larry Wilson’s appointment to the IPRO Board of Directors in December 2006. Each issue of PAC Notes contains legislative news and other information from the National Kidney Foundation (NKF). A first-hand patient profile, Consumer Activity Report, ESRD related Web sites, consumer information and contact information for Network 2 are also included. PAC Notes is published in both English and Spanish and distributed to all facilities.

Network Notes, which is directed to renal professionals, was produced and distributed in Fall/Winter 2006. This issue included the ESRD Network Statement of Work (SOW), information on Disaster Preparedness, Fistula First project accomplishments, the quarterly census and the annual survey information. Also, included were biographies of Network 2 new employees.


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2. Web Site

The ESRD Network of NY Web Site was developed to serve patients and their families, dialysis and transplant providers, and the community at large. The Web site, www.esrd.ipro.org, has information including:

Emergency Planning

A link to Dialysis Facility Compare

Grievance Procedures

Information for Patients

Patient Safety

Information for Professionals

Resources

News and Events

Archived Newsletters

Network Annual Reports

The Web site provides information about Network 2 as well as educational and resource materials in both English and Spanish. A search feature allows the viewer to search within the site itself or across the Internet. This site is federal code 508 compliant and is updated regularly with new content. The “Contact Us” feature allows the viewer to contact a Network 2 staff member with questions or requests for additional information.

3. Vocational Rehabilitation

ESRD patients who contacted Network 2 in 2006 received individualized vocational counseling on issues such as problems on the job, new career options, how to obtain training, concerns about loss of benefits, how to make the transition when returning to work, and job seeking skills, such as preparing resumes, interviews, and disclosure of disability.


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Facility social workers were given information to help their patients deal with vocational concerns. Patient inquiries included requests for advice on working with Vocational and Educational Services for Individuals with Disabilities (VESID), the Americans with Disabilities Act, Social Security work incentives and income allowances, trial work periods, available medical coverage, and other patient concerns.

4. Employer Recognition Awards

A program to honor employers who hire and offer support to workers with chronic kidney disease was established in 2003. Information on the program appears at www.ipro.esrd.org and is included in both Network newsletters, which reach both patients and professionals. In addition, letters and posters describing the award program were sent to dialysis and transplant units in 2006.

Nominations were received from a range of occupations. Six individuals from five companies were honored at the September 2006 Network Council meeting, as follows:

Tom Tsounis - Golub Corporation, Plattsburgh, NY

Gary Wagoner - Westaff, Plattsburgh, NY

Ana Yeomans - Stillwater Central Schools, Stillwater, NY

Larry McGee - Curtis Door Systems, Inc., Plattsburgh, NY

Deborah Cary Murnion - VCS, Inc., New City, NY

Phyllis B. Frank - VCS, Inc., New City, NY

In an outreach to providers, the Network invited medical directors, unit administrators, and other facility professional staff to attend the Council Meeting held at the LaGuardia Airport Marriott Hotel, East Elmhurst on June 2, 2006. A guest speaker from the New York State Department of Health (NYS DOH) presented on collaborative efforts with Network 2 designed to improve care. The Network Vocational Rehabilitation Specialist presented Employer Recognition Awards to employers who supported and assisted ESRD patients in the workplace. Network 2's Patient Services Coordinator spoke about the Decreasing Dialysis Patient-Provider Conflict toolkit. The President of the Network and Interim Executive Director presented highlights about the 2006-2009 SOW.


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Goal 3: To improve the collection, reliability, timeliness, and use of data to measure processes of ESRD care and outcomes, maintain the ESRD Patient Registry, and support the national ESRD Network Program Data Reporting, Reliability and Validity

Network 2 collects, maintains, validates and analyzes patient data for individuals receiving ESRD services in New York State as mandated by the Social Security Act and as required by contract. Network 2 maintains patient information in the SIMS database and replicates it to the central SIMS database repository on a daily basis.

The central repository receives similar data from the 18 Network organizations across the country, constituting the national ESRD patient registry. Renal Management Information Systems (REMIS) is a database that contains information on provider billing for ESRD services and Medicare entitlement data, and has an operational interface to the SIMS central repository. REMIS serves as the primary mechanism to store and access ESRD patient and facility information in the ESRD Program Management and Medical Information System Database to enable the determination of the Medicare coverage periods for ESRD patients. The purpose of maintaining the Network patient registry is to ensure a patient’s renal medical condition has reached end stage and to register all ESRD patients (Medicare and Non-Medicare) with the United States Renal Data System (USRDS) as mandated by law.

1. CMS Forms Processed

To register an ESRD patient, the treating dialysis or transplant facility must submit a Medical Evidence form (Form CMS 2728-U3) to the Network within 45 days of initiation of chronic treatment. Network 2 enters the data into SIMS to determine if the patient meets the criteria for ESRD. Upon the death of a patient, the provider must submit a death notification form (Form CMS-2746 -U2) within 30 days.

As shown in the table below, between 2005 and 2006, Network 2 experienced an 11% increase in the number of forms processed. In 2006, the total number of new patients starting treatment (incident) was 7,319, representing an increase of 286 patients over 2005. The total number of all patients receiving treatment (prevalent) was 23,073, representing an increase of 304 patients over 2005.


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Figure 14. CMS Forms Processed 2001-2006

Year Medical Evidence

(Form 2728) Death Notification

(Form 2746) 2001 6,030 4,554 2002 7,443 4,635 2003 7,591 5,884 2004 6,790 4,950 2005 7,158 5,160 2006 8,195 5,461

2. Patient Events

In addition to documenting incident and prevalent patients, Network 2 tracks patient events. Providers submit Patient Activity Reports (PAR) monthly, which indicate changes in patient treatment modality status and include events such as transfers-in or -out of the facility.

At the end of 2006, the 254 facilities (239 dialysis and 15 transplant facilities) in Network 2 were requested to verify the patient census and reconcile any discrepancies. The CMS Facility Survey Form (Form CMS-2744B), along with the patient beginning and ending census and patient events for the year, was

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printed and sent to providers in February 2007. The facilities verified the patient census, made changes to the form and submitted any previously omitted forms and events for the year. Network 2 entered these corrections in SIMS.

Figure 16. Number of Patient Events 2001-2006 Year # of Events Entered

2001 27,920

2002 29,815

2003 34,651

2004 31,630

2005 30,081

2006 35,685

3. Provider and Personnel Database

Network 2 maintains a provider database in SIMS that includes facility names, demographic information, treatment modalities offered, shifts, and key personnel. The NYS DOH notifies Network 2 of facilities that are newly approved, have changed their name, owner, or provider number or that have closed. Providers also notify the Network of changes to facility information and personnel as they occur, and update their facility roster annually. Network 2 staff updates the information in SIMS when changes are received.

The updated SIMS provider database is uploaded to the CMS Dialysis Facility Compare (DFC) Web site monthly. This Web site, which is accessible via www.medicare.gov, lists all Medicare-certified dialysis facilities nationally and provides dialysis facility characteristics such as name, address, telephone number, date of Medicare certification, shifts starting at or later than 5 PM, number of treatment stations, types of dialysis offered, and ownership type. Quality measures, adequacy of dialysis, treatment of anemia and patient survival are also included.

4. Quality Assurance of Patient Data

Network 2 is required to monitor the submission of accurate and timely data from ESRD providers within New York. Network 2 staff monitor submitted forms for accuracy, completeness, and timeliness, communicating with providers using various reports, such as the Reject Report and Missing Forms Report, which are printed and sent to providers each month. The Reject Report notifies the provider of missing or inaccurate information on a form that was submitted.


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The Missing Forms Report notifies the provider of forms that were not received. Corrected data must be submitted within three days, while missing forms must be provided within seven days of receipt of the report.

The accuracy and completeness of the Network’s databases are verified in several ways. This includes SIMS accretions and notifications and REMIS alerts. Accretions are defined as patients that are not in SIMS but are known to CMS through other renal databases. Notifications are discrepancies in the data elements between SIMS and other renal databases. REMIS alerts are related to patient entitlement status and serve as a method of communicating information about patient status among all REMIS users. Network 2 staff investigates these data discrepancies weekly. Accretions and notifications are accepted or rejected in SIMS and alerts are corrected in SIMS by Network data staff or CMS.

The United Network for Organ Sharing (UNOS) and CMS developed a process of reporting kidney transplantation events to the National Renal Registry in 1994. Every month UNOS supplies Network 2 with updates on kidney transplants from their Web site. Within 30 days, data staff reconciles the kidney transplant information in SIMS with the transplant data received from UNOS. Quarterly, the Network notifies transplant centers of any forms they are delinquent in sending to UNOS.

5. Annual Compliance Reports

The facilities are notified semi-annually of their accuracy and timeliness of form submission by way of a compliance report, which allowed the facility to compare timeliness and accuracy for both 2728 and 2746 forms to the Network compliance rate. The CMS goal for semi-annual compliance is 80% and the goal for annual compliance is 90%. Facilities that did not meet the compliance rate were asked to submit a performance improvement plan (PIP) to the Network. The CMS Project Officer is sent a list of providers and their compliance rates. Of the 70 facilities (28%) that did not meet the semi-annual compliance rate in 2006, 13 submitted an improvement plan. Forty of the 70 (68%) providers managed to show some improvement in their compliance rate during the course of the year. However, 59 providers failed to meet both the semi-annual and annual goals. Only one provider managed to increase compliance from below 80% on the semi-annual report to above 90% on the annual report. For the annual compliance report, providers who failed to meet the annual goal of 90% were instructed to complete a PIP that incorporates, at a minimum: 1) Identification of the obstacles preventing the provider from achieving their compliance goals; 2) A detailed description of steps the facility will take to improve future performance; and 3) Identification of the facility personnel who will be responsible for implementing steps to be taken. The PIP must be signed


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by the facility Medical Director, Administrator and the Data Contact to the key personnel at the facility who are involved in improving the facility’s compliance.

Figure 17. Number of Facilities Failing to Meet Compliance Rate Semi-annual Below 80% Annual Below 90%

70 182

6. Other Data Management Activities

Data Requests

In the State of New York, prior to opening a new dialysis facility or increasing the number of treatment stations, an application for the Certificate of Need must be approved by the NYS DOH and is reviewed for NYS specific requirements. The Network receives requests from both the applicants and the DOH for the number of patients within the zip codes of the community where the facility will be located. The Network refers these requestors to the report of patients by zip code located on the Network 2 Web site. To maintain patient privacy, if there are less than 10 patients in a zip code, the number of patients in that zip code is not reported. If this affects most of the area requested, Network 2 will report the total number of patients located in the county.

After the transition to IPRO, Network 2 began a close working relationship with the New York DOH regarding needs analysis throughout NYS. The initial request from the DOH involved data on a number of facilities from the Central New York area. The request was for the number of stations and the number of patients for 10 facilities over a six-month period. A subsequent request was made for a list of providers with ESRD Medicare provider numbers and provider names as well as the number of stations for the entire State. This request was soon followed by 12 additional requests for the confirmation of provider ESRD numbers, as well as contact information and addresses.

The Network also responded to select inquiries from Medicare Advantage organizations regarding the status of CMS-2728 forms and the transplant status of ESRD Medicare beneficiaries who were members of Medicare Advantage organizations. In 2006, Network 2 processed 176 requests for this information. The information given included first date of dialysis or transplant date and the date CMS-2728 forms were submitted to CMS.

Business Continuity and Contingency Plan

CMS requires each Network to develop a written Business Continuity and Contingency Plan (BCCP) that would outline the roles and responsibilities of staff, CMS, Computer Sciences Corporation (CSC), and Network vendors in the case of a disaster. The plan provides documented procedures for making backup


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copies of software, operating data, and user processes for recovering data and returning all systems to an operational level in the event they are lost, destroyed or otherwise inoperable. The plan, which has been approved by CMS, includes prevention strategies, assessment of disaster, recovery operations, and lists of contact information for staff, CMS, CSC and vendors.

New Patient Information Packets

The Forum of ESRD Networks mails informational materials to all new ESRD patients. The new patients along with their addresses are obtained from the SIMS patient database. The Forum of ESRD Networks notifies Network 2 of any packets that are not deliverable and any address corrections. The Network 2 staff investigates the reason for the returned packets and makes the address changes in SIMS. The Forum is notified when this is complete so they can send the packet to the patient. Network 2 has an average return rate of approximately 7.5%. In an effort to decrease the number of packets returned, Network 2 implemented an address validation process in October 2006 using Microsoft MapPoint to filter out invalid addresses but no significant decrease in returns was noted by the end of the year. The Network will continue to implement this process in 2007 and will re-evaluate its effectiveness by the middle of the contract year.

Changes in the Workflow Process

CMS forms 2728 and 2746 must be entered into SIMS with complete and accurate information no later than 15 working days of receipt. Events on the monthly patient activity report must be entered into SIMS within 10 working days of receipt. Network 2 data staff continue to develop work process strategies to improve efficiency. In late 2005, the work process was changed to a centralized organization of forms and monthly activity reports. Each data staff member is given tasks they are responsible for such as 2728, 2746, monthly activity reports, notification, accretions, etc. When a staff member is out of the office or unavailable another pre-determined staff member is responsible to complete their tasks. All forms entry is monitored monthly for compliance.

Data Library

Many of the procedures that are done in the data department reference to several sources, such as online manuals, the SOW, and the Medicare ESRD Network Organizations Manual. In addition, Network 2 has developed a data department policy and procedures manual, which combines various data references into one central location.

Some of the procedures contained in the data department policy and procedure manual include:


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Procedure for Local Server Backup and Offsite Storage

Semi-Annual and Annual Compliance Reports

Document Contacts in SIMS

Process Data Management Utilities

Data Department Deliverables Schedule

Processing Forms in SIMS

Access and Use of the Network 2 Global Calendar

Policy for Requested Medical Evidence Form (2728)

Policy for Processing Monthly Patient Activity Reports

Procedure to Handle Returned New Patient Packets

Processing Notifications and Accretions

Processing REMEDY Assignments and Monthly Server Maintenance

Updating the Transplant Database with the Use of UNOS

Creating a Seed Database

Download VISION files from QNet into SIMS

Protocol for VISION Training and Use

All of the above policies and procedures are based upon CMS contract deliverables and have been developed to ensure the data maintained by the Network 2 information management system is accurate and up-to-date.

CMS Software Support

CMS and the ESRD Networks are working together to build an integrated ESRD information system known as CROWN. This system will facilitate the collection and maintenance of information about the Medicare ESRD program, individuals with ESRD, and the services provided to them. CROWN implementation began in June 2002 and includes Vital Information System to Improve Outcomes in Nephrology (VISION) software, SIMS, Central SIMS and REMIS. VISION allows data entry at the facility level, which is subsequently sent to the Network via Quality Net Exchange (QNet), a secure Web-based environment. The Network imports the VISION data received through QNet into SIMS. This data is replicated to the SIMS Central Repository every night. Once the data is imported into the Network data system, it is consolidated by the CMS data system (REMIS) to determine if the patient is Medicare eligible.


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VISION

In 2005, the contractual goal for Network 2 was to have 70 facilities trained and 35 facilities reporting through VISION. At the end of 2005, 33 facilities had been trained and three were reporting via VISION. There were no VISION training requirements in 2006. While Network 2 continues to support and maintain those trained to submit data via VISION, at this time, CMS is not recruiting or training new facilities to use VISION.

VISION Signature Verification

Each electronically submitted 2728 and 2746 form is printed out by the facility and signed by the patient and physician in blue ink. The printed form with original signatures is then sent to the Social Security Office and a copy is placed in the patient’s record. Network 2 verifies a 3% sample of patient and physician signatures on these forms annually (Figure 18.). For 2006, this task was completed in the third quarter.

Figure 18. 2729 and 2746 Forms Validated 2006 a. Number of forms imported from VISION 2006 100 b. Total number of forms selected 3 c. Total number of forms received 5 d. Total percent of forms validated 100%

CROWN

As the ESRD system closes in on adopting CROWN Web as the system of record. An area of concern for Network 2 is the business rules that will be incorporated into the system when completing forms and has actively participated in developing procedure for electronic data collection. Network staff attended all CROWN Web Responsiveness and Feedback Tree (CRAFT) telephone conferences in 2006. As a result of some discussions that have taken place during these calls, one of the ideas shared by the Network involves the addition of depression as a comorbid condition. Additionally, the Network has raised the issue of race codes when asked to provide feedback regarding CROWN business requirements. Due to a lack of a clear definition for the race code of Hispanic patients, the Network must regularly clean up missing and/or inaccurate data. To promote the entry of accurate self-reported data, all elements including the race code must be clearly defined in the kidney data dictionary. The ESRD Network of New York has forwarded these issues to FMQAI, the Florida ESRD Network in response to their inquiry for elements to be considered.


36

Goal 4: Improve collaboration with providers and facilities to ensure achievement of goals 1 through 3 through the most efficient and effective means possible, with recognition of the differences among providers (independent, hospital-based, member of a group, affiliate of an organization, etc.) and the associated possibilities/capabilities.

Developing and maintaining cooperative relationships within the renal community, including facilities, is key to quality improvement and to meeting Network goals. Through ongoing collaboration, these new relationships are developing or becoming reengaged. In the following sections, the Network describes its performance and activities that were conducted to meet the goals listed above.

1. Coalition

Disaster preparedness is central to our efforts to facilitate successful outcomes for ESRD patients and providers in the event of a crisis. The decision to establish a Coalition for Disaster Preparedness in New York City was made in 2006.

A proposal for a Network Disaster Preparedness Coalition was approved by CMS in December 2006 and a kick-off meeting was held in February 2007. A CMS consultant assisted Network 2 with the development of the Coalition and specific methods for disaster preparedness in NYC’s five boroughs. This geographic area houses 50% of Network 2’s ESRD population and facilities and is vulnerable to disasters, both natural and man-made. Today, the Coalition is one of the largest in the country, including nearly 70 members from the renal community.

In parallel to Coalition efforts, Network 2 is also developing a specific internal disaster preparedness plan to enhance communication between Network employees, outside agencies and providers. The development of Network 2’s Disaster Plan, which was completed in March 2007, involves improving and, in some instances, initiating communication with outside

agencies. New partnerships have already begun to form due to these communications.

2. Centers for Medicare and Medicaid Services

There has been frequent communication between Network 2 and the CMS Boston Regional office during the transition of leadership to the IPRO ESRD Network of NY. Network 2 also participates in monthly CMS/ESRD Network conference calls.


37

3. Quality Improvement Organization

IPRO, as the New York Quality Improvement Organization (QIO), and the ESRD Network of NY continue to build their relationship and work toward improving the lives of ESRD patients. Network 2 and IPRO are collaborating on the development of surgeon-specific data reports utilizing Medicare claims data. Network 2 collaborated with IPRO’s statistician/analyst on mortality rates in NY. IPRO also assisted in developing a state map displaying AVF rates by facility.

4. NY State Department of Health

Bureau of Health Facility Planning

The NYS DOH Bureau of Health Facility Planning receives and evaluates applications for proposed ESRD facilities and expansion of existing facilities. The Bureau conducts appropriate research to determine the impact of the proposed facility on existing facilities and whether there is a need for additional treatment stations in the application area. Network 2 supports the NYS DOH in this evaluation by providing facility data including the number of patients by facility and in total in each zip code; utilization reports to include all providers, number of stations and number of patients; and to verify provider names, addresses and numbers.

Network 2 has developed custom reports to provide this data to the NYS DOH. They include dialysis patient counts by zip code of residence, list of patient counts on a monthly basis, and transfer in and transfer out events for every facility.

Survey and Certification Agency

The NYS DOH met with Network 2 via conference call to discuss the State Survey Agency (SSA) survey process and areas of potential collaboration between our agencies.

A coalition was developed by the NYS DOH to address the clinical scope of practice issues for LPNs and patient care technicians in dialysis facilities. Representatives from the DOH, State Education Department, Network 2, NYS Nurse’s Association, Union 1199, DaVita, and Fresenius attended.

The main focus of this group is to develop a training program for LPNs to access central venous catheters for dialysis in the chronic outpatient setting. The training program and annual competency was developed and sent to facilities in July 2006. All LPNs should have completed training for accessing central venous catheters for dialysis as of October 1, 2006. Enforcement of this training is ongoing via DOH survey and recertification visits to individual facilities.


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5. ESRD Networks

Network 2 worked collaboratively with the Network of New England (Network 1) to transition leadership in 2006.

6. Professional Organizations

The Network conducted activities in cooperation with American Nephrology Nurses Association (ANNA) in 2006. The Network Quality Improvement Coordinator (QIC), who serves as the chapter treasurer of the Long Island chapter of ANNA, attends monthly educational committee meetings. The committee developed two all-day conferences for nephrology nurses that were presented in May and November 2006. The May meeting included a one-hour presentation by the QIC entitled, “Updates from the ESRD Network.” The chapter also participates in planning the Network 2 Annual Meeting and Scientific Program and in processing its application for Continuing Education Units (CEUs).

7. Spring Network Council Meeting/Provider Session

In an outreach to providers, Network 2 invited medical directors, unit administrators, and other facility professional staff to attend the June Council Meeting at the LaGuardia Airport Marriott Hotel in East Elmhurst, NY on June 2, 2006. A guest speaker from the NYS DOH gave a presentation on collaborative activities with Network 2 designed to improve care.

The Network Vocational Rehabilitation Specialist presented employer recognition awards for support in assisting ESRD patients in the workplace. The Network 2 Patient Services Coordinator presented on the Decreasing Dialysis Patient-Provider Conflict toolkit. The President of the Network and the Interim Executive Director presented highlights on the 2006-2009 SOW.

8. Fall Annual Network Meeting Scientific Program

Facility providers and other renal community members attended the Fall Network Annual Meeting held on September 29, 2006 at the LaGuardia Airport Marriott Hotel in East Elmhurst, NY. “Professional Challenges in Dialysis Patient-Centered Care” was the theme of the teaching day. The event was attended by 165 physicians, nurses, social workers, dietitians and patient representatives. The goals of the workshop were to:

Discuss how the Fistula First initiative impacts mortality rates;

Develop effective treatment goals for chronic mineral bone disease;

Develop better staff response to patients with mental health issues and minimize conflict;


39

Communicate effectively to patients at their level of understanding; and

Design a practical physical rehabilitation program in dialysis units.

The conference started with a Network Council meeting, during which the SOW was reviewed, and then segued into an educational meeting. Awards were distributed for achievements in Fistula First improvement and data forms compliance, and employers were recognized for their ongoing support of their ESRD patient employees.

Goal 5: To improve patient perception of care and experience of care, and resolve patients’ complaints and grievances regarding ESRD facilities and providers

Network 2 maintained consistent efforts throughout 2006 to assist, facilitate and educate ESRD facilities in resolving beneficiary complaints and grievances. Complaints and grievances are classified as informal, formal or referral on intake. Examination of a formal grievance involves CMS-specific investigation criteria, a grievance determination, due process for involved parties and a final written report. The Medical Review Board or the Grievance Committee reviews and makes the determination. Specific steps to achieve these determinations are outlined in the Grievance Policy.

There were no formal grievances in 2006. Fifty-eight beneficiary complaints were resolved informally in 2006, an increase of 7% over the previous year. Referrals were made to the agencies deemed appropriate by Network 2 staff, the Grievance Committee and Medical Review Board.

1. Patient Advisory Committee Activities

A Patient Advisory Committee (PAC) chairperson meeting was held in August 2006, at which attendees were updated on Network contract changes, the relocation of Network 2 to IPRO’s Lake Success, NY office and the distribution of current contact information. An important initiative for Network 2 in 2007 is to increase membership and involvement in the PAC. Facility PAC representatives, who are patients within the facility, are mentored by the chairpersons on patient empowerment activities. These patient representatives encourage patient-staff communications, educate patients on safety awareness and provide other educational information to encourage patients to be more involved in their health care. The chairpersons’ goals for PAC representatives are to:

Be a link between patients in the unit and Network 2,

Address patient concerns,

Provide information and promote understanding,


40

Improve communication between patients and staff,

Help improve the quality of life of ESRD patients,

Empower consumers to be involved in their healthcare, emphasizing “KNOW YOUR NUMBERS!,"

Promote exercise while emphasizing to "check with your doctor first,"

Encourage patients to seek counsel from their social workers, and

Organize social events to promote a sense of community.

2. Dealing with the Challenging Patient

Facilities were required to send documentation on all disruptive/abusive patients and to include Network 2 staff in the process of discharging patients with violent behavior. Facilities used all available Network 2 resources, i.e., the Decreasing Dialysis Patient-Provider Conflict (DPC) toolkit, in-services, the Policy Statement on Patient Referral, Transfer and Discharge and Web site, www.esrd.ipro.org. In 2006, Network 2 received 85 calls related to patient transfer/discharge.

At the core of the DPC toolkit is the staff-training component, which is designed for all levels of staff, particularly dialysis staff who provide direct patient care but who may not have received training in professionalism or conflict resolution. The training aims to build the staff's conflict resolution and communication skills, and improve understanding of how their interactions with patients, their families, friends and other staff may trigger or escalate conflict in the dialysis setting.

DPC training components include:

Create a Calm Environment

Open Yourself to Understanding Others

Need a Nonjudgmental Approach?

Focus on the Issue

Look for Solutions

Implement Agreement

Continue to Communicate

During 2006, Network 2 continued its series of one-day regional workshops for facility staff entitled “Help! Nonviolent Crisis Intervention in the Dialysis Unit” with presentations in Albany (October) and New York City (November). The


41

Network 2 Patient Services Coordinator and the QIC demonstrated methods for reducing disruptive and threatening situations. 33 participants, including nurses, social workers and unit administrators, from 17 facilities practiced techniques for reducing verbal threats, maintaining personal safety, and gaining cooperation from challenging individuals. Trainee evaluations of the two workshops provided an overall rating of 4.81 on a scale of 1-5.

Since April 2002, 228 facility staff have attended Network 2’s crisis management training workshops from 152 (64%) of the 239 dialysis outpatient facilities in the state. DPC Toolkit contents were reviewed and the necessity for facility-level staff training utilizing the toolkit was discussed.

3. Technical Assistance

In 2006, Network 2 continued to receive calls for technical assistance from facility staff, and experienced a trend toward requests for help on issues of abusive, disruptive and threatening behaviors from patients, discharge procedures, if discharge is applicable, and non-payment.

In response, the transfer and discharge policy was frequently faxed to providers as a reference tool and reviewed by Network 2 staff with facilities at professional meetings, whenever appropriate.

Some callers requested assistance regarding due process procedures to resolve issues and prevent patient discharge. In cases where a physical assault or serious threat of physical assault occurred, the facility immediately terminated treatment. In cases of aggressive and/or disruptive behavior without physical assault or serious threat of physical assault, detailed steps for behavior modification intervention strategies were provided. In all cases, Network 2 staff recommended use of the DPC toolkit to train staff on conflict prevention.

Most beneficiary complaints were resolved by Network 2 staff interacting with dialysis unit staff on behalf for the patient, i.e., providing suggestions for intervention and encouraging increased education and communication with the patient.

In addition to its proactive efforts to address complaints and grievances through education of dialysis unit staff on the DPC toolkit, Network 2 distributed posters (as shown in the image above) to facilities to publicize grievance procedures and Network 2 contact information for obtaining assistance.


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4—Sanction Recommendations

Public 98-369 amends Section 1881(c) of the Social Security Act states the Network can recommend to CMS the imposition of an alternative sanction when the Network documents that an ESRD provider is not cooperating in meeting Network goals and objectives. The Federal Regulations that implement this statute are contained in 42CFR 405.2181.

No sanctions were recommended to CMS regarding any ESRD provider in Network 2 during 2006.


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5—Recommendations for Additional Facilities

No specific recommendations for additional facilities were made during 2006.


44

6—Data Tables

The following data tables are supplied, using the SIMS template, at the end of this document.

Table 1. Newly Diagnosed Chronic ESRD Patients

Table 2. Living ESRD Dialysis Patients

Table 3. Dialysis Modality - Self-Care Settings - Home

Table 4. Dialysis Modality - In-Center

Table 5. Renal Transplant by Transplant Center

Table 6. Renal Transplant Recipients

Table 7. Dialysis Deaths

NY OTHER TOTALAge Group

ESRD Network 2 Table #1

Newly Diagnosed Chronic ESRD Patients(ESRD Incidence)

Newly diagnosed chronic ESRD patients by state of residence, age, gender, race, and primary diagnosis for calendar year 2006

00-04 19 2 21 05-09 8 1 9 10-14 13 3 16 15-19 34 3 37 20-24 53 4 57 25-29 103 1 104 30-34 129 6 135 35-39 206 5 211 40-44 303 7 310 45-49 429 5 434 50-54 577 11 588 55-59 722 14 736 60-64 762 13 775 65-69 797 16 813 70-74 822 17 839 75-79 846 14 860 80-84 766 14 780 >=85 583 11 594 Missing 0 0 0 Total 7172 147 7319

Female 3166 48 3214 Male 4006 99 4105 Missing 0 0 0 Total 7172 147 7319

Gender

Race

American Indian/Alaska Native 28 0 28 Asian 298 2 300 Black or African American 2174 16 2190 More than one race selected 67 3 70 Native Hawaiian or Other Pacific Islander 23 0 23 White 4328 87 4415 Missing 254 39 293 Total 7172 147 7319

Cystic Kidney 148 5 153 Diabetes 2956 29 2985 Glomerulonephritis 575 11 586 Hypertension 1592 23 1615 Other 1044 33 1077 Other Urologic 148 2 150 Missing 287 39 326 Unknown 422 5 427 Total 7172 147 7319

Primary Diagnosis

Source of information: Network SIMS DatabaseDate of Preparation: June 2007Race: The categories are from the CMS-2728 Form.Diagnosis: Categories are from the CMS-2728. A diagnosis of 'unknown' is ICD-9 code 7999.This table cannot be compared to the CMS facility survey because the CMS Facility Survey is limited to dialysis patients receiving outpatient services from Medicare approved dialysis facilities. This table includes 196 patients with transplant therapy as an initial treatment.This table includes 109 patients receiving treatment at VA facilities.

NY OTHER TOTALAge Group


Living ESRD Dialysis Patients(ESRD Dialysis Prevalence)

00-04 24 1 25 05-09 7 0 7 10-14 26 1 27 15-19 57 0 57 20-24 180 3 183 25-29 337 2 339 30-34 497 7 504 35-39 857 9 866 40-44 1213 10 1223 45-49 1658 20 1678 50-54 2138 18 2156 55-59 2626 12 2638 60-64 2638 15 2653 65-69 2701 14 2715 70-74 2581 16 2597 75-79 2286 13 2299 80-84 1857 10 1867 >=85 1228 11 1239 Missing 0 0 0 Total 22911 162 23073

All active Dialysis Patients by state of residence, age, race, gender and primary diagnosis as of 12/31/06


Gender

Race


Cystic Kidney 653 11 664 Diabetes 9134 54 9188 Glomerulonephritis 2697 23 2720 Hypertension 5507 35 5542 Other 2577 22 2599 Other Urologic 479 1 480 Missing 199 5 204 Unknown 1665 11 1676 Total 22911 162 23073

Primary Diagnosis

Source of information: Network SIMS Database

Date of Preparation: June 2007

Race: The categories are from the CMS-2728 Form.

Diagnosis: Categories are from the CMS-2728. A diagnosis of 'unknown' is ICD-9 code 7999.

This table cannot be compared to the CMS facility survey because the CMS Facility Survey is limited to dialysis patients

receiving outpatient services from Medicare approved dialysis facilities.

The numbers may not reflect the true point prevalence due to different definitions for transient patients.

This table includes 274 patients receiving treatment at VA facilities.

Number of living patients by modality by dialysis facility self-care settings as of December 31, 2005 and December 31, 2006

Dialysis Modality

Self-Care Settings – Home

HEMO CAPD CCPD IPD

ESRD Network 2Table #3 — Part 1

TOTAL

330169 0 0 0 0 0 0 0 0 0 033016F 1 1 0 0 4 3 0 0 5 433017F 0 0 0 2 0 3 0 0 0 5330191 0 4 4 4 5 3 0 0 9 11330193 0 1 3 1 2 2 0 0 5 4330194 0 0 0 0 0 0 0 0 0 0330195 0 0 0 0 0 0 0 0 0 0330196 0 0 0 0 0 0 0 0 0 0330198 0 0 0 0 0 0 0 0 0 0330199 0 0 0 1 2 1 0 0 2 233019F 0 0 1 1 0 0 0 0 1 1330201 0 0 0 0 0 0 0 0 0 0330202 0 0 0 0 0 0 0 0 0 0330204 0 0 9 7 11 7 1 1 21 15330209 0 0 24 13 6 7 0 0 30 2033020F 0 0 0 0 0 0 0 0 0 0330211 0 0 0 0 0 0 0 0 0 0330214 0 0 0 0 0 0 0 0 0 0330219 0 0 0 0 0 0 0 0 0 0330226 0 0 12 12 9 12 0 0 21 24330229 0 0 1 0 0 0 0 0 1 0330230 0 0 0 0 0 0 0 0 0 0330231 0 0 0 0 0 0 0 0 0 0330233 0 0 0 0 0 0 0 0 0 0330239 0 0 1 1 25 22 0 0 26 23330240 0 0 0 0 0 0 0 0 0 0330250 0 0 9 9 0 0 0 0 9 9330273^ 0 0 0 0 0 0 0 0 0 0330275 0 0 0 0 0 0 0 0 0 0330286 0 0 0 0 0 0 0 0 0 0330290 0 0 0 0 0 0 0 0 0 0330350 0 0 0 0 0 0 0 0 0 0330357 0 0 14 15 4 4 0 0 18 19330394 1 0 3 0 15 0 0 0 19 0330395 0 0 0 0 0 0 0 0 0 0330396^ 0 0 0 0 0 0 0 0 0 0330397 0 0 0 0 0 0 0 0 0 0330401 0 0 2 2 6 8 0 0 8 10332009 0 0 7 4 5 3 0 0 12 7332504 0 0 0 0 0 0 0 0 0 0332506 0 0 0 0 0 0 0 0 0 0332508 0 0 31 0 12 0 0 0 43 0332510 0 0 0 0 0 0 0 0 0 0332511 0 0 2 3 5 4 0 0 7 7332512 0 0 0 0 0 0 0 0 0 0


Dialysis Modality


HEMO CAPD CCPD IPD


TOTAL

332513 0 0 3 6 14 11 0 0 17 17332514 0 0 0 0 0 0 0 0 0 0332516 0 0 2 4 1 0 0 0 3 4332517 0 0 0 0 0 0 0 0 0 0332518 0 0 2 2 3 2 0 0 5 4332519 0 0 0 0 0 0 0 0 0 0332520 28 24 24 18 14 16 0 0 66 58332521 0 0 0 0 0 0 0 0 0 0332522 0 0 2 0 5 3 0 0 7 3332523 0 0 2 6 3 5 0 0 5 11332524 0 0 0 0 0 0 0 0 0 0332525 0 0 4 3 0 0 0 0 4 3332528 0 0 4 5 6 7 0 0 10 12332529 0 0 0 0 0 0 0 0 0 0332530 0 0 0 0 0 0 0 0 0 0332531 0 0 0 0 0 0 0 0 0 0332532 0 0 1 3 7 15 0 0 8 18332533^ 0 0 0 0 0 0 0 0 0 0332534 0 0 0 0 0 0 0 0 0 0332535 0 0 0 0 0 0 0 0 0 0332536 0 0 1 0 11 14 0 0 12 14332537 0 0 0 0 0 0 0 0 0 0332538 0 0 0 0 0 0 0 0 0 0332539 0 0 0 0 0 0 0 0 0 0332540 0 0 4 2 6 4 0 0 10 6332541 0 0 1 0 0 0 0 0 1 0332542 0 0 2 0 3 3 0 0 5 3332543 0 0 0 0 0 0 0 0 0 0332544 0 0 0 0 0 0 0 0 0 0332545 1 1 6 12 20 17 0 0 27 30332546 0 0 0 0 0 0 0 0 0 0332547 0 0 0 0 0 0 0 0 0 0332548 0 0 0 0 0 0 0 0 0 0332549 3 13 1 0 0 0 0 0 4 13332550 0 0 0 0 0 0 0 0 0 0332551 0 4 28 36 3 2 0 0 31 42332552 0 0 0 0 0 0 0 0 0 0332554 0 0 0 0 0 0 0 0 0 0332555 0 0 0 0 0 0 0 0 0 0332556 0 0 0 0 0 0 0 0 0 0332557 31 30 3 1 7 4 0 0 41 35332558 0 0 0 0 0 0 0 0 0 0332559 0 0 0 0 0 0 0 0 0 0332560 0 0 3 4 0 0 0 0 3 4332561 0 0 0 0 0 0 0 0 0 0


Dialysis Modality


HEMO CAPD CCPD IPD


TOTAL

332562 0 0 4 4 0 2 0 0 4 6332563 0 0 0 0 0 0 0 0 0 0332564 0 0 0 0 0 0 0 0 0 0332565 0 0 0 0 0 0 0 0 0 0332566 0 0 0 0 0 0 0 0 0 0332567 0 0 0 0 0 0 0 0 0 0332568 0 0 0 0 0 0 0 0 0 0332569 0 0 5 12 18 19 0 0 23 31332570 1 0 1 2 14 17 0 0 16 19332571 0 0 0 0 0 0 0 0 0 0332572 0 0 1 0 0 0 0 0 1 0332574 0 0 0 0 0 0 0 0 0 0332576 0 0 0 0 0 0 0 0 0 0332577 0 0 0 0 0 0 0 0 0 0332578 0 0 0 0 0 0 0 0 0 0332579 0 0 9 3 13 15 0 0 22 18332580 0 0 0 0 0 0 0 0 0 0332581 0 0 3 3 0 0 0 0 3 3332582 0 0 0 0 0 0 0 0 0 0332583 0 0 0 0 0 0 0 0 0 0332584 0 0 0 0 0 0 0 0 0 0332585 0 0 0 0 0 0 0 0 0 0332586 0 0 1 3 6 7 0 0 7 10332587 0 0 0 0 0 0 0 0 0 0332588 0 0 15 13 3 11 0 0 18 24332589 0 0 2 1 1 2 0 0 3 3332590 0 0 0 0 0 0 0 0 0 0332591 0 0 0 0 0 0 0 0 0 0332592 0 0 0 0 0 0 0 0 0 0332593 0 0 4 3 2 1 0 0 6 4332594 1 1 0 0 0 0 0 0 1 1332595 0 0 0 0 0 0 0 0 0 0332596 0 0 0 0 0 0 0 0 0 0332597 0 0 0 0 0 0 0 0 0 0332598 0 0 0 0 0 0 0 0 0 0332599 0 0 0 0 0 0 0 0 0 0332600 0 0 9 7 6 15 0 0 15 22332601^ 0 0 0 0 0 0 0 0 0 0332602 0 0 0 0 0 0 0 0 0 0332603 0 0 0 0 0 0 0 0 0 0332604 0 0 0 0 0 0 0 0 0 0332605 0 0 0 0 0 0 0 0 0 0332606 0 0 0 0 0 0 0 0 0 0332607 0 0 0 0 0 0 0 0 0 0332608 0 0 6 7 5 9 0 0 11 16


Dialysis Modality


HEMO CAPD CCPD IPD


TOTAL

332609^ 0 0 0 0 0 0 0 0 0 0332610 0 0 0 0 0 0 0 0 0 0332612 0 0 7 10 3 4 0 0 10 14332613 0 0 10 9 6 5 0 0 16 14332614 0 0 0 0 0 0 0 0 0 0332615 0 0 5 4 56 53 0 0 61 57332616 0 0 0 0 0 0 0 0 0 0332617 2 1 3 3 11 9 0 0 16 13332618 0 0 0 0 0 0 0 0 0 0332619 0 0 0 0 0 0 0 0 0 0332620 0 0 3 7 0 0 0 0 3 7332621 0 0 12 12 15 12 0 0 27 24332622 0 0 0 0 0 0 0 0 0 0332624 0 0 0 0 0 0 0 0 0 0332625 1 0 0 0 0 0 0 0 1 0332626 0 0 0 0 0 0 0 0 0 0332627 0 0 19 15 31 26 0 0 50 41332628 0 0 0 0 0 0 0 0 0 0332629 0 0 0 0 1 1 0 0 1 1332630 0 0 0 0 0 0 0 0 0 0332631 0 0 0 0 0 0 0 0 0 0332632 0 13 3 1 7 5 0 0 10 19332633 0 0 6 5 25 19 0 0 31 24332634 0 0 0 0 0 0 0 0 0 0332635 0 0 0 0 0 0 0 0 0 0332636 0 0 0 0 0 0 0 0 0 0332637 0 0 0 0 0 0 0 0 0 0332638 0 0 0 0 0 0 0 0 0 0332639 0 0 0 0 0 0 0 0 0 0332640 0 0 0 0 0 0 0 0 0 0332641 0 0 0 0 0 0 0 0 0 0332642 0 0 0 0 0 0 1 0 1 0332644 0 0 0 0 0 0 0 0 0 0332645 0 0 0 0 0 0 0 0 0 0332646 0 0 0 0 0 0 0 0 0 0332647 0 0 0 0 0 0 0 0 0 0332648 0 0 0 0 0 0 0 0 0 0332649 0 0 2 3 9 7 0 0 11 10332650 0 0 0 0 0 0 0 0 0 0332651 0 0 0 0 0 0 0 0 0 0332652# 0 0 0 0 0 0 0 0 0 0333300 0 0 0 0 4 3 0 0 4 3333503 9 6 0 0 0 0 0 0 9 6333504 10 8 5 3 3 2 0 0 18 13333506 0 0 0 0 0 0 0 0 0 0


Dialysis Modality


HEMO CAPD CCPD IPD


TOTAL

333510 0 0 0 0 0 0 0 0 0 0333511 0 0 0 0 0 0 0 0 0 0333515 0 0 0 0 0 0 0 0 0 0333516^ 0 0 0 0 0 0 0 0 0 0333517 0 0 0 0 0 0 0 0 0 0333518 0 0 0 0 0 0 0 0 0 0333520 0 0 0 0 0 0 0 0 0 0333522 0 0 0 0 0 0 0 0 0 0333523 0 0 0 0 0 0 0 0 0 0333524 0 0 1 0 4 9 0 0 5 9333525 0 0 0 0 0 0 0 0 0 0333526 0 0 0 0 0 0 0 0 0 0333527 1 1 8 9 6 5 0 0 15 15333529 0 0 0 0 0 0 0 0 0 0333531 2 2 0 0 0 0 0 0 2 2333532 0 0 0 0 0 0 0 0 0 0333533 0 0 0 0 0 0 0 0 0 0333534 0 0 0 1 2 1 0 0 2 2333535 0 0 0 0 0 0 0 0 0 0333536 0 0 9 10 0 0 0 0 9 10333537^ 0 0 0 0 0 0 0 0 0 0333538 0 0 0 0 0 0 0 0 0 0333539 0 0 5 5 0 1 0 0 5 6333541 0 0 0 0 0 0 0 0 0 0333542 0 0 0 0 0 0 0 0 0 0333543 1 0 0 0 0 0 0 0 1 0333544 6 6 6 8 13 13 0 0 25 27333545 0 0 0 0 0 0 0 0 0 0333546 0 3 5 6 22 39 0 0 27 48333547# 0 0 0 28 0 17 0 0 0 45333548# 0 0 0 3 0 3 0 0 0 6

Source of Information: Facility Survey (CMS 2744) and Network SIMS Database Date of Preparation: May 2007 This table includes 8 Veterans Affairs Facility patients for 2005 and 13 Veterans Affairs Facility patients for 2006. # Provider not operational in 2005 ^ Provider not operational in 2006


Dialysis Modality


HEMO CAPD CCPD IPD


TOTAL

330169 1 3 0 0 1 3 1 333016F 76 64 0 0 76 64 81 6833017F 42 40 0 0 42 40 42 45330191 100 106 0 0 100 106 109 117330193 111 110 0 0 111 110 116 114330194 9 3 0 0 9 3 9 3

Number of living patients by modality by dialysis facility in-center as of December 31, 2005 and December 31, 2006

Dialysis Modality

In-Center

HEMOTOTAL OF HOME

& IN-CENTER*TOTALPD


330195 3 9 0 0 3 9 3 9330196 3 3 0 0 3 3 3 3330198 2 6 0 0 2 6 2 6330199 49 45 0 0 49 45 51 4733019F 25 27 0 0 25 27 26 28330201 83 87 0 0 83 87 83 87330202 111 125 0 0 111 125 111 125330204 61 59 0 0 66 60 87 75330209 113 116 0 0 113 116 143 13633020F 57 59 0 0 57 59 57 59330211 2 1 0 0 2 1 2 1330214 6 10 0 0 6 10 6 10330219 39 54 0 0 39 54 39 54330226 169 171 0 0 169 171 190 195330229 59 58 0 0 59 58 60 58330230 31 34 0 0 31 34 31 34330231 2 0 0 0 2 0 2 0330233 35 32 0 0 35 32 35 32330239 74 85 0 0 74 85 100 108330240 84 80 0 0 84 80 84 80330250 66 82 0 0 66 82 75 91330273^ 0 0 0 0 0 0 0 0330275 97 94 0 0 97 94 97 94330286 24 30 0 0 24 30 24 30330290 8 10 0 0 8 10 8 10330350 10 1 0 0 10 1 10 1330357 6 0 0 0 6 0 24 19330394 127 131 0 0 127 131 146 131330395 64 75 0 0 64 75 64 75330396^ 0 0 0 0 0 0 0 0330397 25 0 0 0 25 0 25 0330401 98 97 0 0 98 97 106 107332009 185 188 0 0 185 188 197 195332504 91 93 0 0 91 93 91 93332506 112 112 0 0 112 112 112 112332508 223 0 0 223 0 266 0332510 61 59 0 0 61 59 61 59332511 172 170 0 0 172 170 179 177332512 120 128 0 0 120 128 120 128

332513 94 105 0 0 94 105 111 122332514 192 174 0 0 192 174 192 174332516 184 178 0 0 184 178 187 182


Dialysis Modality

In-Center

HEMOTOTAL OF HOME

& IN-CENTER*TOTALPD


332517 330 334 0 0 330 334 330 334332518 98 105 0 0 98 105 103 109332519 102 87 0 0 102 87 102 87332520 241 244 0 0 241 244 307 302332521 95 106 0 0 95 106 95 106332522 190 184 0 0 190 184 197 187332523 131 137 0 0 131 137 136 148332524 106 105 0 0 106 105 106 105332525 138 151 0 0 138 151 142 154332528 147 133 0 0 147 133 157 145332529 65 66 0 0 65 66 65 66332530 163 155 0 0 163 155 163 155332531 212 209 0 0 212 209 212 209332532 88 88 0 0 88 88 96 106332533^ 0 0 0 0 0 0 0 0332534 62 85 0 0 62 85 62 85332535 167 170 0 0 167 170 167 170332536 39 35 0 0 39 35 51 49332537 56 53 0 0 56 53 56 53332538 111 111 0 0 111 111 111 111332539 187 188 0 0 187 188 187 188332540 103 108 0 0 103 108 113 114332541 265 257 0 0 265 257 266 257332542 174 151 0 0 174 151 179 154332543 63 67 0 0 63 67 63 67332544 127 128 0 0 127 128 127 128332545 133 136 0 0 133 136 160 166332546 76 72 0 1 76 73 76 73332547 182 189 0 0 182 189 182 189332548 111 128 0 0 111 128 111 128332549 87 84 0 0 87 84 91 97332550 102 94 0 0 102 94 102 94332551 142 146 0 0 142 146 173 188332552 82 66 0 0 82 66 82 66332554 81 78 0 0 81 78 81 78332555 49 47 0 0 49 47 49 47332556 131 135 0 0 131 135 131 135332557 58 65 0 0 58 65 99 100332558 147 147 0 0 147 147 147 147332559 56 60 0 0 56 60 56 60332560 124 126 0 0 124 126 127 130332561 116 0 0 0 116 0 116 0


Dialysis Modality

In-Center

HEMOTOTAL OF HOME

& IN-CENTER*TOTALPD


332562 61 58 0 0 61 58 65 64


Dialysis Modality

In-Center

HEMOTOTAL OF HOME

& IN-CENTER*TOTALPD


332563 149 152 0 0 149 152 149 152332564 105 92 0 0 105 92 105 92332565 119 122 0 0 119 122 119 122332566 155 154 0 0 155 154 155 154332567 101 127 0 0 101 127 101 127332568 90 85 0 0 90 85 90 85332569 138 143 0 0 138 143 161 174332570 125 122 0 0 125 122 141 141332571 94 88 0 0 94 88 94 88332572 90 96 0 0 90 96 91 96332574 78 76 0 0 78 76 78 76332576 173 164 0 0 173 164 173 164332577 199 198 0 0 199 198 199 198332578 126 121 0 0 126 121 126 121332579 0 0 0 0 0 0 22 18332580 50 50 0 0 50 50 50 50332581 172 171 0 0 172 171 175 174332582 147 149 0 0 147 149 147 149332583 106 108 0 0 106 108 106 108332584 48 48 0 0 48 48 48 48332585 89 102 0 0 89 102 89 102332586 74 78 0 0 74 78 81 88332587 40 35 0 0 40 35 40 35332588 120 113 0 0 120 113 138 137332589 230 234 0 0 230 234 233 237332590 120 125 0 0 120 125 120 125332591 43 47 0 0 43 47 43 47332592 78 65 0 0 78 65 78 65332593 168 160 0 0 168 160 174 164332594 97 79 0 0 97 79 98 80332595 143 140 0 0 143 140 143 140332596 90 103 0 0 90 103 90 103332597 52 56 0 0 52 56 52 56332598 88 110 0 0 88 110 88 110332599 63 77 0 0 63 77 63 77332600 98 102 0 0 98 102 113 124332601^ 0 0 0 0 0 0 0 0332602 140 149 0 0 140 149 140 149332603 114 115 0 0 114 115 114 115332604 58 51 0 0 58 51 58 51332605 86 88 0 0 86 88 86 88332606 127 122 0 0 127 122 127 122332607 150 150 0 0 150 150 150 150332608 95 104 0 0 95 104 106 120


Dialysis Modality

In-Center

HEMOTOTAL OF HOME

& IN-CENTER*TOTALPD


332609^ 0 0 0 0 0 0 0 0332610 120 110 0 0 120 110 120 110332612 185 177 0 0 185 177 195 191332613 182 186 0 0 182 186 198 200332614 34 34 0 0 34 34 34 34332615 172 178 0 0 172 178 233 235332616 12 8 0 0 12 8 12 8332617 92 91 0 0 92 91 108 104332618 79 0 0 0 79 0 79 0332619 129 141 0 0 129 141 129 141332620 132 142 0 0 132 142 135 149332621 132 134 0 0 132 134 159 158332622 123 140 0 0 123 140 123 140332624 5 0 0 0 5 0 5 0332625 87 85 0 0 87 85 88 85332626 7 1 0 0 7 1 7 1332627 74 86 0 0 74 86 124 127332628 92 97 0 0 92 97 92 97332629 175 187 0 0 175 187 176 188332630 12 24 0 0 12 24 12 24332631 60 62 0 0 60 62 60 62332632 81 91 0 0 81 91 91 110332633 158 151 0 0 158 151 189 175332634 43 32 0 0 43 32 43 32332635 145 150 0 0 145 150 145 150332636 35 37 0 0 35 37 35 37332637 71 104 0 0 71 104 71 104332638 25 24 0 0 25 24 25 24332639 67 74 0 0 67 74 67 74332640 35 45 0 0 35 45 35 45332641 52 51 0 0 52 51 52 51332642 132 149 0 0 132 149 133 149332644 67 101 0 0 67 101 67 101332645 44 46 0 0 44 46 44 46332646 101 123 0 0 101 123 101 123332647 27 48 0 0 27 48 27 48332648 46 74 0 0 46 74 46 74332649 101 110 0 0 101 110 112 120332650 5 45 0 0 5 45 5 45332651 75 78 0 0 75 78 75 78332652# 0 77 0 0 0 77 0 77333300 8 9 0 0 8 9 12 12333503 182 162 0 0 182 162 191 168333504 180 179 0 0 180 179 198 192

333510 61 58 0 0 61 58 61 58333511 182 173 0 0 182 173 182 173333515 176 190 0 0 176 190 176 190333516^ 0 0 0 0 0 0 0 0333517 61 48 0 0 61 48 61 48333518 42 49 0 0 42 49 42 49333520 24 24 0 0 24 24 24 24333522 93 95 0 0 93 95 93 95333523 18 22 0 0 18 22 18 22333524 178 177 0 0 178 177 183 186333525 46 46 0 0 46 46 46 46333526 64 65 0 0 64 65 64 65333527 136 161 0 0 136 161 151 176333529 32 32 0 0 32 32 32 32333531 70 71 0 0 70 71 72 73333532 28 33 0 0 28 33 28 33333533 57 50 0 0 57 50 57 50333534 46 44 0 0 46 44 48 46333535 95 114 0 0 95 114 95 114333536 60 62 0 1 60 63 69 73333537^ 0 0 0 0 0 0 0 0333538 30 30 0 0 30 30 30 30333539 179 187 0 0 179 187 184 193333541 128 135 0 0 128 135 128 135333542 32 32 0 0 32 32 32 32333543 10 9 0 0 10 9 11 9333544 155 155 0 0 155 155 180 182333545 23 26 0 0 23 26 23 26333546 88 91 0 0 88 91 115 139333547# 0 219 0 0 0 219 0 264333548# 0 116 0 0 0 116 0 122

Source of Information: Facility Survey (CMS 2744) and Network SIMS Database *Total from Table #3 plus total from Table #4 (for last column of report year) Date of Preparation: May 2007 This table includes 270 Veterans Affairs Facility patients for 2005 and 265 Veterans Affairs Facility patients for 2006. # Provider not operational in 2005 ^ Provider not operational in 2006


Dialysis Modality

In-Center

HEMOTOTAL OF HOME

& IN-CENTER*TOTALPD


333506 152 135 0 0 152 135 152 135

TOTAL TRANSPLANTS PERFORMED

PATIENTS WAITING FOR TRANSPLANT *

Number of transplants performed by transplant center calendar year 2005 and calendar year 2006

Transplant Center 2005 20052006 2006

ESRD Network 2Table #5

Renal Transplant by Transplant Center

43 55 252330005 261 199 251 285330012 214 60 55 175330013 120

177 201 198330024 916 18 12 191330046 184 94 99 891330059 854

170 234 210330101 0 33 46 260330214 283 44 44 88330219 68

110 107 260330234 40 42 25 145330241 143 73 61 303330285 250 95 96 486330350 506 70 71 344330393 359 3 0 0333300 7

1,231 1,357 NY Total 1,231 1,357 NETWORK TOTAL:

Source of information: Network SIMS Database/CMS-2744Date of Preparation: May 2007* These numbers are not added to State or Network totals because some patients may be placed on more than one waiting list.

The numbers are only accurate for each center.# Provider not operational in 2005^ Provider not operational in 2006

CADAVERICLIVING

RELATEDLIVING

UNRELATED TOTAL

00-04 6 3 0 9 05-09 5 2 1 8 10-14 13 3 0 16 15-19 36 8 0 44 20-24 13 18 1 32 25-29 22 26 2 50 30-34 58 23 10 91 35-39 46 35 13 94 40-44 85 41 17 143 45-49 102 37 27 166 50-54 112 33 24 169 55-59 104 39 18 161 60-64 115 29 22 166 65-69 76 33 17 126 70-74 40 12 7 59 75-79 12 7 2 21 80-84 1 0 0 1 >=85 1 0 0 1 Missing 0 0 0 0 Total 847 349 161 1357

AGE GROUP


Renal Transplant RecipientsRenal transplant recipients by transplant type, age, race, gender and primary diagnosis for calendar year 2006

Female 352 156 66 574 Male 495 193 95 783 Missing 0 0 0 0 Total 847 349 161 1357

Gender

Race

American Indian/Alaska Native 12 4 2 18 Asian 54 14 11 79 Black or African American 331 82 18 431 More than one race selected 7 5 1 13 Native Hawaiian or Other Pacific Islander 4 1 0 5 White 424 229 123 776 Missing 15 14 6 35 Total 847 349 161 1357

Cystic Kidney 63 17 26 106 Diabetes 190 74 46 310 Glomerulonephritis 189 85 25 299 Hypertension 175 43 16 234 Other 134 65 25 224 Other Urologic 17 11 2 30 Missing

Source of information: Network SIMS DatabaseDate of Preparation: May 2007Race: The categories are from the CMS-2728 Form.Diagnosis: Categories are from the CMS-2728. A diagnosis of 'unknown' is ICD-9 code 7999.This table includes 0 patients receiving treatment at VA facilities.

17 29 9 55 Unknown 62 25 12 99 Total 847 349 161 1357

Primary Diagnosis

NY OTHER TOTALAGE GROUP

ESRD Network 2 Table #7 — Part 1

Dialysis Deaths

00-04 1 0 1 05-09 0 0 0 10-14 1 0 1 15-19 5 0 5 20-24 7 0 7 25-29 8 1 9 30-34 22 1 23 35-39 53 0 53 40-44 111 0 111 45-49 189 1 190 50-54 275 3 278 55-59 414 6 420 60-64 456 6 462 65-69 586 4 590 70-74 690 6 696 75-79 784 12 796 80-84 751 9 760 >=85 764 12 776 Missing 0 0 0 Total 5117 61 5178

Deaths of dialysis patients by state of residence, age, race, gender, primary diagnosis and cause of death for calendar year 2006


Gender

Race


Cystic Kidney 85 2 87 Diabetes 2191 20 2211 Glomerulonephritis 350 3 353 Hypertension 1265 20 1285 Other 670 9 679 Other Urologic 104 0 104 Missing 59 1 60 Unknown

Continued on next page

393 6 399 Total 5117 61 5178

Primary Diagnosis

NY OTHER TOTAL

ESRD Network 2 Table #7 — Part 2

Dialysis DeathsDeaths of dialysis patients by state of residence, age, race, gender, primary diagnosis

and cause of death for calendar year 2006

Cardiac 2190 24 2214 Gastro Intestinal 60 0 60

Primary Cause of Death

Infection 926 8 934 Liver Disease 48 0 48 Vascular 288 2 290 Missing 258 7 265 Other 812 12 824 Unknown 535 8 543 Total 5117 61 5178

Source of information: Network SIMS DatabaseDate of Preparation: May 2007Race: The categories are from the CMS-2728 Form.Diagnosis: Categories are from the CMS-2728. A diagnosis of 'unknown' is ICD-9 code 7999.This table cannot be compared to the CMS Facility Survey because the CMS Facility Survey is limited to those deaths reported by only Medicare-approved facilities.This table includes 70 patients receiving treatment at VA facilities.

1—Preface...1—Preface Statement from the Chairman In June 2006, the Centers for Medicare and Medicaid Services (CMS) awarded the End Stage Renal Disease (ESRD) Network 2 contract

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