Clinical Performance Measures Project and Activities: 2004
In February, 2004 our Medical Review Board discussed the Network’s performance in the 2003 CPM Project, the appropriateness of existing goals for specific indicators and opportunities for outreach and education that could positively impact patient outcomes. Based upon the MRB’s deliberations, the following goals were established for 2004:
Adequacy of Dialysis (in-center hemodialysis patients) – attain/maintain 80% of patients with URR > 65% or 84% of patients with Kt/v > 1.2.
Anemia Management - attain/maintain 70% of patients to have a mean hemoglobin ≥11 gm/dL
Vascular Access (CPM I) – A primary arterial venous fistula (AVF) should be the access for at least 60% of all new patients initiating hemodialysis.
Vascular Access - Increase use of fistulas - more than 50% of prevalent hemodialysis patients over 18 years of age should have an AV fistula (national goal).
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.
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.
Nutrition - 35% of patients to have a mean serum albumin > 4.0/3.7 gm/dL (BCG/BCP).
MRB recommendations for specific activities in 2004 included:
· Utilizing the ELAB facility-specific data to create profiles on selected indicators, including adequacy of dialysis, anemia and nutritional status.
· Focusing on the patient population that falls below desired outcomes and encouraging in-house, facility-level quality improvement activities to identify and intervene with patients at risk.
· Provision of educational resources, examples of best practices, links to “experts” and tools. Anemia management and monitoring of stenosis were selected as topics for educational outreach.
· Utilizing facility-specific vascular access data to track the Network’s progress toward its AVF prevalence and incidence goals. Identifying regions/providers/individual facilities that appear to need focused attention for improvement, as well as top performers.
· Monitoring catheter use via the facility-specific vascular access data, and follow-up with facilities exhibiting high prevalence of catheter use.
· Continued exploration of possible causes for the low serum albumin outcomes for this Network.
· Use of ELAB, NVAII and other available data to identify facilities with “best practices” and unique programs that could be shared throughout the Network.
A revised CPM Plan was submitted to our Project Officer in April 2004, based upon the MRB’s recommendations for follow-up from the 2003 CPM Project and reconsideration of individual CPM goals. A summary of significant outcomes and trends for our Network was sent to our facilities via an eGroup mailing in April, and posted on our website. Highlights of the 2003 Project findings, MRB recommendations for further attention and other pertinent information were sent to clinical staff at each facility. A guide to stenosis monitoring, developed by our QI Coordinator, was posted on our website and hard copy sent to clinical staff. (http://www.nwrenalnetwork.org/fist1st/StenosisMonitoring.doc)
CPM 2004 Project Highlights:
In the spring and summer of 2004, Northwest Renal Network participated in the eleventh year of this cooperative data gathering effort with CMS. Our Clinical Performance Measures Project patient sample for the 2004 study covered the last calendar quarter of 2003 and included 509 hemodialysis patients (481adult, 24 pediatric), 62 adult peritoneal dialysis patients and 55 Veterans Administration patients.
Preliminary data from the national 2004 CPM Project was sent to our MRB for review in December 2004. In addition, Network staff prepared graphs on Northwest Renal Network CPM outcomes and trends, and presented this data to the Medical Review Board and Board of Directors at a combined meeting on December 10, 2004. (A more detailed discussion of opportunities for improvement and revision of the Network’s CPM goals occurred during a March, 2005 Medical Review Board meeting.) Findings of the 2004 CPM Project are posted on our website: http://www.nwrenalnetwork.org/statscpm.htm
Key observations on individual performance measures:
q There has been a small dip in our outcomes for the proportion of patients meeting the hemoglobin target. Performance with regard to anemia status had shown steady improvement since 1993, so 2004 may have been an aberrant year. Data from the 2005 CPM project (final quarter 2004 labs) and LDO outcomes data will be evaluated to identify any trends of concern.
q Northwest Renal Network continues to be among the leaders in percentage of patients with mean Kt/V greater than or equal to 1.2 in December 2003, with 92% of patients achieving this target. (Nationwide 91% of patients had a Kt/V greater than or equal to 1.2).
q Our Network continues to lead the nation in fistula rates, reaching 56% of prevalent hemodialysis patients in the 2004 CPM Project sample (last quarter 2003 data), compared to a national average of 35% in the 2004 CPM Project sample. According to our latest data, the prevalent fistula rate was 57.5% as of December 2004 (Source: LDO and non-LDO data collected for the Fistula First Project.)
q Our Network’s comparative standing with regard to serum albumin did not improve. For the CPM 2004 Project, the national average was 39% of patients achieving target serum albumins of ≥3.7 for BCP and ≥4.0 for BCG. Northwest Renal Network had the lowest proportion of patients meeting the criteria for this measure in the U.S. This continues to be a conundrum, given our positive performance with regard to other outcome measures and patient survival. The Medical Review Board, Network staff and regional associations of renal dietitians continue to explore possible root causes, including inflammation, lab variance and correlation to other outcome measures.
Graphic summaries of these findings, and trend data, are presented at http://www.nwrenalnetwork.org/statscpm.htm.