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

This presentation was developed by Northwest Renal Network while under contract with the Centers for Medicare & Medicaid Services, Baltimore, Maryland, Contract #HHSM NW016C. The contents presented do not necessarily reflect CMS policy.

RR of Hospitalization Higher Patient Hemoglobin Values Associated with Lower Risk of Hospitalization p< p=0.05 p=0.77 (Ref) Patient Hemoglobin, g/dL p=0.001 Overall RR = 0.94 (p < ) per 1 g/dL higher hemoglobin (n=435)(n=2484)(n=1994)(n=1789)(n=1296) DOPPS I: 7 countries, patients on dialysis > 180 days, adjusted for age, gender, black race, 15 comorbid classes, spktv,serum PO 4, serum calcium, albumin, country, facility clustering. Pisoni et al AJKD 44, (2004)

RR of Death Higher Hemoglobin Levels Associated with Lower Mortality Risk p=0.04p=0.08 Ref. Patient Hemoglobin, g/dL p=0.34 Overall RR = 0.95 (p = 0.003) per 1 g/dL higher hemoglobin DOPPS I: 7 countries, patients on dialysis > 180 days, adjusted for age, gender, black race, 15 comorbid classes, spktv,serum PO 4, serum calcium, albumin, country, facility clustering. Pisoni et al AJKD 44, (2004) (n=506) (n=2740) (n=2202) (n=1403) (n=1936) p=0.19

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 PO 4, serum calcium, albumin, country, and facility clustering. Pisoni RL et al. AJKD, 44: (2004)

Large improvement in mean Hgb in US from 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

Patient Factors Diabetes ESA Deficiency RBC Lifespan SHPT Iron Status Co- Morbidities

Intercurrent Issues Infection/ Inflammation Hospitalization Vascular Access Events Catheters New to Dialysis (1 st 90 days) Blood Loss Kausz et al., AJKD, 45, 2005

IT TAKES APPROXIMATELY 6 MONTHS AFTER INITIATION OF DIALYSIS TO ACHIEVE Hb > 11 g/DL Hemodialysis Peritoneal dialysis Months after initiation of dialysis Average HB (g/dL) USRDS 2003

Post-hospitalization Hb (g/dL) Before Hospitalization 1 month2 months p<0.001 Hb Levels May Remain Below the NKF- DOQI Target for at Least 2 Months After Each Hospitalization p<0.01 Yaqub. AJ Nephrol 2001, 21:30-396

Practice Patterns Protocol Design KDOQI Hgb Targets CMS Reimbursement Protocol Compliance KDOQI Iron Targets Lab Sampling

New Patients Vascular Access Choice Post-Hospitalization Patients Patients with Co-Morbidities

10 g/dL 12 g/dL  Tight range  Variability from many sources

 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...

 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.

Lynda K. Ball, MSN, RN, CNN Quality Improvement Director x 111