2011 ESRD Network of Texas, Inc. Network Coordinating Council Annual Meeting
Feb 09, 2016
2011 ESRD Network of Texas, Inc.
Network Coordinating Council
Annual Meeting
CHAIRMAN’S REPORTMelvin Laski, MD
Network Coordinating Council (NCC) Composition Network Elections Bylaws revision vote
Network Growth Network Demographics Supporting Quality Care
Network Coordinating Council
Composition: One representative appointed by each
certified facility in the Network area (Texas)
Role of representative: Annually Elect the:
Executive Committee Nominating Committee Approve Bylaws revisions
Provide input into activities of the Network
Communicating with the NCC
Methods Annual input requested via voluntary survey Annual Goals & Objectives packet
Sent to NCC Rep Submission of signed acknowledgement and
agreement required
NOMINATING COMMITTEE 11-12
Melvin Laski, MD, Lubbock Richard Gibney, MD, Waco Robert Hootkins, MD, Austin Tom Lowery, MD, Tyler
11-12 EXECUTIVE COMMITTEE
Melvin Laski, MD, Chairman Manny Alvarez, MD, Vice ChairmanLarry McGowan, TreasurerCharles Orji, MD , SecretaryRichard Gibney, MD
Immediate Past ChairmanRuben Velez, MD, MRB ChairLaura Yates, RN, CNN, At LargeJD Bell, MD, At LargeLeigh Anne Tanzberger, At Large
Slate of Officers
ESRD Network of Texas, Inc. Bylaws Revision Article IV. Quorum:
Remove quorum requirements for delegates present at the meeting.
Allow for votes by mail to count in determining quorum. Remove adjourning and rescheduling meetings due to lack of
quorum. Voting: Change from 2/3 to 1/2 the required delegate
votes, with mail vote accepted, to remove an officer, delegate or committee member or to amend the bylaws .
Mail Voting: Add voting by mail including electronic mail by receipt of the
proposal with notice of the meeting, or after the meeting to absent delegates, with votes counted
together with those cast at the meeting if returned within specified time frame.
Count mail votes by delegates in quorum determination. When stated in notice, if a delegate is absent from the meeting and fails to vote by mail within the specified time period, the delegate vote may be counted in favor of the proposal.
Article V. Officers: Replace Executive Committee for Council
when secretary presents unaudited financial statements at the end of each fiscal year.
Article VI. Meeting Notice: Add electronic mail notice. Action without a Meeting: Replace all with 50% of
delegates voting to approve.
Article XI. Amendments: Replace 2/3 with 1/2 the number of
votes required to repeal or amend the bylaws.
Changes to update terminology and agencies:
Network Coordinating Council
VOTE
2010 Network #14 Growth & Trends•CMS Certified Facilities • Facility Ownership• Growth in Patient Census • Patients Transplanted
NETWORK GROWTHNumber of Medicare Certified
Providers
1990
1995
2000
2005
2006
2007
2008
2009
2010
0100200300400500
144236 305
409 414 435 457 469 496
CMS Annual Facility Survey Data
20 facilities awaiting Medicare Certification at year end
Ownership of Dialysis facilities by Percent of
facilities 2010
Regional5%
Nat'l Chain81%
Pediatric1%
Independent9%
Military1%
Prison0%
Hospital3%
FMC
49%
ARA1%
USRC9%
Davita
31%
DCI0% NRI
3%RV2%
Liberty2% Satellite
3%
National Chain Ownership TX Dialysis facilities
2010
1991
1995
2000
2005
2006
2007
2008
2009
2010
0
10,000
20,000
30,000
40,000
50,000
60,000
Prevalent Pt.'sNew Pt's.Deaths
Number of Patients, Texas
37,457
9,746
6,387
ESRD byPrimary Diagnosis
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0
1000
2000
3000
4000
5000
Diabetes Hypertension Glomerulonephritis
Cystic Other Unknown
Num
ber o
f Pat
ient
s
Incident
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
Diabetes Hypertension Glomerulonephritis
Cystic Other Unknown
Num
ber
of P
atie
nts
Prevalent
Prevalent Primary Diagnosis (%)
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0%10%20%30%40%50%60%70%80%90%
100%
Diabetes Hypertension Glomerulonephritis Cystic Other Unknown
16
At the end of 2010 • 48,394 persons
were receiving renal replacement therapy
• Of these: • 37,457 dialysis • 10,937
transplanted4,799,762 dialysis treatments delivered in Texas in 2010
Dialysis77%
Transplant23%
Self care & Setting
In Ctr HD92%
Self Care8%
Dialysis Setting
Home Dialysis
0%10%20%30%40%50%60%70%80%90%
100%
CCPDCAPDHome HD
10.2% in 2010
Home Dialysis Modality
1995
2000
2005
2007
2008
2009
2010
0500
100015002000250030003500
CCPDCAPDHome Hemodialysis
Num
ber
of p
atie
nts
Texas & National Gross Mortality
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0
5
10
15
20
25
30
21.923.322.9
21 20.720.521.8
20.420.721.621.621.321.320.921.521.420.820.219.919.618.918.217.817.5
Texas MortalityNational Mortality
US 0920.5%
Cause of Death
2000
2005
2006
2007
2008
2009
2010
0%10%20%30%40%50%60%70%80%90%
100%
UnknownOther Vascular Liver Disease Infection Gastro Intestinal Cardiac
% Diabetic = 57.8
16 12 10 17 1 8 6 9 USA 13 18 7 15 11 5 14 4 2 30%
2%
4%
6%
8%
10%
12%
14%
16%13
.8%
11.7
%
11.7
%
10.7
%
9.8%
9.5%
9.5%
9.2%
8.8%
8.8%
8.7%
8.5%
8.5%
8.3%
8.0%
7.7%
7.5%
5.9%
5.7%
2009 National ESRD Data SummaryPercent of ESRD Home Patients As of 12/31/2009
Per
cent
of P
atie
nts
Race of Prevalent Patients In Texas
1995
2000
2005
2010
010203040506070
White incl. Hispanic Black Other/ Unknown
Perc
ent o
f Pat
ient
s
Ethnicity Texas ESRD Patients
Hispanic45%Non Hispanic
55%
1995 2000 2005 2006 2007 2008 2009 20100.0
10.0
20.0
30.0
40.0
50.0
60.0
50.7 51.3 51.8 51.047.5
52.7 53.1 53.549.3 48.7 48.2 48
52.547.3 46.9 46.5
Male Female
Perc
ent
of p
atie
nts
Prevalent Patient Gender (%)
Age of Prevalent ESRD patients in Texas 2010
0-201%
21-345% 35-44
10%
45-5419%
55-6428%
65-7422%
75+15%
Average Age Prevalent 59
Transplants by Race
1995 2000 2005 2006 2007 2008 2009 20100
102030405060708090
100
18.9 17.2 19.8 18.9 21.8 21.3 22.6 22.8
62.6 75.6 75.6 74.2 73.4 70.4 70.5 72.9
18.57.2 4.6 6.9 4.8 8.3 6.9 4.3
OtherWhiteBlack
1411804 1011 1187 1233 13001275 1352
Total Transplants by Donor Type
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
0
200400
600800
1000
120014001600
Living Related Living Unrelated Deceased
Num
ber o
f Pat
ient
s
Percent of Patients Transplanted
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
05000
10000150002000025000300003500040000
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
Mean patient census# Transplanted Pats% Transplanted
THANK YOU
Report from the Executive Director
Glenda Harbert, RN, CNN, CPHQ
MISSION Statement
The ESRD Network of Texas, Inc. supports quality dialysis & kidney transplant healthcare through patient services, education, quality improvement & information management.
At year end 2010ESRD Network #14
•The second largest Network in number of patients (48,394) at year end behind Network 6 (49,308)
The 3rd largest Network in number of dialysis Providers (496) behind Network 6 (583) and Network 9 (520)
Topics Overview- Network activities Involuntary Discharge TEEC & Disaster Preparedness DSHS Referrals The Future
Activities of the Network Quality Improvement Community Information &
Outreach Information Management
Quality Improvement Quality Improvement Projects
Improving Management of AnemiaQuality of Care Concerns, Elab Data Collection & CPM’sVascular Access Improvement Projects
2 year outliers for clinical labs
New Activities in 2010-11 Patient Specific Profiles Collaborative Site Visits Large Nephrology Group
Profiles
Facility Vascular Access Profile with Patient Specific Data (PSD)
Overview
• Facility Ranking • AVF, Cath,
Goals, • Benchmarking
Analysis• Change in VA/3 mos
• Performance Categories
Priorities
• VA changes – going the wrong way
• Questions to trigger action
PSD Facilit
y Profile
PSD: Patient Specific Data
I. Overview• Ranking with other Network Facilities• % AVF Utilization Rate • % Catheter Utilization < 90 days & >
90 days• Benchmarking
04-2010 05-2010 06-2010 07-20100
1020304050607080
Percent AVF Utilization Rate% Facility AVFs in Use CMS GoalNetwork 14 Average of Top 10% Facilities
Perc
ent
of F
acili
ty P
atie
nts
Your facility ranks 240 out of 456 facilities in the Network (lowest to highest)
52.4%
47.4%
% Above% Below
July 2010Facility Census 99# of Facility AVFs in Use 56% of Facility AVFs in Use 56.6
Facility Vascular Access Profile with Patient Specific Data (PSD)
II. Analysis• Vascular Access Patterns
• Three Month Timeframe
• Performance Categories
GoodImproving
Caution ImprovingCaution Neutral
Caution WorseWorse
Cath only <90 days…AVF
Cath with AVF….AVG only
AVF…..Cath with AVF
Cath with AVF….AVF Cath with AVF….Cath with AVF
Cath with AVG…..Cath only < 90 days
Cath with AVG….AVF AVG with AVF Maturing…AVG only
AVG with AVF Maturing…Cath only < 90 days
Facility Vascular Access Profile with PSD
III. Vascular Access Facility Priorities• Performance Levels – Caution Worse &
Worse• Patient Identification Information• Questions designed to trigger a
response/action for the specific vascular access per patient
Patient Name
SSN Date of
Birth
Starting Access……Ending Access Y/N
AAA XXXXXXXXXX
--/--/-- AVF….AVG onlyHave you implemented stenosis monitoring?
BBBB XXXXXXXXXX
--/--/-- Catheter with AVF…..Catheter with AVGHave you developed & implemented a vascular access plan for this patient?
CCC XXXXXXXXXX
--/--/-- Catheter only < 90 days…..Cather only >=90 daysDid you consider AVF for this patient?
Facility Vascular Access Profile with PSD
Vascular Access Collaborative Site Visits
NW QI Staff
Focus Facilities
CSVs across Texas
Based on Tracer methodology
7 functions Opening Conference Tour of the Facility Review of Key
Documents Patient Interviews Staff Interviews QAPI Committee Exit Conference
100% would recommend to other unitsNon-Maturing, Non-Functioning AVF
Long Term Catheter Utilization
NW14 CORE Catheter ReductionCATHETEROPERATIONREDUCTION &ELIMINATION
25 Focus Facilities• >15%Catheters > 90
days• Forum of ESRD
Networks Catheter Reduction
Toolkit• Vascular Access Patient
Specific Data profiles• Goal: Reduce the % of
adult HD patients with catheter > 90 days in 70% of focus facilities
20 Large Physician Groups• 8 or more physicians• Group Profiles based
on payor source of patients who initiate with a catheter ONLY & are followed by a nephrologist prior
• Focus on groups with highest catheter rates
• Collaboration with TMF
Group X All Groups0102030405060708090
Vascular Access Type at Start of DialysisPatients with Pre-Dialysis Nephrology Care
and InsuranceJanuary – June 2010
% o
f VA
Typ
e
Large Nephrology Group Profiles
Data source 2728
Community Information & Outreach
TEEC & Disaster preparednessPatient & Provider Technical Assistance & Education
Complaints & Grievances Involuntary Discharge
What is TEEC?
The mission of TEEC is to ensure a coordinated preparedness, plan, response and recovery to emergency events affecting the Texas ESRD community.
TEEC Steering Committee Mikki Ward, RN (Chair) Kelley Harris (Chair Elect) Debbie Heinrich, RN (Secretary) Karen Walton, RN (Treasurer) John Dahlin Eugenia De Los Reves, RN Balbi Godwin, RN Vanessa Guillory, RN Bobbi Wagner Glenda Harbert, RN (ED for Network
14) Doug Havron, RN, MS Becky Heinsohm, RN (consultant) Bonnie Leshikar Kevin Burns Nick Jayne
Derek Jakovich, JD (consultant) Minnie Malone, RN (consultant) Connie Oden, RN Glenda Payne, RN (consultant) Alex Rosenblum, RN Narendra Singh Steven Tays Andrea Fichtner, MPH Sylvia Spencer Valerie Ficke
In the last year ….. Wildfires Snow, ice storms Flooding Brush with hurricanes
Disaster Preparation Activities
Drills with EMSystem Mentoring for independent
facilities Disaster Plan checklist Webinar
New Activities in 2010-11MonitorEMSyste
m complianc
e Report to DSHS when non-
complaint 2
consecutive
monthsCoach facilities
for reporting complianc
e
Review and
provide feedback
on disaster
plans (82)
Tier 1 Coastal
CountiesMay, 2010 195
Facilities15,198
Patients
Pre-Hurricane Preparations
All facilities must pre-plan for backup dialysis
with another provider
Patients should be STRONGLY encourage
d to evacuate
Any patient with limited
mobility, support
systems & or transportation MUST be
registered for evacuation with 211
Telling patients to
go the hospital for dialysis is
NOT a disaster plan!
10 Ja
n Feb Mar Apr
May Jun Jul Aug
Sep Oct Nov Dec
11 Ja
n Feb Mar AprMay Jun
e50556065707580859095
100
All Providers% C
ompl
ianc
eEMSystems Monthly UpdatesPercent Compliant Facilities
2010-2011
EMSystems Monthly UpdatesPercent Compliant Facilities
2010-2011
10 Ja
nFe
bMar Apr May Jun Jul Aug Se
pOct Nov Dec
11-Ja
nFe
bMar Apr May Jun
65
70
75
80
85
90
95
100
LDOIndependentRegional
% C
ompl
ianc
e
Percent of Facilities that Updated EMSystem during 5/11 Drill
Compli-ant; 266;
55.5%
Non-compli-
ant; 213; 44.5%
Complaints, Grievances & Involuntary Discharge (IVD)
NW 14 Trends in “negative contacts”
Percent of total
Tr Rela
ted/Q
OC
Disruptiv
e
Pt Tra
nsfer/D
isch
Abusive
NonCompliance
05
101520253035404550
44
7.9
16
1 1.4
38
5
24
15
34
4
17
3 5
23
128
2007
2008
2009
2010
Perc
ent o
f Tot
al
Data is a subset, does not equal 100% of contacts
1 Complaint, 68,
17%2 Complaints;
18; 4%
3 Complaints, 3, 1%
>3 Com-plaints; 1; 0%
None; 319; 78%
Most facilities have no complaints
Causes of Beneficiary Complaints 2010
Physical Environment; 3
Staff Re-lated; 21
QOC/Treatment;
29
Information; 5
Transfer/Discharge 6
Professional Ethics, 6
Financial; 2
Abusive/Disruptive, 1
Other; 1
Cause of Formal Grievances
Pro-fes-
sional-ism/
Ethics
IVD Medical/QOC
End of Life
00.5
11.5
22.5
33.5
44.5
1 1 1 1
4
2 2
0
1 1
3
0
2
0
3
0
2007200820092010
20072008200920100123456789
10Number of FG
Trending Involuntary Discharge
2007 2008 2009 2010
0
10
20
30
40
50
60
4454
42 424046
39 40
# Pts DC# Facilities DC
Number of Patients IVDRemained the Same over last2 years. <0.1%Of total patients
Number of Involuntary Discharges by Type 2010
N = 42
Ongoing Disruptive/Abusive Behavior
Physician Termination
Severe Immediate Threat
Can Not Meet Medical Need
Non-Payment
Other
0 2 4 6 8 10 12 14 169
3
16
5
4
5
25 of 42 IVD (59.5%) are acceptable reasons in the regulations
IVD averted 2010
Averted 23
IVD 42
• Patient at risk of IVD
• Work with patient & facility to maintain placement
IVD January 1-May 31, 2011
Non-Pay-
ment; 2
Term. By Physician; 3
Immediate/ Severe, 3
Ongoing Disruptive ; 1
Cause of Discharge
A total of 8 discharges
Status of Patients IVD Jan- May 2011
2
2
7
2
Patient Placement Status
UnknownDeceasedAdmitted to another clinicNot Admitted
IVD demographics 201066% Male
46% White
63% non- Hispanic
Who are they?
30-59 years old
30-39
18%
40-4939%
50-5924%
60-69
11%
70-795%
80+3%
Age of IVD Pts. 2010
DSHS Referral Update
Number of Cases & Levels
2007 2008 2009 201002468
1012141618
10 0 0
6
2
9
23
8
16
5
0
4
0 00 01
3
Level I
Level II
Level III
Closure
Not Certi-fied Re-ferrals
Common Themes Unsafe Infection Control Practices
Simultaneous care of Hepatitis B negative and Hepatitis B positive patients
Failure to follow vaccination program Poor hand washing practices Inappropriate use of Personal Protective Equipment
(PPE) Deficient disinfection practices Deficient catheter care
Failure to implement Quality Assessment and Performance Improvement (QAPI) Lack of tracking, trending and analyzing Inconsistent participation of Interdisciplinary team
members Failure to recognize, report and track Adverse Events
Common ThemesUnsafe Physical Environment
Hazardous chemicals in inappropriate areasTechnical/Water Treatment Practices
Not testing properly Lack of staff knowledge Unsafe Reuse practices Machine maintenance & integrity Reuse practices and procedures
Common Themes Nursing services
Competency issues Medication administration RN staffing ratios Lack of f/u critical labs
Patient Safety Concerns Lack of patient assessments (pre, during & post) Lack of staff knowledge regarding emergency
equipment Pre, Intra and Post treatment assessment and
management PA & POC
Missing Missing assessments
DSHS Referral Facilities
followed in 2010
by year of referral 201
0 10/ 33%
2009
20/ 67%
Continued 7
Initial
Survey; 3
Re-leased 20
Disposition of DSHS Referrals at year end 2010
Percent of DSHS Released Referral Facilities With Improved Outcomes at
Release n=20Improved all 4 indicators at time
of release from CAP
25.0%Improved upon 3 of the 4 indica-
tors at time of re-lease from CAP
30.0%
Improved upon 2 of the 4 indica-
tors at time of re-lease from CAP
25.0%
Improved upon 1 of the 4 indica-
tors at time of re-lease from CAP
15.0%
Improved upon 0 of the 4 indica-
tors at time of re-lease from CAP
5.0%
Chart Title
14/15 (93.3%) with improvement in fewer than 4/4 Indicators met or exceeded MRB QOC cut point at time of referral
Percent of DSHS Released Referral Facilities With Improved
Outcomes by Clinical Indicator at Release N=20
Catheter >= 90 days
AVF Rate
Anemia
Adequacy
0 10 20 30 40 50 60 70 80
70.0
70.0
57.9
60.0Chart Title
PercentFacilities with no improvement met or exceeded MRB QOC cut-point at referral
Percent of DSHS Referral Facilities that Met MRB Clinical Indicators Cut Points
at year end 2010 n=20
Catheter >= 90 days
AVF Rate
Anemia
Adequacy
84 86 88 90 92 94 96 98 100
95.0
100.0
90.0
100.0
Percent
Patients directly impacted with improved outcomes DSHS referrals
> 490 patients with improved outcomes Removal of Catheter > 90 days AVF placed Anemia improved HD Adequacy improved
9,968 patients potentially impacted
Future Nationally
National Quality Strategy The Three Part Aim Healthcare Acquired Infections
(HAI) Quality Incentive Program Crown Web
National Quality StrategyMaking
Care SaferEnsuring
Person and Family-
Centered Care
Coordinating Care
Effectively
Promoting Prevention
Supporting Better Health in
CommunitiesMaking Care More
Affordable
HHS 2011 National Quality StrategySix National Priorities1.
1. Making care safer by reducing harm caused in the delivery of care.
2. Ensuring that each person and family are engaged as partners in their care.
3. Promoting effective communication and coordination of care.
4. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with
cardiovascular disease.5. Working with communities to promote wide use of best practices to
enable healthy living.
6. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health
care delivery models.
Reduced Costs
Better Care
Better Health
The Three Part Aim
The Three Part Aim
Quality Incentive Program (QIP) Performance Score Report (PSR)
QIP PSR review period 7/15-8/15/11
MIPPA Section 153(c) ESRD QIP Requirements
Develop a method for assessing each provider or facility’s total performance on the measures relative to performance standards and the performance period
Apply an appropriate payment reduction to providers and facilities that do not meet or exceed the established total performance score
Publicly report results through websites and certificates posted at facilities
• Access QIP Performance Score Report via the Dialysis Facility Reports (DFR) website.
• Access information sent in last 2 weeks • May submit ONE formal inquiry per
provider to ask questions and raise issues to CMS.
– MIPPA Section 153(c) does not permit a formal appeals process.
Public Reporting of Scores Fall 2011• PSRs will be finalized and made available
to the public on the Dialysis Facility Compare (DFC) website.
certificate
s Poste
d by
12/15/11
What happened to Crown Web?
• Phase II Expanded- all Networks, 13 Facilities in Texas, ends 3rd week of September
• Phase III- November 2011• Full Implementation- February 2012• For more information
• Visit CW booth
Not FMC, Davita, DCI ? NRAA has collaborated with CMS to
submit data via the HIE NRAA as a Health Information
Exchange (HIE) will serve as the intermediary to electronically submit data to CMS for the ESRD Program.
A pilot is scheduled for fall 2011 Facilities must have an EHR
NW 14 Future Patient Safety Initiative Anemia Management QIP Continued focus on averting
IVD More Webinars, fewer mail-outs
We are a small staffTrying to be bigger & better However we can!
Thank you for all that you do
Alone we can do so little, together we can do so much. Helen Keller
Report fromMedical Review
Board (MRB)Chairman
Ruben Velez, M.D., F.A.C.P.
•
My Assignment Today! Review geographic representation
and functions of MRB
Share current NW #14 clinical
indicator data
Highlight opportunities for improvement
The ESRD Network of Texas, Inc.
MRB Functions Evaluate quality and appropriateness of care delivered to ESRD patients in Texas
Propose Corrective Action Plans (CAP) for dialysis units with Level 2-3 deficiencies to Texas Department of State Health Services (DSHS)
Analyze NW #14 data and recommend clinical outcome profiling cut-points
Serve as primary advisory panel to Network to promote improved patient care and safety through QI activities
Utilize NW #14 data to identify Network-wide improvement opportunities
The ESRD Network of Texas, Inc.
Current Geographic Representation of MRB
Ruben Velez, MDTrish White, RNMay Beth Callahan, SWDianne MorganJohn Dahlin. CHT Camille May, RN Thank you for serving!Donald Molony, MDOsama Gaber, MDJane Louis, RDMartha Donaho, MSWLeisha Sanders, RN-welcome
Clyde Rutherford, MDSam Al-Akash, MD
Mohanram Narayanan, MDGreg Jaffers, MD
Kaylynne Duran, RNJana Zimmer, RD- welcome
Mazeen Arar, MDAnna GonzalezNavid Saigal, MD
Robert Hootkins, MDDeborah Heinrich, RN
Jennie Lang House, RDThank youfor serving!
The ESRD Network of Texas, Inc.
2011 MRB Cut-Pointsbased on review of 2010 Elab data
HD PDMore than 80/85% of patients should have URR > 65% (TBD)
✔
More than 80% of patients have a Kt/V > 1.7 (TBD for HD)
✔
More than 50% of patients should have Hgb > 10.0 & < 12.0
✔ ✔
Less than 20% of patients should have Hgb < 10.0 ✔ ✔More than 70% patients should have TSAT > 20% ✔ ✔Serum Albumin - recommend facilities follow KDOQI/KDIGO
✔ ✔
More than 40% patients with PO4 > 3.5 & < 5.5 ✔ ✔More than 50% patients have Ca > 8.4 & < 9.5 ✔ ✔Prevalent AVF rate of more than 50%* ✔10% or fewer patients are using a catheter only > 90 days*
✔
The ESRD Network of Texas, Inc. * Based on Fistula First data
Potential Quality of Care Outliersbased on review of 2010 Elab data
Number of Facilities reporting…..Total number of facilities reporting
HD497
PD154
< 85% of patients with URR > 65% 20< 90% of patients have a Kt/V > 1.7 5 22< 50% of patients with a Hgb > 10.0 & < 12.0 48 53> 20% of patients with a Hgb < 10.0 12 25< 70% of patients with a TSAT > 20% 7 7< 40% patients with PO4 between > 3.5 & < 5.5 23 35< 50% patients with Ca between > 8.4 & < 9.5 41 23< 50% Prevalent Arteriovenous Fistula rate* 133> 10% of patients are using a catheter only > 90 days*
95
The ESRD Network of Texas, Inc. * Based on Fistula First January 2011 data
Number of Adult HD Patients per NetworkUS Total = 354,305
4th Quarter 2010
6 14 18 9 2 11 7 8 5 17 15 4 3 13 10 12 1 160
500010000150002000025000300003500040000
3384
133
681
2999
324
358
2296
822
125
2031
119
892
1955
819
105
1691
015
483
1521
214
349
1418
411
783
1081
997
33
Network
# o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter dataThe ESRD Network of Texas, Inc.
HD AdequacyPercent of Patients with URR > 65%
14 3 15 1 16 8 10 4 2 9 US 7 6 12 11 18 5 13 1785868788899091929394 93.4 93.2 93.2 93.092.9
92.192.191.6
91.191.191.190.9 90.790.3
89.889.789.4 89.4
88.0
Network
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter data
93.4%
91.1%
The ESRD Network of Texas, Inc.
2002 2003 2004 2005 2006 2007 2008 2009 2010*88
89
90
91
92
93
94
91.0 91.0
92.0
91.0 91.0
90.0
92.7
93.5 93.4
Network 14
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter dataThe ESRD Network of Texas, Inc.
HD AdequacyPercent of Patients with URR > 65%
HD AdequacyPercent of Patients with Kt/V > 1.2
3 14 15 1 8 12 4 10 16 7 US 2 9 17 18 6 13 5 1192
93
94
95
96
9796.4
96.196.1 96.0 95.9 95.995.895.8 95.795.3 95.395.2 95.2
95.0 95.094.794.6
94.3
93.7
Network
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter data
96.1%
95.3%
The ESRD Network of Texas, Inc.
HD AdequacyPercent of Patients with Kt/V > 1.2
2002 2003 2004 2005 2006 2007 2008 2009 2010*0
20
40
60
80
100 94.0 96.0 94.0 93.0 95.0 93.0 95.7 96.3 96.1
Network 14
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter dataThe ESRD Network of Texas, Inc.
HD Anemia ManagementPercent of Patients with HGB < 10.0 gm/dL
15 18 17 16 14 7 6 12 8 13 US 10 1 4 5 3 11 9 20123456789
10
4.9 5.3 5.4 5.5 5.7 6.1 6.5 6.5 6.6 6.6 6.6 6.7 6.9 6.9 7.1 7.5 7.5 7.6
9.5
Network
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter data
5.7%6.6%
The ESRD Network of Texas, Inc.
2002 2003 2004 2005 2006 2007 2008 2009 2010*0123456789
10
6.0 6.0
3.04.0 4.0
5.05.8 5.4 5.7
Network 14
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter dataThe ESRD Network of Texas, Inc.
HD Anemia ManagementPercent of Patients with HGB < 10.0 gm/dL
HD Anemia ManagementPercent of Patients with HGB > 10.0 and < 12.0 gm/dL
17 1 3 18 4 7 10 2 11 9 US 5 16 8 12 13 6 14 155658606264666870727476
73.671.9
71.1 70.970.869.469.2 68.7 68.668.568.467.7 67.3 67.266.766.666.3 66.2
63.1
Network
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter dataThe ESRD Network of Texas, Inc.
66.2%
68.4%
2008 2009 2010*30
40
50
60
70
58.260.0
66.2
Network 14
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter dataThe ESRD Network of Texas, Inc.
HD Anemia ManagementPercent of Patients with HGB > 10.0 and < 12.0 gm/dL1
1 Not stratified by this range with cut-point prior to 2008
HD Bone & Mineral MetabolismPercent of Patients with Phosphorus 3.5 to 5.5
11 3 4 15 18 10 17 2 12 5 16 US 9 1 14 7 6 13 848
50
52
54
56
58
6058.5 58.3
57.856.9 56.5 56.4 56.4 56.2 55.9 55.6 55.3 55.3 55.2 54.8
53.8 53.753.1
52.0 51.9
Network
% o
f Pat
ient
s 53.8%
*2011 preliminary QOC results – 2010 4th quarter data
55.3%
The ESRD Network of Texas, Inc.
Number of Adult PD Patients per NetworkUS Total = 29,202 4th Quarter 2010
6 18 14 9 17 8 7 11 5 15 16 12 13 10 2 4 1 30
500
1000
1500
2000
2500
3000
350032
01
2571
2414
2139
1928
1852
1616
1587
1521
1330
1312
1303
1267
1125
1101
1036
1022
877
Network
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter dataThe ESRD Network of Texas, Inc.
PD AdequacyPercent of Patients with Kt/V > 1.7
16 3 12 15 17 14 1 11 10 5 US 18 9 7 8 6 2 4 1382
84
86
88
90
92
9492.1
91.590.9 90.690.6
90.190.0 89.7 89.489.189.189.0 88.9 88.688.3
86.786.5 86.4 86.0
Network
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter data
90.1%
89.1%
The ESRD Network of Texas, Inc.
2006 2007 2008 2009 2010*0
20
40
60
80
100 91.1 89.9 90.6 91.0 90.1
Network 14
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter dataThe ESRD Network of Texas, Inc.
PD AdequacyPercent of Patients with Kt/V > 1.7 1
1 Not stratified with cut-point prior to 2006
16 12 6 15 13 4 18 9 11 5 7 8 17 US 14 3 1 10 202468
1012141618
9.2 9.4 10.010.110.410.510.510.610.610.810.910.910.910.911.311.611.713.1
15.9
Network
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter data
PD Anemia ManagementPercent of Patients with HGB < 10.0 gm/dL
The ESRD Network of Texas, Inc.
11.3%10.9%
2007 2008 2009 2010*0123456789
101112
7.2
8.9 8.8
11.3
Network 14
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter data
PD Anemia ManagementPercent of Patients with HGB < 10.0 gm/dL1
The ESRD Network of Texas, Inc. 1 Not stratified by cut-point prior to 2007
PD Anemia ManagementPercent of Patients with HGB > 10.0 and < 12.0
17 2 18 4 5 9 16 12 1 7 US 3 10 14 13 6 8 11 150
10
20
30
40
50
60
7064.0 61.8 61.2 60.459.558.958.6 58.3 58.258.258.157.8 57.6 56.656.456.356.0 55.3
51.6
Network
% o
f Pat
ient
s
58.1%
*2011 preliminary QOC results – 2010 4th quarter dataThe ESRD Network of Texas, Inc.
56.6%
2008 2009 2010*30
40
50
60
51.5
57.5 56.6
Network 14
% o
f Pat
ient
s
*2011 preliminary QOC results – 2010 4th quarter data
PD Anemia ManagementPercent of Patients with HGB > 10.0 and < 12.01
The ESRD Network of Texas, Inc. 1 Not stratified by this range with cut-point prior to 2008
Iron ManagementPercent of Patients with TSAT > 20%
14 3 13 5 7 10 18 6 15 11 US 2 4 8 12 9 17 1 16767880828486889092 90.0 89.3 88.4 88.3 88.3 88.2 87.9 87.7 87.4 87.2 87.0 86.7
85.3 85.2 84.9 84.4 84.1 84.081.6
% o
f H
D P
atie
nts
*2011 preliminary QOC results – 2010 4th quarter dataThe ESRD Network of Texas, Inc.
90.0%
87%
14 6 18 15 17 7 5 11 8 13 US 3 1 4 12 9 10 16 2767880828486889092 91.1 90.9 90.9 90.7 90.6 90.2 90.1 89.6 89.5 89.4 89.3 89.2
87.6 87.1 87.1 86.9 86.9 86.785.5
% o
f PD
Pat
ient
s
91.1%
89.3%
Network 14 Iron ManagementPercent of Patients with TSAT > 20%
2002 2003 2004 2005 2006 2007 2008 2009 2010*5060708090
10085.0 83.0 84.0 82.0 82.0 81.0
87.0 88.0 90.0
% o
f H
D
Pati
ents
*2011 preliminary QOC results – 2010 4th quarter dataThe ESRD Network of Texas, Inc.
2006 2007 2008 2009 2010*50
60
70
80
90
10086.6 87.7 88.8 91.2 91.1
% o
f P
D P
atie
nts
Network 14 Vascular Access
CATHETEROPERATIONREDUCTION &ELIMINATION
14 13 8 5 17 18 12 US 15 4 11 6 9 10 7 3 2 1 160
5
10
15
20
25
30
3531.630.8
28.327.926.125.725.325.124.924.924.323.323.323.223.122.6
21.118.918.1
Network
Perc
ent I
ncre
ase
in A
VF
25.1%
ESRD Networks & U.S. ComparisonPercent Increase in AVF
from Baseline to December 2010
31.6%
Fistula First Dashboard Dec 2010The ESRD Network of Texas, Inc.
NW 14 Vascular AccessMonthly Tracking - Prevalent AVF Rate
Fistula First Dashboard The ESRD Network of Texas, Inc.
Jan-10Fe
b-10Mar-
10Ap
r-10
May-10
Jun-10
Jul-10Au
g-10Se
p-10Oct-
10Nov
-10Dec-
10Jan
-11Fe
b-11Mar-
11Ap
r-11
51.0%52.0%53.0%54.0%55.0%56.0%57.0%58.0%59.0%60.0%61.0%
57.3%58.3% 1.3%
ESRD Networks & U.S. ComparisonPercent of Prevalent Patients with AV Fistula
December 2010
16 15 18 17 1 2 7 US 14 4 3 10 12 13 11 8 5 9 60
10
20
30
40
50
60
70 66.4 64.461.3 61.0 60.9 59.9 57.5 57.4 57.2 57.1 57.0 56.6 56.4 56.3 55.4 54.5 54.3 53.5 52.4
Network
% o
f Pat
ient
s
Fistula First Dashboard Dec. 2010
57.2%57.4%
The ESRD Network of Texas, Inc.
Dec. 2010 NW14 ranked 8th among NWs compared to Dec. 2009 ranked 10th with AVF rate 53.6%
Network 14Percent of Prevalent Patients with AV Fistula
2002 2003 2004 2005 2006 2007 2008 2009 2010*0
10
20
30
40
50
60
26.029.0
35.0
43.0 42.046.0
50.853.6
57.2
Network 14
% o
f Pat
ient
s
*Fistula First Dashboard Dec 2010The ESRD Network of Texas, Inc.
Liberty57.4%
(35.2%)
Gregg50.3%
(30.2%)
Tarrant50.3%
(17.6%) Dallas53.8%
(15.8%)
Jefferson57.6%
(44.6%)Harris57.9%
(32.7%)
Galveston59.9%
(29.0%)
Fort Bend73.7%
(45.9%)
El Paso68.5%
(28.6%)
Lubbock43.9%
(28.5%)
McLennon74.6%
(53.2%)
Bell56.5%
(15.5%)
Montgomery59.3%
(33.8%)
Brazoria58.5%
(35.7%)
Nueces55.4%
(32.5%)
Cameron50.9%
(19.5%)
Hidalgo56.7%
(36.1%)
Webb48.7%
(29.6%)
Bexar63.7%
(46.3%)
Travis60.4%
(32.4%)
Hays66.1%
(42.3%)
Smith48.3%
(34.8%)
Williamson63.4%
(24.9%)
Ector73.3%
(45.2%)
Collin55.0%
(21.2%)
Nacogdoches45.8%
(27.9%)
Grayson73.6%
(19.3%)
*Counties with 2 or less facilities censored
AV Fistula Rate By County*as of April 2011
Fistula Utilization10-19% 20-29%30-39%
( ) = % change from October 2003
40-49%50-59%60-69%>= 70%
Tom Green47.8%
(26.9%)
Atascosa66.7%
(51.9%)
Brazos63.2%(-2.5%)
Guadalupe67.7%48.6%)
Kaufman55.3%
(17.5%)
Johnson41.6%(4.4%) Congratulations
!
Counties with AVF rate > 70%:
Ector 73.3%Grayson 73.6%McLennon 74.6%Fort Bend 73.7%
ESRD Networks & U.S. ComparisonPercent of Prevalent Patients with AV Graft
December 2010
16 15 1 2 12 3 17 4 18 7 10 11 13 US 9 5 14 8 60
5
10
15
20
25
30
12.413.9
15.316.6
17.9 18.1 18.1 18.4 18.6 18.9 19.0 19.1 20.1 20.2 20.422.9
24.0 25.0
28.4
Network
% o
f Pat
ient
s
Fistula First Dashboard Dec 2010
24.0%
20.2%
The ESRD Network of Texas, Inc.
Network 14Percent of Prevalent Patients with AV Graft
2002 2003 2004 2005 2006 2007 2008 2009 2010*0
10
20
30
40
50
60 56.052.0
44.0
32.0 32.0 31.027.4 25.7 24.0
Network 14
% o
f Pat
ient
s
*Fistula First Dashboard Dec 2010The ESRD Network of Texas, Inc.
ESRD Networks & U.S. ComparisonPercent of Prevalent Patients with Catheter
14 6 18 8 17 16 15 US 5 2 13 7 1 10 4 3 11 12 90
5
10
15
20
25
30
18.719.120.120.420.821.121.722.322.823.323.523.523.824.524.524.925.425.626.0
Network
% o
f Pat
ient
s
Fistula First Dashboard Dec 2010
18.7%
22.3%
The ESRD Network of Texas, Inc.
Network 14Percent of Prevalent Patients with Catheter
2002 2003 2004 2005 2006 2007 2008 2009 2010*0
5
10
15
20
25
30
17.019.0
21.023.0 24.0
21.0 21.4 20.318.7
Network 14
% o
f Pat
ient
s
Fistula First Dashboard Dec 2010The ESRD Network of Texas, Inc.
ESRD Networks & U.S. ComparisonsPercent of Prevalent Patients with Catheter > 90 days
14 18 6 17 16 8 7 US 5 13 15 9 1 12 11 2 10 4 30
2
4
6
8
10
12
14
6.2 6.67.3 7.6 7.6
8.2 8.5 8.8 9.3 9.3 9.410.0 10.2 10.4 10.6 10.7 10.7 10.9
11.5
Network
% o
f Pat
ient
s
Fistula First Dashboard Dec 2010
8.8%
6.2%
The ESRD Network of Texas, Inc.
Network 14Percent of Prevalent Patients with Catheter > 90 days
2002 2003 2004 2005 2006 2007 2008 2009 2010*0
5
10
15
20
12.0
9.0 9.0 8.6 8.5 8.47.2 7.1
6.2
Network 14
% o
f Pat
ient
s
*Fistula First Dashboard Dec 2010The ESRD Network of Texas, Inc.
Network 14 Quality ImprovementProjects
Supporting Quality Care
Improving Vascular Access across Texas
Percentage of Focus Facilities with Improved/Worse/No Change AVF RatesBaseline (April 2010) to February 2011
% Improved % Worse % No Change
84.7%n=61
13.9%n=10
1.4% n=1 Change in RatesApril 2010 – February 2011
AVF Rate: +6.3% avg. facility change
All CathRate: -5.8% avg. facility change
Cath>=90 Days: -1.2% avg. facility change
Maturing AVFs: -2.8% avg. facility change
72 Focus Facilities with AVF Rate < 55% & > 8 Maturing Fistulas
Improving Anemia in ESRD Facilities 14 HD Focus Facilities 8 PD Focus Facilities
Anemia Module
Assessment of ESA Utilization 13 Focus Facilities & 27 Benchmark Facilities
Expand to other facilities in 2011
Professional & technical coaching
ResultsSevere Anemia Hgb < 10 gm/dL 100% HD focus facilities met MRB cut-point 75% PD focus facilities met MRB cut-point
Anemia Management Hgb 10-12 gm/dL 85% HD focus facilities met MRB cut-point 50% PD focus facilities met MRB cut-point
Additional requirements were implemented for all focus facilities not meeting cut-point during project.
AnemiaQuality
Improvement
Closing Thoughts
The ESRD Network of Texas, Inc.
Opportunities for Improvement
Target Range for Anemia Management
Continue to improve Permanent Vascular Access Fistulas Focus on Catheter Reduction & Healthcare Associated Infections (HAIs)
Network 14 – supporting quality care in collaboration with YOU