2005 Annual Report: ESRD Clinical Performance Measures Project

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I. Introduction

The End-Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project, now in its 12th year, is a national effort led by the Centers for Medicare & Medicaid Services (CMS) and its 18 ESRD Networks to assist dialysis providers to improve patient care and outcomes. Since 1994, the Project has documented continued improvements, specifically in the areas of adequacy of dialysis and anemia management. The providers of dialysis services are to be commended for their ongoing efforts to

A. Medicare’s ESRD Program

The Social Security Amendments of 1972 (PL 92-603) extended Medicare coverage to individuals with end-sage renal disease (ESRD) or chronic kidney failure who require dialysis or a kidney transplant to maintain life. To qualify for Medicare under the renal provision, a person must have ESRD and either be entitled to a monthly insurance benefit under Title II of the Social Security Act (or an annuity under the Railroad Retirement Act); or be fully or currently insured under Social Security; or be

B. Project methods

The purpose of the ESRD CPM Project is to provide comparative data to ESRD caregivers to assist them in assessing and improving the care provided to dialysis patients. Data collected in 1994 (for October-December 1993) established a baseline estimate for important clinical measures of care for adult in-center hemodialysis patients in the United States.17 From 1994 to 1998, CMS collected ESRD data under the ESRD CIP. The purpose of these data collections was to determine whether patterns in

Data Collection

Two data collection forms were used: a 4-page in-center hemodialysis form and a 4-page peritoneal dialysis form (Appendix 2, Appendix 3); the use of these forms was authorized through the National Institutes of Health (NIH) clinical exemption process. Descriptive information for each selected patient and dialysis facility was printed onto the data collection forms that were downloaded by Networks from the Network Standard Information Management System (SIMS). If demographic information (eg,

D. Report format

This report describes CPMs and other findings for both the adult in-center hemodialysis patient sample and the adult peritoneal dialysis patient sample in separate sections, V and VI, respectively, for the following study periods: October-December 2004 for the adult in-center hemodialysis patients and October 2004-March 2005 for the adult peritoneal dialysis patients. This report also describes findings on clinical parameters of care for pediatric in-center hemodialysis and peritoneal dialysis

III. Clinical Performance Measures (CPMs)

The clinical information abstracted by facility staff is used in this report to describe some of the CPMs that were developed from the NKF-DOQI Guidelines and other quality indicators for several aspects of care for adult dialysis patients. These CPMs do not apply to patients aged < 18 years. The CPMs were developed in the areas of hemodialysis and peritoneal dialysis adequacy, vascular access and anemia management. A complete description of the 13 CPMs appears in Appendix 1 (page S68).

The Hemodialysis Adequacy CPMs described in this report are

CPM I. The patient’s delivered dose of hemodialysis is measured at least once per month.

CPM II.The patient’s delivered dose of hemodialysis reported in the patient’s chart is calculated by using formal urea kinetic modeling (UKM) or the Daugirdas II formula for single-pool Kt/V (spKt/V).

CPM III. The patient’s (for patients on hemodialysis therapy ≥ 6 months and dialyzing 3 times/wk) delivered dose calculated from data points on the data collection form (monthly measurement averaged during the

The Peritoneal Dialysis Adequacy CPMs described in this report are

CPM I. The patient’s total solute clearance for urea and creatinine is measured routinely (defined for this report as at least once during the 6-month study period).

CPM II. The patient’s total solute clearance for urea (weekly Kt/Vurea) and creatinine (weekly creatinine clearance) is calculated in a standard way. (See Peritoneal Dialysis Adequacy CPM II in Appendix 1, page S69).

CPM III. For patients on continuous ambulatory peritoneal dialysis (CAPD) therapy, delivered peritoneal dialysis dose

The Vascular Access CPMs described in this report are

CPM I. A primary arteriovenous (AV) fistula (AVF) should be the access for at least 50% of all new patients initiating hemodialysis therapy. A native AVF should be the primary access for 40% of prevalent patients undergoing hemodialysis.

CPM II. Less than 10% of long-term maintenance hemodialysis patients should be maintained on catheters continuously for ≥ 90 days as their permanent long-term dialysis access.

CPM III. A patient’s AV graft should be monitored routinely for stenosis. (See Vascular

The Anemia Management CPMs described in this report are

CPM I. The target hemoglobin for patients prescribed epoetin is 11-12 g/dL (110-120 g/L). Patients with a mean hemoglobin > 12 g/dL (>120 g/L) and not prescribed epoetin were excluded from analysis for this CPM.

CPM IIa. For anemic patients (hemoglobin < 11 g/dL [<110 g/L] in at least 1 study month) or patients prescribed epoetin, percentage of transferrin saturation and serum ferritin concentration are assessed (measured) at least once in a 3-month period for hemodialysis patients and at least

Note Regarding Race

In this report, several tables describe important clinical characteristics of adult in-center hemodialysis and peritoneal dialysis patients for the following race groups: American Indian/Alaska Native, Asian/Pacific Islander, black, white, and other/unknown. In the figures, these clinical characteristics are compared by race group; however, comparisons are limited to white versus black. The reason for this is sample size. Because of small sample size (Table 2), the 95% confidence intervals

IV. Other significant findings and trends

ESRD CPM Data Trends

The figures on the following pages show the trends in the End-Stage Renal Disease (ESRD) Clinical Performance Measure (CPM) data for various study periods.

Please note that when a single year, such as 2004, is used in displaying data, it refers to October, November, and December of that year for hemodialysis patients. When a single year, such as 2005, is used for peritoneal dialysis patients, it refers to January, February, and March of that year, as well as October, November, and December of

V. Adult in-center hemodialysis patients

This section describes the findings for the sampled adult in-center hemodialysis patients for selected Clinical Performance Measures (CPMs) and other quality indicators related to adequacy of dialysis, vascular access, anemia management, and serum albumin. Each of these subsections is further broken down into 3 parts:

(1) national findings for selected CPMs for October-December 2004 (serum albumin information is not considered a CPM for this report);

(2) a description of other quality indicators

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