Transcript www.nwrenalnetwork.org

Improving Sub-Optimal
Hemoglobins
October 14, 2010
Lynda K. Ball, MSN, RN, CNN
Quality Improvement Director
Northwest Renal Network
CMS DISCLAIMER
This presentation was developed by
Northwest Renal Network
while under contract with the
Centers for Medicare & Medicaid Services,
Baltimore, Maryland,
Contract #HHSM-500-2010-NW016C.
The contents presented do not
necessarily reflect CMS policy.
RR of Hospitalization
Higher Patient Hemoglobin Values
Associated with Lower Risk of
Hospitalization
1.8
Overall RR = 0.94 (p < 0.0001)
1.55
per 1 g/dL higher hemoglobin
1.4
1.16
1.09
1
1.01
(Ref)
p=0.77
1
0.6
0.2
p<0.0001
p=0.001
p=0.05
(n=435)
(n=2484)
(n=1994)
(n=1789)
(n=1296)
<8
8-9.99
10-10.99
11-11.99
=>12
Patient Hemoglobin, g/dL
DOPPS I: 7 countries, patients on dialysis > 180 days, adjusted for age, gender, black
race, 15 comorbid classes, spktv,serum PO4, serum calcium, albumin, country, facility
clustering. Pisoni et al AJKD 44, 94-111 (2004)
Higher Hemoglobin Levels
Associated with Lower Mortality Risk
RR of Death
1.4
Overall RR = 0.95 (p = 0.003)
per 1 g/dL higher hemoglobin
1.26
1.2
1.06
1.09
1
1
0.92
0.8
0.6
0.4
p=0.04
p=0.34
p=0.08
Ref.
p=0.19
(n=506)
(n=2740)
(n=2202)
(n=1936)
(n=1403)
<8
8-9.99
10-10.99
11-11.99
=>12
Patient Hemoglobin, g/dL
DOPPS I: 7 countries, patients on dialysis > 180 days, adjusted for age, gender, black
race, 15 comorbid classes, spktv,serum PO4, serum calcium, albumin, country, facility
clustering. Pisoni et al AJKD 44, 94-111 (2004)
HIGHER FACILITY MEAN
HEMOGLOBIN CONCENTRATIONS
Lower Mortality Risk
(RR of death=0.90 for every 1 g/dL higher
facility mean Hgb concentration, p=0.02)
DOPPS I: 7 countries, adjusted for age, gender, black race, 15 comorbid classes,
spktv,serum PO4, serum calcium, albumin, country, and facility clustering.
Pisoni RL et al. AJKD, 44: 94-111 (2004)
DOPPS SUMMARY
• Large improvement in mean Hgb in US from 1997-2002
• In 2002, 27% of US HD patients had a Hgb <11 g/dL
• New ESRD patients in US: much lower Hgb values (10.4
g/dL) at time of starting HD compared with prevalent HD
patients (11.7 g/dL)
• Predictors of having a higher Hgb include:
~ higher albumin
~ higher TSAT
~ not using a catheter for vascular access
~ higher country mean EPO dose
• Higher Hgb levels are associated with significantly lower
mortality and hospitalization risks
FACTORS: ANEMIA AND HGB VARIABILITY
Diabetes
ESA
Deficiency
CoMorbidities
Patient
Factors
Iron
Status
RBC
Lifespan
SHPT
FACTORS: ANEMIA AND HGB VARIABILITY
Infection/
Inflammation
Blood
Loss
Hospitalization
Intercurrent
Issues
New to
Dialysis
(1st 90
days)
Vascular
Access
Events
Catheters
Kausz et al., AJKD, 45, 2005
IT TAKES APPROXIMATELY
6 MONTHS AFTER INITIATION OF
DIALYSIS TO ACHIEVE Hb > 11 g/DL
Hemodialysis
Peritoneal dialysis
11.25
11.17
12.0
Average HB (g/dL)
11.5
11.0
10.
5
10.0
10.49
10.4
10.66
10.77
9.5
4
USRDS 2003
5
Months after initiation of dialysis
6
Hb Levels May Remain Below the NKFDOQI Target for at Least 2 Months
After Each Hospitalization
12.0
Hb (g/dL)
11.5
11.0
p<0.001
p<0.01
1 month
2 months
10.
5
10.0
9.5
Before
Hospitalization
Yaqub. AJ Nephrol 2001, 21:30-396
Post-hospitalization
FACTORS: ANEMIA AND HGB VARIABILITY
Protocol
Design
KDOQI
Hgb
Targets
Lab
Sampling
Practice
Patterns
KDOQI
Iron
Targets
CMS
Reimbursement
Protocol
Compliance
FOCUS GROUPS?
New Patients
Vascular Access Choice
Post-Hospitalization
Patients
Patients with
Co-Morbidities
THE TARGET RANGE
10 g/dL
 Tight
12 g/dL
range
 Variability from many sources
QUALITY ASSESSMENT AND PERFORMANCE
IMPROVEMENT (QAPI) – CfC
The dialysis facility must develop, implement,
maintain, and evaluate an effective, data-driven
QAPI program with participation of the
members of the interdisciplinary team.
 It must focus on indicators related to improved
health outcomes, and the prevention and
reduction of medical errors.

For more info . . .
http://www.nwrenalnetwork.org/CfC/MAT.pdf
QUALITY INCENTIVE PROGRAM (QIP)

Quality Incentive Program (QIP) for dialysis
services—the first pay for performance program in
fee-for-service—that will link a facility’s payment to
how well it meets new performance standards.

The % of Medicare patients with hemoglobins less
than 10 g/dL is one of three elements for the
Quality Incentive Program (QIP, Medicare
Improvements for Patients and Providers Act of
2008 [MIPPA 153c]).

The QIP will take effect on Jan. 1, 2012.
FOR TECHNICAL ASSISTANCE:
Lynda K. Ball, MSN, RN, CNN
Quality Improvement Director
206.923.0714 x 111
[email protected]
http://www.nwrenalnetwork.org/QI/QI.htm