2011 ESRD Network of Texas, Inc.
Network Coordinating Council
Annual Meeting
CHAIRMAN’S REPORT
Melvin 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

Slate of Officers
Melvin Laski, MD, Chairman
Manny Alvarez, MD, Vice Chairman
Larry McGowan, Treasurer
Charles Orji, MD , Secretary
Richard Gibney, MD
Immediate Past Chairman
Ruben Velez, MD, MRB Chair
Laura Yates, RN, CNN, At Large
JD Bell, MD, At Large
Leigh Anne Tanzberger, At Large
11-12 EXECUTIVE COMMITTEE
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 GROWTH
Number of Medicare Certified Providers
500
400
300
200
100
0
20 facilities
awaiting
Medicare
Certification
at year end
CMS Annual Facility Survey Data
Ownership of Dialysis facilities
by Percent of facilities 2010
Nat'l Chain
81%
Regional
5%
Hospital
3% Prison
0%
Military
1%
Pediatric
1%
Independent
9%
National Chain Ownership TX Dialysis facilities
2010
Number of Patients, Texas
60,000
50,000
37,457
40,000
Prevalent Pt.'s
30,000
New Pt's.
20,000
Deaths
10,000
9,746
0
6,387
ESRD by
Primary Diagnosis
Incident
Prevalent
20000
5000
18000
4000
Number of Patients
14000
3000
12000
10000
8000
2000
6000
4000
1000
2000
Diabetes
Glomerulonephritis
Other
Hypertension
Cystic
Unknown
Diabetes
Glomerulonephritis
Other
Hypertension
Cystic
Unknown
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
0
1992
0
1991
Number of Patients
16000
Prevalent Primary Diagnosis
(%)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Diabetes
Hypertension
Glomerulonephritis
Cystic
Other
Unknown
16
• 48,394
Transplant
23%
Dialysis
77%
•37,457
4,799,762 dialysis treatments
delivered in Texas in 2010
Self care & Setting
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Dialysis Setting
Self
Care
8%
CCPD
CAPD
Home HD
Home
Dialysis
10.2% in 2010
In Ctr
HD
92%
Home Dialysis Modality
Number of patients
3500
3000
2500
2000
CCPD
1500
CAPD
Home Hemodialysis
1000
500
0
1995 2000 2005 2007 2008 2009 2010
Texas & National Gross Mortality
30
25
20
21.9
US 09
20.5%
23.3 22.9
21 20.7 20.5
21.8
20.4 20.7
21.6 21.6 21.3 21.3
15
10
5
0
Texas Mortality
National Mortality
20.9
21.5 21.4
20.8
20.2 19.9
19.6
18.9
18.2 17.8
17.5
Cause of Death
100%
90%
80%
Unknown
70%
Other
60%
Vascular
50%
Liver Disease
40%
Infection
30%
Gastro Intestinal
20%
Cardiac
10%
0%
2000 2005 2006 2007 2008 2009 2010
% Diabetic = 57.8
2009 National ESRD Data Summary
Percent of ESRD Home Patients As of 12/31/2009
16%
14%
12%
8%
6%
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%
2%
11.7%
4%
13.8%
Percent of Patients
10%
16
12
10
17
1
8
6
9
USA
13
18
7
15
11
5
14
4
2
3
0%
Race of Prevalent Patients In Texas
Percent of Patients
70
60
50
40
30
20
10
0
White incl. Hispanic
Black
Other/ Unknown
Ethnicity Texas ESRD Patients
Non Hispanic
55%
Hispanic
45%
Prevalent Patient Gender (%)
Percent of patients
60.0
50.0
50.7
49.3
51.3
48.7
51.8
48.2
51.0
48
52.5
52.7
53.1
53.5
47.5
47.3
46.9
46.5
40.0
30.0
20.0
10.0
0.0
1995
2000
2005
2006
Male
2007
Female
2008
2009
2010
Age of Prevalent ESRD patients in
Texas 2010
75+
15%
0-20
1%
35-44
10%
45-54
19%
65-74
22%
55-64
28%
Average Age Prevalent 59
21-34
5%
Transplants by Race
100
90
80
70
60
50
40
30
20
10
0
804
18.5
62.6
18.9
1011 1187 1233 1275 1300 1352 1411
7.2
75.6
4.6
75.6
6.9
74.2
4.8
73.4
8.3
70.4
6.9
70.5
4.3
72.9
Other
White
Black
17.2
19.8
18.9
21.8
21.3
22.6
22.8
1995 2000 2005 2006 2007 2008 2009 2010
Total Transplants by Donor Type
Number of Patients
1600
1400
1200
1000
800
600
400
200
0
Living Related
Living Unrelated
Deceased
Percent of Patients Transplanted
40000
35000
12.00%
10.00%
30000
25000
20000
15000
8.00%
6.00%
0
# Transplanted Pats
% Transplanted
4.00%
10000
5000
Mean patient census
2.00%
0.00%
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 2010
ESRD 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 Anemia
 Quality of Care Concerns, Elab Data
Collection & CPM’s
 Vascular
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
PSD
Facility
Profile
• AVF, Cath, Goals,
• Benchmarking
Analysis
Priorities
PSD: Patient Specific Data
• Facility Ranking
• Change in VA/3 mos
• Performance Categories
• VA changes – going
the wrong way
• Questions to
trigger action
Facility Vascular Access Profile
with Patient Specific Data (PSD)
Overview
Ranking with other Network Facilities
% AVF Utilization Rate
% Catheter Utilization < 90 days & > 90 days
Benchmarking
July 2010
Facility Census
# of Facility AVFs in Use
% of Facility AVFs in Use
%
Above
47.4
%
% Below
52.4
%
Percent AVF Utilization Rate
99
56
56.6
Your facility ranks
240 out of 456
facilities in the
Network (lowest to
highest)
Percent of Facility Patients
I.
•
•
•
•
% Facility AVFs in Use
CMS Goal
Network 14
80
Average of Top 10% Facilities
60
40
20
0
04-2010
05-2010
06-2010
07-2010
Facility Vascular Access Profile with PSD
II. Analysis
• Vascular Access Patterns
• Three Month Timeframe
• Performance Categories
Good
Improving
Caution Improving
Caution Neutral
Caution Worse
Worse
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
AAA
XXXXXXXXX
X
--/--/--
AVF….AVG only
Have you implemented stenosis
monitoring?
BBBB
XXXXXXXXX
X
--/--/--
Catheter with AVF…..Catheter with
AVG
Have you developed &
implemented a vascular access plan
for this patient?
CCC
XXXXXXXXX
X
--/--/--
Catheter only < 90 days…..Cather
only >=90 days
Did you consider AVF for this
patient?
Y/
N
Vascular Access Collaborative Site Visits
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 units

Focus
Faciliti
es
NW QI
Staff
CSVs across
Texas
Non-Maturing, Non-Functioning AVF
Long Term Catheter Utilization
CATHETER
OPERATION
REDUCTION &
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
Large Nephrology Group Profiles
Vascular Access Type at Start of Dialysis
% of VA Type
Patients with Pre-Dialysis Nephrology Care and Insurance
January – June 2010
90
80
70
60
50
40
30
20
10
0
AVF
AVG
Cath only
Cath & AVG
Cath & AVF
Data source 2728
Group X
All Groups
6.3
2.1
77.1
12.5
2.1
25.1
6.4
43.1
21.7
3.6
Community Information & Outreach
 TEEC
& Disaster preparedness
 Patient & 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)

Derek Jakovich, JD (consultant)

Debbie Heinrich, RN (Secretary)

Minnie Malone, RN (consultant)

Karen Walton, RN (Treasurer)

Connie Oden, RN

John Dahlin

Glenda Payne, RN (consultant)

Eugenia De Los Reves, RN

Alex Rosenblum, RN

Balbi Godwin, RN

Narendra Singh

Vanessa Guillory, RN

Steven Tays

Bobbi Wagner

Andrea Fichtner, MPH

Glenda Harbert, RN (ED for Network
14)

Sylvia Spencer

Valerie Ficke

Doug Havron, RN, MS

Becky Heinsohm, RN (consultant)

Bonnie Leshikar

Kevin Burns

Nick Jayne
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 2010-11
Monitor
EMSystem
compliance
Report to
DSHS
when noncomplaint 2
consecutive
months
Review and
provide
feedback
on disaster
plans (82)
Coach
facilities for
reporting
compliance
Tier 1 Coastal
Counties
May, 2010
195 Facilities
15,198
Patients
Pre-Hurricane Preparations
All facilities
must pre-plan
for backup
dialysis with
another
provider
Patients
should be
STRONGLY
encouraged 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!
100
EMSystems Monthly Updates
Percent Compliant Facilities
2010-2011
95
% Compliance
90
85
80
75
70
65
60
55
50
All Providers
100
EMSystems Monthly Updates
Percent Compliant Facilities
2010-2011
% Compliance
95
90
85
80
75
LDO
70
Independent
65
Regional
Percent of Facilities that Updated
EMSystem during 5/11 Drill
Compliant,
266, 55.5%
Noncompliant,
213, 44.5%
Complaints, Grievances &
Involuntary Discharge (IVD)
Percent of Total
NW 14 Trends in “negative
contacts”
Percent of total
50
45
40
35
30
25
20
15
10
5
0
44
38
34
2007
24
23
2008
16 17
12
7.9
5 4
Data is a subset, does not equal 100% of contacts
2009
8
1 1
3
5 5
1.4
2010
Most facilities have no complaints
1 Complaint, 68,
17%
2 Complaints, 18,
4%
3 Complaints,
3, 1%
>3 Complaints, 1,
0%
None, 319,
78%
Causes of Beneficiary Complaints 2010
Financial,
Abusive/
2
Disruptive, 1
Professional
Ethics, 6
Other, 1
Physical
Environment, 3
Transfer/
Discharge 6
Information, 5
Staff
Related, 21
QOC/Treatment,
29
Cause of Formal Grievances
10
Number of FG
8
6
4
2
0
2007 2008 2009 2010
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
4
33
2
1 1
2
2
1 1
1
0
2007
1
000
2008
2009
2010
Trending Involuntary Discharge
60
54
50
40
44
40
46
42
39
42
40
30
# Pts DC
20
# Facilities DC
10
0
2007
2008
2009
2010
Number of
Patients IVD
Remained the
Same over last
2 years. <0.1%
Of total patients
Number of Involuntary Discharges
by Type 2010
N = 42
25 of 42 IVD (59.5%) are
acceptable reasons in the
regulations
Other
5
Non-Payment
4
Can Not Meet Medical Need
5
Severe Immediate Threat
16
Physician Termination
3
Ongoing…
0
9
10
20
IVD averted 2010
IVD
42
Averted
23
•Patient at risk of IVD
•Work with patient &
facility to maintain
placement
IVD January 1-May 31, 2011
Ongoing
Disruptive , 1
Cause of Discharge
NonPayment, 2
Term. By
Physician, 3
Immediate/
Severe, 3
A total of 8
discharges
Status of Patients IVD
Jan- May 2011
Patient Placement Status
2
2
Unknown
Deceased
2
Admitted to another
clinic
Not Admitted
7
IVD demographics 2010
66% Male
46% White
63% non- Hispanic
Age of IVD Pts.
2010
70-79
60-69 5% 80+
3%
11%
50-59
24%
30-39
18%
40-49
39%
30-59 years old
Who are
they?
DSHS Referral Update
Number of Cases & Levels
18
Level I
16
16
14
Level II
12
10
8
1
5
4
3
4
0
Level III
6
6
2
9
8
2
00 0
2007
0 0
2008
0
1
2009
3
2
0
0
2010
Closure
Not
Certified
Referrals
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 Themes

Unsafe Physical Environment


Hazardous chemicals in inappropriate areas
Technical/Water Treatment Practices





Not testing properly
Lack of staff knowledge
Unsafe Reuse practices
Machine maintenance & integrity
Reuse practices and procedures
Common Themes

Nursing services





Patient Safety Concerns




Competency issues
Medication administration
RN staffing ratios
Lack of f/u critical labs
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
Disposition of
DSHS Referrals at
year end 2010
Continued
2010
10/
33%
2009
20/
67%
7
Released
20
Initial
Survey,
3
Percent of DSHS Released Referral Facilities
With Improved Outcomes at Release n=20
Improved all 4
indicators at
time of release
from CAP
25.0%
Improved upon
0 of the 4
indicators at
time of release
from CAP
5.0%
Improved upon
1 of the 4
indicators at
time of release
from CAP
15.0%
Improved upon
3 of the 4
indicators at
time of release
from CAP
30.0%
Improved upon
2 of the 4
indicators at
time of release
from CAP
25.0%
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
Adequacy
60.0
Anemia
57.9
AVF Rate
70.0
Catheter >= 90
days
70.0
0
20
40
60
80
Percent
Facilities 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
Adequacy
100.0
Anemia
90.0
AVF Rate
100.0
Catheter >= 90
days
95.0
85
90
95
Percent
100
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 Strategy
Making Care
Safer
Promoting Prevention
Supporting Better
Health in
Communities
Making Care More
Affordable
Ensuring
Person and
FamilyCentered Care
Coordinating
Care
Effectively
HHS 2011 National Quality Strategy
Six National Priorities
1.
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.
The Three Part Aim
Better
Care
The
Three
Part Aim
Reduced
Costs
Better
Health
Quality Incentive Program (QIP)
Performance Score Report (PSR)
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
QIP PSR review period
7/15-8/15/11
•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.
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 staff
Trying 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
gharbert@nw14.esrd.net
469-916-3801
Report from
Medical 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
Jennie Lang House, RD
Thank you
for serving!
Robert Hootkins, MD
Deborah Heinrich, RN
Mazeen Arar, MD
Anna Gonzalez
Navid Saigal, MD
The ESRD Network of Texas, Inc.
Kaylynne Duran, RN
Jana Zimmer, RD-
Ruben Velez, MD
Trish White, RN
May Beth Callahan,
SW
Dianne Morgan
John Dahlin. CHT
Camille
May, RN
Thank you
for
Mohanram Narayanan, MD
Greg Jaffers,
MD
serving!
Donald Molony, MD
Osama Gaber, MD
Jane Louis, RD
Martha Donaho, MSW
Leisha Sanders, RNwelcome
Clyde Rutherford, MD
Sam Al-Akash, MD
2011 MRB Cut-Points
based on review of 2010 Elab data
HD
More than 80/85% of patients should have URR > 65%
(TBD)
PD
✔
✔
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 Outliers
based on review of 2010 Elab data
Number of Facilities reporting…..
Total number of facilities reporting
HD
497
PD
154
< 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
* Based on Fistula First January 2011 data
The ESRD Network of Texas, Inc.
Number of Adult HD Patients per Network
11783
10819
9733
4
3
13 10 12
1
16
14184
17 15
14349
5
15212
8
15000
15483
19105
7
16910
19558
11
19892
2
20000
20311
22125
25000
22968
14 18
29993
6
30000
24358
# of Patients
35000
33681
40000
33841
US Total = 354,305
4th Quarter 2010
10000
5000
0
9
Network
*2011 preliminary QOC results – 2010 4th quarter data
The ESRD Network of Texas, Inc.
HD Adequacy
Percent of Patients with URR > 65%
93.4%
94
% of Patients
93
93.4 93.2 93.2
93.0 92.9
91.1%
92.1 92.1
92
91.6
91.1 91.1 91.1 90.9
90.7
91
90.3
89.8 89.7
90
89.4 89.4
89
88.0
88
87
86
85
14
3
15
1
16
8
10
4
2
9 US 7
6
12 11 18
5
13 17
Network
The ESRD Network of Texas, Inc.
*2011 preliminary QOC results – 2010 4th quarter data
HD Adequacy
Percent of Patients with URR > 65%
94
% of Patients
93.4
2009
2010*
92.7
93
92.0
92
91
93.5
91.0
91.0
91.0
91.0
90.0
90
89
88
2002
2003
2004
2005
2006
2007
2008
Network 14
The ESRD Network of Texas, Inc.
*2011 preliminary QOC results – 2010 4th quarter data
HD Adequacy
Percent of Patients with Kt/V > 1.2
97
97
96.1%
96.4
96.1 96.1 96.0
95.9 95.9 95.8 95.8
95.7
% of Patients
96
96
95.3%
95.3 95.3 95.2 95.2
95
95.0 95.0
94.7 94.6
95
94.3
94
93.7
94
93
93
92
3
14 15
1
8
12
4
10 16
7 US 2
9
17 18
6
13
5
11
Network
The ESRD Network of Texas, Inc.
*2011 preliminary QOC results – 2010 4th quarter data
HD Adequacy
Percent of Patients with Kt/V > 1.2
% of Patients
100
94.0
96.0
94.0
93.0
95.0
93.0
95.7
96.3
96.1
2002
2003
2004
2005
2006
2007
2008
2009
2010*
80
60
40
20
0
Network 14
The ESRD Network of Texas, Inc.
*2011 preliminary QOC results – 2010 4th quarter data
HD Anemia Management
Percent of Patients with HGB < 10.0 gm/dL
10
9.5
9
6.6%
% of Patients
8
5.7%
7
6
5
4.9
5.7
5.3 5.4 5.5
6.1
6.9 6.9 7.1
6.7
6.6
6.6
6.6
6.5 6.5
7.5 7.5 7.6
4
3
2
1
0
15 18 17 16 14
7
6
12
8
13 US 10
1
4
5
3
11
9
2
Network
The ESRD Network of Texas, Inc.
*2011 preliminary QOC results – 2010 4th quarter data
HD Anemia Management
Percent of Patients with HGB < 10.0 gm/dL
10
9
% of Patients
8
7
6
6.0
6.0
5.8
5.0
5
4
4.0
4.0
2005
2006
5.4
5.7
3.0
3
2
1
0
2002
2003
2004
2007
2008
2009
2010*
Network 14
The ESRD Network of Texas, Inc.
*2011 preliminary QOC results – 2010 4th quarter data
HD Anemia Management
Percent of Patients with HGB > 10.0 and < 12.0 gm/dL
76
74
73.6
71.9
% of Patients
72
68.4%
71.1 70.9 70.8
70
69.4 69.2
68
68.7 68.6 68.5 68.4
66.2%
67.7 67.3
67.2
66
66.7 66.6 66.3
66.2
64
63.1
62
60
58
56
17
1
3
18
4
7
10
2
11
9 US 5
16
8
12 13
6
14 15
Network
The ESRD Network of Texas, Inc.
*2011 preliminary QOC results – 2010 4th quarter data
HD Anemia Management
Percent of Patients with HGB > 10.0 and < 12.0 gm/dL1
% of Patients
70
60
66.2
58.2
60.0
50
40
30
2008
2009
2010*
Network 14
1
The ESRD Network of Texas, Inc.
Not stratified by this range with cut-point prior to 2008
*2011 preliminary QOC results – 2010 4th quarter data
HD Bone & Mineral Metabolism
Percent of Patients with Phosphorus 3.5 to 5.5
60
% of Patients
58
58.5 58.3
57.8
56.9
56
56.5 56.4 56.4
56.2
55.3%
55.9
55.6
55.3 55.3 55.2
53.8%
54.8
53.8 53.7
54
53.1
52.0 51.9
52
50
48
11
3
4
15 18 10 17
2
12
5
16 US 9
1
14
7
6
13
8
Network
The ESRD Network of Texas, Inc.
*2011 preliminary QOC results – 2010 4th quarter data
Number of Adult PD Patients per Network
1101
1036
1022
15 16 12 13 10
2
4
1
1000
877
1125
1267
5
1303
11
1312
7
1500
1330
1521
8
1587
17
1616
1852
2000
1928
2500
2139
% of Patients
3000
2414
2571
3500
3201
US Total = 29,202
4th Quarter 2010
500
0
6
18 14
9
3
Network
The ESRD Network of Texas, Inc.
*2011 preliminary QOC results – 2010 4th quarter data
PD Adequacy
% of Patients
Percent of Patients with Kt/V > 1.7
93
92
91
90
89
88
87
86
85
84
83
82
92.1
90.1%
91.5
90.9
90.6 90.6
90.1 90.0
89.1%
89.7
89.4
89.1 89.1 89.0 88.9
88.6
88.3
86.7 86.5
86.4
16
3
12 15 17 14
1
11 10
5 US 18
9
7
8
6
2
4
86.0
13
Network
The ESRD Network of Texas, Inc.
*2011 preliminary QOC results – 2010 4th quarter data
PD Adequacy
Percent of Patients with Kt/V > 1.7
% of Patients
100
1
91.1
89.9
90.6
91.0
90.1
2006
2007
2008
2009
2010*
80
60
40
20
0
Network 14
1
The ESRD Network of Texas, Inc.
Not stratified with cut-point prior to 2006
*2011 preliminary QOC results – 2010 4th quarter data
PD Anemia Management
Percent of Patients with HGB < 10.0 gm/dL
18
15.9
% of Patients
16
10.9%
14
12
10
9.2
9.4
11.3%
13.1
11.3 11.6 11.7
10.9
10.9
10.9
10.9
10.8
10.5 10.5 10.6 10.6
10.0 10.1 10.4
8
6
4
2
0
16 12
6
15 13
4
18
9
11
5
7
8
17 US 14
3
1
10
2
Network
The ESRD Network of Texas, Inc.
*2011 preliminary QOC results – 2010 4th quarter data
PD Anemia Management
% of Patients
Percent of Patients with HGB < 10.0 gm/dL1
12
11
10
9
8
7
6
5
4
3
2
1
0
11.3
8.9
8.8
2008
2009
7.2
2007
2010*
Network 14
1
The ESRD Network of Texas, Inc.
Not stratified by cut-point prior to 2007
*2011 preliminary QOC results – 2010 4th quarter data
PD Anemia Management
Percent of Patients with HGB > 10.0 and < 12.0
70
64.0
% of Patients
60
58.1%
56.6%
61.8 61.2 60.4
59.5 58.9 58.6 58.3 58.2 58.2 58.1
57.8 57.6 56.6 56.4 56.3
56.0 55.3
50
51.6
40
30
20
10
0
17
2
18
4
5
9
16 12
1
7 US 3
10 14 13
6
8
11 15
Network
The ESRD Network of Texas, Inc.
*2011 preliminary QOC results – 2010 4th quarter data
PD Anemia Management
Percent of Patients with HGB > 10.0 and < 12.01
60
57.5
56.6
% of Patients
51.5
50
40
30
2008
2009
2010*
Network 14
1
The ESRD Network of Texas, Inc.
Not stratified by this range with cut-point prior to 2008
*2011 preliminary QOC results – 2010 4th quarter data
Iron Management
% of HD Patients
92
90
88
86
84
82
80
78
76
% of PD Patients
Percent of Patients with TSAT > 20%
92
90
88
86
84
82
80
78
76
90.0
89.3
88.4 88.3 88.3 88.2 87.9
87.7 87.4 87.2
87 86.7
90.0%
85.3 85.2 84.9
84.4 84.1 84.0
81.6
87%
14
3
13
5
7
10 18
6
15 11 US
2
4
8
12
9
17
1
16
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 86.7
85.5
91.1%
89.3%
14
6
18 15 17
The ESRD Network of Texas, Inc.
7
5
11
8
13 US
3
1
4
12
9
10 16
2
*2011 preliminary QOC results – 2010 4th quarter data
Network 14 Iron Management
% of HD Patients
Percent of Patients with TSAT > 20%
100
90
85.0
83.0
84.0
82.0
82.0
81.0
2002
2003
2004
2005
2006
2007
88.0
90.0
2008
2009
2010*
80
70
60
50
100
90
% of PD Patients
87.0
86.6
87.7
88.8
2006
2007
2008
91.2
91.1
2009
2010*
80
70
60
50
The ESRD Network of Texas, Inc.
*2011 preliminary QOC results – 2010 4th quarter data
Network 14 Vascular Access
CATHETER
OPERATION
REDUCTION &
ELIMINATION
ESRD Networks & U.S. Comparison
Percent Increase in AVF
from Baseline to December 2010
31.6%
Percent Increase in AVF
35
30
31.6 30.8
25.1%
28.3 27.9
25
26.1 25.7 25.3
25.1 24.9 24.9 24.3
23.3 23.3 23.2 23.1 22.6
21.1
20
18.9 18.1
15
10
5
0
14 13 8
The ESRD Network of Texas, Inc.
5 17 18 12 US 15 4 11 6
Network
9 10 7
3
2
1 16
Fistula First Dashboard Dec 2010
NW 14 Vascular Access
Monthly Tracking - Prevalent AVF Rate
61.0%
60.0%
1.3%
58.3%
59.0%
57.3%
58.0%
57.0%
56.0%
55.0%
54.0%
53.0%
52.0%
51.0%
AVF Rate
Jan10
Feb10
Mar10
Apr10
May10
Jun10
Jul10
Aug10
Sep10
Oct10
Nov10
Dec10
Jan11
Feb11
Mar11
Apr11
53.9% 53.9% 54.0% 54.3% 54.8% 55.4% 55.9% 56.3% 56.5% 56.8% 57.1% 57.3% 57.8% 58.0% 58.0% 58.3%
Contract Goal 54.3% 54.3% 54.3% 54.3% 54.3% 54.3% 56.5% 56.5% 56.5% 56.5% 56.5% 56.5% 56.5% 56.5% 56.5% 59.6%
The ESRD Network of Texas, Inc.
Fistula First Dashboard
ESRD Networks & U.S. Comparison
Percent of Prevalent Patients with AV Fistula
December 2010
70
% of Patients
60
66.4
57.4%
64.4
61.3 61.0 60.9 59.9
57.2%
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
50
40
30
Dec. 2010 NW14 ranked 8th among
NWs compared to Dec. 2009 ranked
10th with AVF rate 53.6%
20
10
0
16 15 18 17
1
2
7 US 14
4
3
10 12 13 11
8
5
9
6
Network
The ESRD Network of Texas, Inc.
Fistula First Dashboard Dec. 2010
Network 14
Percent of Prevalent Patients with AV Fistula
60
50.8
% of Patients
50
40
30
53.6
57.2
46.0
43.0
42.0
2005
2006
35.0
29.0
26.0
20
10
0
2002
2003
2004
2007
2008
2009
2010*
Network 14
The ESRD Network of Texas, Inc.
*Fistula First Dashboard Dec 2010
Fistula Utilization
10-19%
20-29%
30-39%
40-49%
50-59%
60-69%
>= 70%
( ) = % change from
October 2003
AV Fistula Rate By County*
as of April 2011
*Counties with 2 or less facilities censored
Johnson
41.6%
(4.4%)
Tarrant
50.3%
(17.6%)
Lubbock
43.9%
(28.5%)
El Paso
68.5%
(28.6%)
Grayson
73.6%
(19.3%)
Collin
55.0%
(21.2%)
Kaufman
55.3%
(17.5%)
Dallas
McLennon
53.8%
74.6%
(15.8%)
(53.2%)
Tom Green
47.8%
(26.9%)
Congratulations!
Smith
48.3%
(34.8%)
Nacogdoches
45.8%
(27.9%)
Ector
73.3%
(45.2%)
Brazos
63.2%
(-2.5%)
Montgomery
59.3%
(33.8%)
Bell
56.5%
(15.5%)
Williamson
63.4%
(24.9%)
Gregg
50.3%
(30.2%)
Liberty
57.4%
(35.2%)
Travis
60.4%
(32.4%)
Hays
66.1%
(42.3%)
Harris
57.9%
(32.7%)
Bexar
63.7%
(46.3%)
Fort Bend
73.7%
(45.9%)
Guadalupe
67.7%
48.6%)
Atascosa
66.7%
Webb
(51.9%)
48.7%
(29.6%)
Brazoria
58.5%
(35.7%)
Nueces
55.4%
(32.5%)
Hidalgo
56.7%
(36.1%)
Cameron
50.9%
(19.5%)
Jefferson
57.6%
(44.6%)
Galveston
59.9%
(29.0%)
Counties with
AVF rate > 70%:
Ector 73.3%
Grayson 73.6%
McLennon 74.6%
Fort Bend 73.7%
ESRD Networks & U.S. Comparison
Percent of Prevalent Patients with AV Graft
December 2010
30
24.0%
20.2%
% of Patients
25
22.9
20
15
12.4
13.9
15.3
16.6
18.6 18.9 19.0 19.1
17.9 18.1 18.1 18.4
24.0
28.4
25.0
20.1 20.2 20.4
10
5
0
16 15
1
2
12
3
17
4
18
7
10 11 13 US 9
5
14
8
6
Network
The ESRD Network of Texas, Inc.
Fistula First Dashboard Dec 2010
Network 14
Percent of Prevalent Patients with AV Graft
60
56.0
52.0
% of Patients
50
44.0
40
32.0
32.0
31.0
30
27.4
25.7
24.0
20
10
0
2002
2003
2004
2005
2006
2007
2008
2009
2010*
Network 14
The ESRD Network of Texas, Inc.
*Fistula First Dashboard Dec 2010
ESRD Networks & U.S. Comparison
Percent of Prevalent Patients with Catheter
30
% of Patients
25
20
22.3%
18.7%
18.7 19.1
20.8
20.1 20.4
21.1 21.7
23.3 23.5
22.3 22.8
23.5 23.8
25.4
24.5 24.5 24.9
25.6 26.0
15
10
5
0
14 6 18 8 17 16 15 US 5
2 13 7
1 10 4
3 11 12 9
Network
The ESRD Network of Texas, Inc.
Fistula First Dashboard Dec 2010
Network 14
Percent of Prevalent Patients with Catheter
30
% of Patients
25
20
23.0
24.0
21.0
21.0
21.4
19.0
20.3
17.0
18.7
15
10
5
0
2002
2003
2004
2005
2006
2007
2008
2009
2010*
Network 14
The ESRD Network of Texas, Inc.
Fistula First Dashboard Dec 2010
ESRD Networks & U.S. Comparisons
Percent of Prevalent Patients with Catheter > 90 days
14
% of Patients
12
8.8%
10
8
6
6.2%
6.2
6.6
7.3
7.6
7.6
8.2
8.5
8.8
9.3
9.3
9.4
10.6 10.7 10.7 10.9
10.4
10.0 10.2
11.5
4
2
0
14 18
6
17 16
8
7 US 5
13 15
9
1
12 11
2
10
4
3
Network
The ESRD Network of Texas, Inc.
Fistula First Dashboard Dec 2010
Network 14
Percent of Prevalent Patients with Catheter > 90 days
% of Patients
20
15
12.0
9.0
10
9.0
8.6
8.5
8.4
7.2
7.1
2008
2009
6.2
5
0
2002
2003
2004
2005
2006
2007
2010*
Network 14
The ESRD Network of Texas, Inc.
*Fistula First Dashboard Dec 2010
Network 14 Quality Improvement
Projects
Supporting Quality Care
Improving Vascular Access across Texas
72 Focus Facilities with AVF Rate < 55% & > 8 Maturing Fistulas
Percentage of Focus Facilities with
Improved/Worse/No Change AVF Rates
Baseline (April 2010) to February 2011
1.4% n=1
13.9%
n=10
84.7%
n=61
% Improved
% Worse
% No Change
Change in Rates
April 2010 – February 2011
AVF Rate:
+6.3% avg. facility change 
All Cath Rate:
-5.8% avg. facility change 
Cath >=90 Days: -1.2% avg. facility change 
Maturing AVFs: -2.8% avg. facility change 
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
Results
Anemia
Quality
Improvement
Severe 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.
Closing Thoughts
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
The ESRD Network of Texas, Inc.