Did Mailing of Incident-Patient AVF Rates

To Nephrologists Influence Practice?

Analysis November 1, 2007

In February 2007, a summary report of AVF (arteriovenous fistula) placement rates among hemodialysis patients at incidence, using data taken from the June 2005-November 2006 Medical Evidence Reports (CMS Forms 2728), were sent to 172 nephrologists practicing within the Northwest Renal Network. Each nephrologist also received his or her own AVF rate for the period. Only nephrologists who signed three or more Forms 2728 during the period were included. See http://www.nwrenalnetwork.org/fist1st/2728AVFReport.htm for a copy of that report. In September 2007, a short follow up questionnaire was sent to the 172 nephrologists. This report summarizes the results of that questionnaire.

Where is your practice located (Western Washington, Eastern Washington, Oregon, Idaho, Montana, Alaska)?

One third (57) of the 172 nephrologists faxed back the questionnaire. There were 18 respondents among the 58 nephrologists in Western Washington who received the report (a 31% response rate), 10 of 21 from Eastern Washington (48%), 18 of 56 from Oregon (32%), 5 of 16 from Idaho (31%), 1 of 14 from Montana (7%), and 5 of 7 from Alaska (71%). 

Do you recall receiving the mailing from the Network? Do you recall reading the report from the Network?

Eighty-two percent of respondents recalled receiving the report, of which all but three recalled reading it. One recalled reading it but didn’t recall receiving it (or misread the questions). Overall, 78% of respondents recalled reading the report. Geographically, 72% percent of Western Washington respondents recalled the report, 70% of Eastern Washington respondents, 88% of Oregon respondents, and 82% of Idaho, Montana and Alaska respondents.

Do you personally enter the information on the Medical Evidence Report Forms (2728)? If no, who is responsible for the completion of this information (dialysis center, your office staff, other)? Do you find the information to be accurate?

Fifty-five percent of respondents reported filling out their Forms 2728 themselves. This percentage varied greatly by location; it was 76% in Western Washington, 56% in Eastern Washington, 50% in Oregon, and only 27% in Idaho, Montana, and Alaska. Eighty percent of respondents who did not enter their own data believed the information on the form to be accurate. When a nephrologist did not enter their own data, the dialysis center did it 94% of the time.

Did you change your practice or processes as a result of the mailing you previously received from the Network?

Among the 57 respondents, ten nephrologists (18% of respondents) indicated that they had changed their practice as a result of the report, three from Western Washington, 2 from Eastern Washington, 2 from Oregon, 3 from Idaho, and none from Montana or Alaska. Seven of the ten responded to the question, “If yes, what did you do?” Responses included:

§ “more aggressive in fistula placement,”

§ “made one person accountable for filling the report and presenting to me in orderly & timely manner,”

§ “group meeting to review network and facility data, and meeting with surgeons to address high catheter rates and strategies to improve fistula maturation rates,”

§ “[cannulation specialist] invited for in-service, and new QI project,”

§ “standing orders to allow nursing to refer for access,”

§ “meet with nephrologists in the same unit to discuss results,” and

§ “pay more attention to fistula placement.”

Would you benefit from receiving this report on a regular basis? If yes, how frequently (quarterly, semi-annually, annually)?

Eighty-six percent of respondents reported that they would benefit from receiving the report on a regular basis. Forty-eight percent of these wanted the information semi-annually, 31% annually, and 21% quarterly.

Do you have any ideas for increasing early referrals to nephrologists?

Thirty-seven percent of respondents had suggestions for increasing early referral to nephrologists. These included, grouped by category:

§ “keep showing us that we can do better; give clear guidelines as to how early AVF should be placed - I never saw a patient who had one too soon,”

§ “I think CKD staging is slowly improving this problem,” “active CKD program,”

§ “make GFR a requirement by all labs,” “add ‘consider nephrology referral’ on lab reports if creatinine over a particular threshold,” “more labs using eGFR,” “add calculated CrCl to all chem panels,” “Cockcroft calculation on labs,” “improving with MDRD eGFR reported on lab results,” “making it mandatory for all labs to report eGFRs with labs,” “I think lab reporting of MDRD GFR is slowly improving this problem,”

§ “referrals are ok - not easily overcome is a patient’s resistance for a surgical procedure when the patient is feeling well; a brochure for patients would be helpful explaining why creation of AVF is recommended to be done early,”

§ “improve education to PCPs,” “improving knowledge of primary care provider,” “education of patients & referring MDs,” “more information to primary doctors,” “more education for primary care patients,” “early identification by FP/PCP; CKD education to providers and provider willingness to adopt care plan will help,” “education,” “public/physician education,” “more education for primary providers,” “primary care seminars,” “more and continued education.”

What do you believe is a plausible and sustainable maximum prevalent-patient AVF rate? For your practice? For the Network?

Analysis by whether respondent indicated a change of practice or not:

Those who indicated they had changed their practice as a result of the report averaged a 68.7% rate for their practice and 66.9% for the Network, while those who did not report changing their practice averaged 70.3% and 64.6% respectively. This suggests that those who did not change their practice had less need to change than those who did. Nephrologists who reported changing their practice comprised 17% of Western Washington respondents, 20% of Eastern Washington respondents, 11% of Oregon respondents, and 60% of Idaho respondents. No Montana or Alaska respondents reported changing their practice.

Analysis by whether respondent recalled reading the report:

Overall, 78% of respondents recalled reading the report. Those who recalled receiving or reading the report believed that a practical and sustainable maximum prevalent-patient AVF rates for their practice was 71.1%, and for the Network was 67.0%; the corresponding rates among those who did not recall the report were practice - 65.4% and Network - 58.2%. This suggests that those who did not recall the report actually had a greater need to read it than those who did recall it.

Conclusions:

This analysis shows the report was considered to be beneficial, with 86% of respondents in support of receiving similar reports in the future. The report demonstrates an impact on practice with 18% of respondents indicating a change in practice.

Evaluation of Process Indicator: The Network received a good response rate of 1/3 of nephrologists. However, there is an opportunity to improve efficacy of follow up questionnaires of this nature. This topic is salient to the specific practice area of the target respondent group, so there is no apparent need for focus there. Areas of consideration in the future could focus more on methodology, such as multiple contacts using pre-questionnaire notifications and follow up reminders; use of web based questionnaires; and introductory wording in notifications that strongly emphasizes the need for their help to improve outcomes.

Northwest Renal Network (NW16) – Analysis of Nephrologist 2728 Data Mailing – page modified 11/15/2007