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

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.

3. RR of Hospitalization Higher Patient Hemoglobin Values Associated with Lower Risk of Hospitalization p<0.0001 p=0.05 p=0.77 (Ref) Patient Hemoglobin, g/dL p=0.001 Overall RR = 0.94 (p < 0.0001) 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, 94-111 (2004)

4. 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, 94-111 (2004) (n=506) (n=2740) (n=2202) (n=1403) (n=1936) p=0.19

5. 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: 94-111 (2004)

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

8. Intercurrent Issues Infection/ Inflammation Hospitalization Vascular Access Events Catheters New to Dialysis (1 st 90 days) Blood Loss 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 Months after initiation of dialysis Average HB (g/dL) 9.5 10.0 10. 5 11.0 11.5 12.0 456 10.4 10.49 10.66 10.77 11.17 11.25 USRDS 2003

10. Post-hospitalization Hb (g/dL) 9.5 10.0 10. 5 11.0 11.5 12.0 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

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

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

13. 10 g/dL 12 g/dL  Tight range  Variability from many sources

14.  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

15.  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. 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