Lynda K. Ball, MSN, RN, CNNQuality Improvement Director

Northwest Renal Network

Improving Sub-Optimal Hemoglobins

October 14, 2010

This presentation was developed byNorthwest Renal Network

while under contract with theCenters for Medicare & Medicaid Services,

Baltimore, Maryland, Contract #HHSM-500-2010-NW016C.

The contents presented do notnecessarily reflect CMS policy.

1.55

1.161.09

1 1.01

0.2

0.6

1

1.4

1.8

<8 8-9.99 10-10.99 11-11.99 =>12

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 PO4, serum calcium, albumin, country, facility clustering. Pisoni et al AJKD 44, 94-111 (2004)

1.26

1.06 1.091

0.92

0.4

0.6

0.8

1

1.2

1.4

<8 8-9.99 10-10.99 11-11.99 =>12

RR of Death

Higher Hemoglobin Levels Associated with Lower Mortality Risk

p=0.04 p=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 PO4, 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

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)

• 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

Kausz et al., AJKD, 45, 2005

IT TAKES APPROXIMATELY6 MONTHS AFTER INITIATION OFDIALYSIS TO ACHIEVE Hb > 11 g/DL

Hemodialysis Peritoneal dialysis

Months after initiation of dialysis

Avera

ge H

B (

g/d

L)

9.5

10.0

10.5

11.0

11.5

12.0

4 5 6

10.4 10.4910.66

10.77

11.1711.25

USRDS 2003

Post-hospitalization

Hb

(g

/dL)

9.5

10.0

10.5

11.0

11.5

12.0

BeforeHospitalization

1 month 2 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

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 . . .http://www.nwrenalnetwork.org/CfC/MAT.pdf

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, CNNQuality Improvement Director206.923.0714 x 111lball@nw16.esrd.net

http://www.nwrenalnetwork.org/QI/QI.htm