2011 esrd network of texas, inc. network coordinating council annual meeting

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


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:


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-


25.0%



15.0%



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

[email protected]

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


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!


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%


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


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


96.1%

95.3%


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


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


5.7%6.6%


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


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


66.2%

68.4%

2008 2009 2010*30

40

50

60

70

58.260.0

66.2

Network 14

% o

f Pat

ient

s


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%


55.3%


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


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


90.1%

89.1%


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


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


PD Anemia ManagementPercent of Patients with HGB < 10.0 gm/dL


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


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%


56.6%

2008 2009 2010*30

40

50

60

51.5

57.5 56.6

Network 14

% o

f Pat

ient

s


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


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


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%


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%


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


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


18.7%

22.3%


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


8.8%

6.2%


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


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


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

2011 esrd network of texas, inc. network coordinating council annual meeting

Documents

meeting notice

mail voting

count mail votes

electronic mail notice

nominating committee

required delegate votes

esrd network of texas

quorum requirements