Northwest Renal Network CPM Review Plan

 

 

Northwest Renal Network utilizes data drawn from the national Clinical Performance Measures Projects to:

 

·         Assess outcomes in key areas,

·         Inform its members and the general ESRD community regarding patient outcomes and opportunities for improvement,

·         Track trends and

·         Guide educational outreach.

 

Data accuracy is enhanced by following a detailed process for collection, review, validation, entry and proofing of all CPM forms submitted by Northwest Renal Network facilities prior to our final transmission of data.

 

In 2004, a new approach to the CPM data collection process was introduced by CMS:  download of CPM data by Large Dialysis Organization (LDO) corporations into eSource, and  then, transmission of forms for LDO-affiliated units to the Networks through SIMS (Standardized Information Management System) for Network staff review and follow-up.  Data collection from our non-LDO, or “independent” facilities, followed our traditional process.

 

This was the first iteration of this approach to data collection and numerous errors and gaps were identified by all Networks in the LDO data, requiring several additional sequences of data collection, validation, and entry.  More than half of Northwest Renal Network’s facilities are not LDO-affiliates, which worked to our advantage in 2004.  Data collection, review, validation and entry for that portion of the CPM sample went smoothly.

 

We continued to retain our data file in-house, to facilitate prompt analysis of Network 16 outcomes, while awaiting the comparative national data.  Findings of this analysis are presented to our Medical Review Board for discussion and disseminated to providers in our region via our eGroups, surface mail, and posting on our website.  Network staff also present this data to ESRD professionals at regional meetings in our five-state area, including ANNA Chapters, state nephrology conferences, provider-specific meetings, and training programs for clinical staff.  When the final CPM Report is produced each year, with national and Network data, copies are distributed to key staff at each Network facility. (The distribution process varies, per instructions in the current contract period).

 

Depending upon the recommendations of our Medical Review Board, and the resources available to the Network, follow-up regarding our Network’s performance on individual clinical performance measures may include:

 

·         Dissemination of specific memos and reports to our providers,

 

·         Inclusion of a summary of findings in each year’s Annual Report  (posted on the web),

 

·         Creation of a subcommittee or workgroup to address areas of specific concern,

 

·         Requests for additional information and/or data from facilities,

 

·         Analysis of outcomes in the context of patient survival, utilizing data abstracted from SIMS,

 

·         Outreach to other Networks to explore common areas of interest, and/or

 

·         Development and dissemination of educational materials to providers and patients.

 

 

Our primary use of the CPM measures is to encourage and facilitate quality improvement among dialysis providers.  We use the Centers for Medicare & Medicaid Services (CMS) guide for target clinical performance outcome measures to identify areas which merit special attention or should take priority in our quality improvement efforts.

 

There is a special emphasis on vascular access outcomes during the current CMS contract period (July 1, 2003 – June 30, 2006).  All Networks  are  focusing  on a common goal of increasing the use of AV fistulas for hemodialysis patients, demonstrating measurable improvement over the three year period.  This National Vascular Access Improvement Initiative (“Fistula First”) includes performance measures for each individual Network, set by CMS.  Northwest Renal Network must demonstrate a 3 % increase in the prevalent rate of AV fistulas in its hemodialysis population by the end of this contract. 

 

At least annually, Northwest Renal Network’s Medical Review Board reviews the latest CPM outcome measures, and any significant trends in outcomes, by performance area.

 

Preliminary data from the 2004 CPM Project was released to the Network on November 30, 2004.  (Copy attached – PDF file).  It was shared with our Medical Review Board and Board of Directors.  Highlights of the findings were briefly discussed at a combined Board/ MRB meeting in Seattle on December 10, 2004.   Additional review and discussion of appropriate follow-up activities occurred on March 8, 2005.  Graphs of trends for key outcomes for all years with available data, as well as comparative performance data vis a vis other Networks, were prepared for this discussion. 

 

At the December 10, 2004  Board/MRB meeting there was limited discussion of the Network’s performance in key areas. There was agreement that increasing the goal for prevalent AVF rates was appropriate, given Network  performance and trends, as well as regional philosophy.  MRB consideration of the appropriateness of current goals for key measures, whether to revise individual goals, and opportunities for outreach and education that could positively impact patient outcomes was deferred until the first quarter of 2005.  This discussion occurred during a MRB conference call on March 8, 2005.  Changes to Network goals are incorporated below.

 

Network goals for the key clinical performance measures identified by CMS, and Network-specific results for the past four years are:

 

                  Adequacy of Dialysis (in-center hemodialysis patients) – attain/maintain 90% of patients with URR > 65% and/or 90% of patients with Kt/v > 1.2. 

 

                  Northwest Renal Network 2001 CPM Project Results:  89% w/Kt/v ³ 1.2

Northwest Renal Network 2002 CPM Project Results:  88% w/Kt/v ³ 1.2

Northwest Renal Network 2003 CPM Project Results:  92% w/Kt/v ³ 1.2

Northwest Renal Network 2004 CPM Project Results:  92% w/Kt/v ³ 1.2

(U.S. 2004 CPM results: 91% w/Kt/v  ³ 1.2)           

 

 

URR data available for 2003 and 2004 Projects:

                 

Northwest Renal Network 2003 CPM Project Results:  89% w/Mean URR ³ 65%

Northwest Renal Network 2004 CPM Project Results:  89% w/Mean URR ³ 65%

(U.S. 2004 CPM results: 87% w/Mean URR ³ 65%)

 

           

                  Anemia Management - attain/maintain 80 % of patients to have a mean hemoglobin of  > 11 gm/dL. 

 

                  Preliminary CPM data for 2004 shows a decrease in this performance measure. However, other indicators were more positive:  The percentage of patients with mean Hgb 11-12.0 g/dL was 40% for our Network in the 2004 CPM study, and 36% for the nation (for patients who were prescribed EPO).  The % of patients with mean Hgb < 10d/dL was 6%, consistent with the national percentage.

 

                  MRB discussion on March 8, 2005 touched on a possible relationship between iron management practices and anemia outcomes.  We’ll be exploring this further.    

 

                  Northwest Renal Network 2001 CPM Project Results: 75%

Northwest Renal Network 2002 CPM Project Results: 78%

Northwest Renal Network 2003 CPM Project Results: 80%

Northwest Renal Network 2004 CPM Project Results: 78%

(U.S. 2004 CPM results: 80%)

 

 

Vascular Access (CPM I) – A primary arterial venous fistula (AVF) should be the access for at least 60% of all new patients initiating hemodialysis (national goal). 

                 

                  Northwest Renal Network 2001 CPM Project Results: 39%

Northwest Renal Network 2002 CPM Project Results: 49%

Northwest Renal Network 2003 CPM Project Results: 45%

Northwest Renal Network 2004 CPM Project Results: 61%

(U.S. 2004 CPM results: 35%)

 

Note: For the CPM Study “initial access” is defined as the access being used at the end of the year by any patient who began dialysis at any time during the year.  (We believe there is confusion here between a patient “initiating” dialysis during the year, and the actual type of access first used for dialysis for that patient.)  For the Fistula First (FF) data reporting “initial  access” is defined as the access in use at the end of the month in which that patient initiated dialysis.  As a result, the  incident fistula rate yielded by the CPM project is higher than that reported via Fistula First data.  We anticipate refinement of the FF data reporting process that will make this our preferred source of outcomes data for this measure.

 

Vascular Access – Increase the  use of fistulas - more than 60% of prevalent hemodialysis patients over 18 years of age should have an AV fistula.

 

Prevalent AVF rates:      

 

                  Northwest Renal Network 2001 CPM Project results: 41%

Northwest Renal Network 2002 CPM Project results: 45%

Northwest Renal Network 2003 CPM Project results: 46%

Northwest Renal Network 2004 CPM Project results: 56% 

Per FF data for December 2004, our prevalent AVF rate was 57.5%

(Note: the Network currently exceeds its CMS performance goal for March 2006).

 

(U.S 2004 CPM Results: 35%

 

                  Vascular Access (CPM II) - Decrease catheter use - Less than 10% of prevalent hemodialysis patients over 18 years of age should be maintained on catheters for 90 days or longer.

 

                 On March 8, 2005 our MRB discussed catheter use, including the possibility that we would see an increase in prevalence of this type of access as a bridge to maturing fistulas. (In the greater ESRD community there have been comments about this occurring).   There was recognition that a subset of our hemodialysis population will be on catheters, permanently,  and the focus for this group should be on preventing infections, morbidity and mortality.  An opportunity to collaborate on a special project with QualisHealth to test interventions aimed at preventing infections is being pursued.

 

                 To assess our performance with regard to catheter use, it would be ideal  to have data that identified patients permanently using catheters as their hemodialysis access separately from the population of patients using catheters while AVFs, or other accesses, matured. (In the future, this may be feasible through the Core Data Set.)  In the CPM data on catheter patients,  there is no information on other accesses that may have been placed.  Further complicating matters, the definitions of catheter patients used in the FF vs. CPM studies are not consistent.   Presently, we believe the FF data gives us a closer measure of the number of patients who are permanently using catheters.

                 

                  Northwest Renal Network 2001 CPM Project Results: 13%

Northwest Renal Network 2002 CPM Project Results: 13%

Northwest Renal Network 2003 CPM Project Results: 17%

Northwest Renal Network 2004 CPM Project Results: 13%

Per FF data for December, 2004: 8.7% of prevalent HD patients had been dialyzing through a catheter for more than 90 days with no other access present or placed.

 

(U.S. 2004 CPM results: 20%)

 

 

                  Vascular Access (CPM III) - Monitoring for stenosis - Monitoring AV grafts for stenosis should occur for 100% of hemodialysis patients utilizing AV grafts as their primary access.  In February, 2004, our MRB discussed problems with the definition of “monitoring” and areas of confusion in the CPM data gathering tool which may have contributed to under-reporting. It was agreed the Network could have a positive influence on this outcome measure by providing education on techniques for monitoring stenosis and the importance of following patients regularly. An educational piece on Monitoring for Stenosis was developed by our QI Coordinator, disseminated to clinical staff and posted on our website.

 

                        Northwest Renal Network 2001 CPM Project Results: 77%

                        Northwest Renal Network 2002 CPM Project Results: 61%

                        Northwest Renal Network 2003 CPM Project Results: 66%

                        Northwest Renal Network 2004 CPM Project Results: 85%

                        (U.S. 2004 CPM Results: 77%)

 

                  Note: The Network and national improvement in this outcome measure may relate as much to clarification of the definition of stenosis monitoring for the 2004 CPM project data collection effort, as to actual changes in practice.

 

 

                  Nutrition - 35% of patients to have a mean serum albumin > 4.0/3.7 gm/dL (BCG/BCP).  (National goal).

           

                  Northwest Renal Network 2001 CPM Project Results: 23%

Northwest Renal Network 2002 CPM Project Results: 27%

Northwest Renal Network 2003 CPM Project Results: 25%

Northwest Renal Network 2004 CPM Project Results: 31%

(U.S. 2004 CPM Results: 39%)

 

                        The prior CPM goal was: % patients w/mean serum albumin > 3.5/3.2 gm/dL : 74%

                 

                        Northwest Renal Network 2003 CPM Project Results: 75%

                        Northwest Renal Network 2004 CPM Project Results: 82%

                        (U.S. 2004 CPM Results: 81%)

 

 

During the March 8, 2005 MRB conference call, it was suggested that we reach out to those Networks with superior results for this outcome, to find out whether there were best practices and/or information we could use in our region.  There was also discussion that results may vary across Networks because of differences in provider practices re: the timing of blood draws for labs, different patient demographics and lab variance.  We continue to observe that this outcome does not correlate with our other measures, including mortality.  There was some discussion of the possibility that this outcome is associated with inflammatory responses in our patient population.

 

                  We will continue to explore possible causes, as well as effective interventions to improve performance in this area. Over the course of the year, individual MRB members, Board of Directors’ members and other providers reported that they had seen a significant increase in their patients’ albumin levels. We are looking forward to the results of the 2005 CPM data collection effort (based on 4th quarter 2004 data) to see if this is reflected in our outcome measures. Changes in labs and lab variance was again posed as a possible factor in the observed increases for a stable population. 

                 

 

CPM Follow-Up Activities for 2005:

 

 

A graphic display of comparative data and outcomes for Northwest Renal Network drawn from prior years’  ESRD Clinical Performance Measures Project Reports and Core Indicators Studies, the final 2004 CPM project data, and other outcomes data, will be reviewed by our MRB, disseminated after their approval, and posted on our website.  We will provide notice of this posting to our facilities via an eGroup mailing (anticipate May 2005).  Dissemination of these results is timed to coincide with release of the annual, hard copy, CPM Highlights Report to facility medical directors, nurse managers and other interested parties. 

 

 

MRB recommendations for specific activities in 2005 include:

 

 

·        A focus on patient populations that fall below desired outcomes, encouraging in-house, facility-level quality improvement activities that will identify and intervene with patients at risk. The Network will provide educational resources, examples of best practices, links to “experts” and tools, as appropriate.

 

·       Outreach to facilities to identify in-house goals for adequacy as measured by Kt/V and/or URR.  Encouragement of facilities to strive for a Kt/V of 1.4.

 

·       Collaboration with Qualishealth QIO (Boise office) on a project testing approaches to preventing access infections.   

 

·        Continuing to use the Fistula First facility-specific vascular access data from our large dialysis organizations (LDOs) and our independent facilities (non-LDO) to track our progress toward AVF prevalence and incidence goals. A second report will be disseminated based upon year-end 2004 measures.  This report will be sent to Medical Directors, Facility Representatives, key clinical staff, and our AVF Data Coordinators at each participating provider.

 

·        Graphs on our outcomes and progress re: AVFs will be updated on our website.

 

·        Outcomes data will be used to identify regions/providers/individual facilities that appear to need focused attention for improvement, as well as top performers. 

 

·        Monitoring catheter use via the facility-specific Fistula First vascular access data, and follow-up with facilities exhibiting high prevalence of catheter use.

 

·        Monitoring serum albumin outcomes for this Network, and providing educational resources for facility staff, including collaborative efforts with our regional dietetic associations.

 

·        Review of the 2005 CPM data, anticipated ELAB data and other available outcomes data to help us identify facilities with “best practices” and unique programs that could be shared throughout the Network.

 

·       Information on CPM outcomes will continue to be posted on our website at www.nwrenalnetwork.org/statscpm.htm.

 

 

 

Questions concerning specific CPM follow-up activities should be directed to Lorabeth Lawson, MPP, Executive Director or Lynda Ball, RN, BSN, CNN, QI Coordinator at 206-923-0714.