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Lynda K. Ball, MSN, RN, CNN Quality Improvement Director Northwest Renal Network

Improving Sub-Optimal Hemoglobins. October 14, 2010. Lynda K. Ball, MSN, RN, CNN Quality Improvement Director Northwest Renal Network. This presentation was developed by Northwest Renal Network while under contract with the Centers for Medicare & Medicaid Services, Baltimore, Maryland,

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Lynda K. Ball, MSN, RN, CNN Quality Improvement Director Northwest Renal Network

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  1. Improving Sub-Optimal Hemoglobins October 14, 2010 Lynda K. Ball, MSN, RN, CNN Quality Improvement Director Northwest Renal Network

  2. 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. CMS Disclaimer

  3. Higher Patient Hemoglobin Values Associated with Lower Risk of Hospitalization RR of Hospitalization Overall RR = 0.94 (p < 0.0001) per 1 g/dL higher hemoglobin p=0.77 p=0.001 p=0.05 (Ref) p<0.0001 (n=435) (n=2484) (n=1994) (n=1789) (n=1296) 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)

  4. Higher Hemoglobin Levels Associated with Lower Mortality Risk Overall RR = 0.95 (p = 0.003) per 1 g/dL higher hemoglobin RR of Death p=0.34 Ref. p=0.19 p=0.04 p=0.08 (n=1403) (n=2740) (n=1936) (n=506) (n=2202) 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)

  5. 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)

  6. 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

  7. factors: anemia and hgb variability

  8. factors: anemia and hgb variability Kausz et al., AJKD, 45, 2005

  9. IT TAKES APPROXIMATELY 6 MONTHS AFTER INITIATION OF DIALYSIS TO ACHIEVE Hb > 11 g/DL Hemodialysis Peritoneal dialysis 12.0 11.25 11.5 11.17 11.0 10.77 10.66 10.49 10.4 10.5 Average HB (g/dL) 10.0 9.5 4 5 6 Months after initiation of dialysis USRDS 2003

  10. Hb Levels May Remain Below the NKF- DOQI Target for at Least 2 Months After Each Hospitalization 12.0 11.5 p<0.001 p<0.01 11.0 Hb (g/dL) 10.5 10.0 9.5 Before Hospitalization 1 month 2 months Post-hospitalization Yaqub. AJ Nephrol 2001, 21:30-396

  11. factors: anemia and hgb variability

  12. Focus groups?

  13. The target range • Tight range • Variability from many sources

  14. 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. http://www.nwrenalnetwork.org/CfC/MAT.pdf For more info . . .

  15. 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.

  16. For Technical Assistance: Lynda K. Ball, MSN, RN, CNN Quality Improvement Director 206.923.0714 x 111 lball@nw16.esrd.net http://www.nwrenalnetwork.org/QI/QI.htm

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