FOUR. Clinical Indicators of Care

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Emery Horton
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1 Clinical Indicators of Care T FOUR The great questions of the time are not decided by speeches and majority decisions but by iron and blood. Otto von Bismarck, Speech to the Prussian Diet

2 78 ž 2000 ATLAS OF ESRD IN THE UNITED STATES All data underlying the figures in this chapter, as well as additional related Delivered Kt/V data, may be viewed & downloaded at 3.7% 4.5% Figure 4.1 Average delivered dialysis dose adult in-center hemodialysis patients The percent change from the average delivered Kt/V in 1996 (1.34) is noted next to the green lines. Data are obtained from the 1999 HCFA Clinical Performance Measures project report, and are shown for October to December of each year (1999 data was not yet available). In the past several years a number of prominent organizations have advanced quality initiatives to improve ESRD patient outcomes. HCFA s Core Indicator Project, incorporated into the Clinical Performance Measures (CPM) Project in 1999, includes data on a random sample of dialysis patients in each ESRD network. Providers collect data on dialysis adequacy, hematocrit level, nutritional status, blood pressure control, and vascular access measures. In addition, the National Kidney Foundation s Dialysis Outcomes Quality Initiative (NKF-DOQI) publishes a set of clinical practice guidelines on hemodialysis and peritoneal dialysis adequacy, vascular access, and anemia management. Following the lead set by these organizations, this chapter presents clinical core indicator data from the USRDS database and from the 1999 HCFA CPM report. The average delivered dialysis dose and urea reduction ratio of hemodialysis patients have increased moderately (figs 4.1 2), while the average weekly Kt/V and creatinine clearance for patients on CAPD have increased 16.2% and 14.5% (figs 4.3 4) since In 1998 the highest numbers of hemodialysis patients meeting the DOQI target URR of ³65% lived in Texas, New Mexico, and the Rocky Mountain region (fig 4.5). Hematocrit levels have improved for patients on both hemodialysis and peritoneal dialysis (fig 4.6). Only minimal racial differences are shown by graphs of the average erythropoietin dose and the percent of EPO-treated patients meeting the target hematocrit (figs 4.8 9). These data illustrate the steady improvements in the percent of patients of all races meeting the minimum DOQI target hematocrit. They show as well that peritoneal dialysis patients on EPO have lower hematocrits than patients on hemodialysis. This may be a result of variations in iron dosing, and of EPO resistance in peritoneal dialysis patients with peritonitis. Because peritoneal dialysis patients receive less I.V. iron than their counterparts on hemodialysis, the issue of inadequate iron replacement should be carefully evaluated. The highest EPO doses are seen in the Midwest, south, and east, yet these regions also have lower average hematocrit levels (figs ), a contrast which merits further investigation. Insertion rates for central venous accesses are highest in the south and east, and are ten times greater overall than the rates for simple fistulas (figs ). The Midwest has seen the highest increase in placement rates of central venous accesses, and the lowest increase in simple fistula use. Since publication of the DOQI guidelines, which suggest that simple fistulas are under-utilized in the U.S. compared to other countries, use of this type of access while still low has increased. It should be noted, however, that because simple fistulas require time to mature, central venous catheters are typically inserted as temporary accesses. A rise in simple fistula use may thus be accompanied by a rise in the use and duration of central venous catheters, which may predispose patients to infectious complications and subsequent EPO resistance. Included in in this chapter Graphs of the average urea reduction ratio, weekly Kt/V, weekly creatinine clearance, and average hematocrit, with maps showing the percent of patients meeting DOQI target URR and hematocrit levels Graphs of the average EPO dose and the percent of EPO-treated patients meeting the target hematocrit, maps of average hematocrit and average EPO dose, and maps showing the ratio of EPO dose to body weight Maps showing insertion rates for central venous and simple fistulas

3 CHAPTER 4 ž CLINICAL INDICATORS OF CARE ž 79 URR (%) % 4.7% 6.6% 6.9% Figure 4.2 Average urea reduction ratio adult in-center hemodialysis patients The percent change from the URR in 1994 (63.8%) is noted next to the green lines. Data are obtained from the 1999 HCFA Clinical Performance Measures project report, which is based on a national sample of adult dialysis patients regardless of insurance payor status, and are shown for October to December of each year (1999 data was not yet available) Average weekly Kt/V (urea) % 11% 15.2% 16.2% Figure 4.3 Average weekly Kt/V adult CAPD patients The percent change from the average weekly Kt/V in 1995 (1.91) is noted next to the green lines. Data are obtained from the 1999 HCFA Clinical Performance Measures project report, which is based on a national sample of adult dialysis patients regardless of insurance payor status, and include the last two months of the previous year and the first four months of each year shown. 70 Figure 4.4 Average weekly creatinine clearance (liters per week per 1.73m 2 ) adult CAPD patients L/week/1.73 m % 7% 10.2% The percent change from the average weekly creatinine clearance in 1995 (61.5 L/week/ 1.73m 2 ) is noted next to the green lines. Data are obtained from the 1999 HCFA Clinical Performance Measures project report, which is based on a national sample of adult dialysis patients regardless of insurance payor status, and include the last two months of the previous year and the first four months of each year shown %

4 80 ž 2000 ATLAS OF ESRD IN THE UNITED STATES Figure 4.5 Percent of patients meeting the DOQI target urea reduction ratio of ³65% prevalent hemodialysis patients, 1998, by HSA weighted by the number of patients in each HSA. URR data are obtained from Medicare Part A dialysis unit claims using the G modifier attached to CPT code 90999, with revenue codes 821 or to to to 85 below 82 Figure 4.6 Average hematocrit by modality prevalent patients with EPO claims The percent change from the average hematocrit in 1994 is noted next to the lines. Data are taken from Medicare Part A dialysis unit claims. Average hematocrit (%) Hemodialysis (1994: 30.6%) Peritoneal dialysis (1994: 30.3%) 7.8% 6.1% Figure 4.7 Percent of patients meeting the minimum DOQI target hematocrit of ³33% prevalent dialysis patients with EPO claims, 1998, by HSA weighted by the number of patients in each HSA. Data are taken from Medicare Part A dialysis unit claims to to to 52 below 46

5 CHAPTER 4 ž CLINICAL INDICATORS OF CARE ž White Black Hemodialysis Peritoneal dialysis Figure 4.8 Average EPO dose per administration, by race prevalent dialysis patients with EPO claims Hemodialysis patients generally receive EPO intravenously, three times per week, during dialysis treatments. Patients on peritoneal dialysis, in contrast, generally receive EPO subcutaneously, less frequently, and in larger doses. Data are taken from Medicare Part A dialysis unit claims Native American Asian 3,000 4,000 5,000 6,000 7,000 8,000 3,000 4,000 5,000 6,000 7,000 8,000 EPO dose per administration (units) White Black Hemodialysis Peritoneal dialysis Figure 4.9 EPO-treated patients meeting the minimum DOQI target hematocrit of ³33%, by race prevalent dialysis patients with EPO claims Data are taken from Medicare Part A dialysis unit claims Native American Asian Percent of patients

6 A T L A S O F E S R D I N T H E Average hematocrit, 1990 U N I T E D S TAT E S Average EPO dose, , ,800 to 3,040 2,640 to 2,800 2,440 to 2,640 below 2, to to to 28.3 below 27.9 Average hematocrit, 1994 Average EPO dose, , ,590 to 4,780 4,400 to 4,590 4,100 to 4,400 below 4, to to to 30.5 below 30.0 Average hematocrit, 1998 Average EPO dose, , ,710 to 5,960 5,470 to 5,710 5,080 to 5,470 below 5, to to to 32.9 below 32.6 Average hematocrit, percent change Average EPO dose, percent change to to to 96 below to to to 15 below 13 Figure 4.10 Average hematocrit (%) Figure 4.11 Average EPO dose per administration (units) prevalent dialysis patients with EPO claims, by HSA prevalent dialysis patients with EPO claims, by HSA These maps are smoothed, and weighted by the total number of hematocrit measures per year in each HSA. Data ranges are unique to each map in order to maintain maximum definition of geographic differences. These maps are smoothed, and weighted by the total number of EPO administrations per year in each HSA. Data ranges are unique to each map in order to maintain maximum definition of geographic differences.

7 CHAPTER 4 ž CLINICAL INDICATORS OF CARE ž 83 Figure 4.12 Ratio of EPO dose to body weight (kg) incident dialysis patients with EPO claims & weight data (2728 form), 1995, by HSA weighted by the total number of EPO administrations per year in each HSA to to to 75 below 66 Figure 4.13 Ratio of EPO dose to body weight (kg) incident dialysis patients with EPO claims & weight data (2728 form), 1998, by HSA weighted by the total number of EPO administrations per year in each HSA to to to 75 below 66 Figure 4.14 Percent change in ratio of EPO dose to body weight (kg) incident dialysis patients with EPO claims & weight data (2728 form), 1995 to 1998, by HSA weighted by the total number of EPO administrations per year in each HSA to to 21 6 to 15 below 6

8 A T LA S O F E S R D I N T H E Central venous accesses, 1991 U N I T E D S TAT E S Simple fistulas, to to to 40 below to to to 500 below 400 Central venous accesses, 1995 Simple fistulas, to to to 40 below to to to 500 below 400 Central venous accesses, 1998 Simple fistulas, to to to 500 below 400 Central venous accesses, percent change to to to 40 below 20 Simple fistulas, percent change to to to 30 below to 71 3 to 14 0 to 3 below 0 Figure 4.15 Insertion rates for central venous accesses Figure 4.16 Insertion rates for simple fistulas per 1,000 patient years at risk, prevalent hemodialysis patients, by HSA per 1,000 patient years at risk, prevalent hemodialysis patients, by HSA These maps are smoothed, and weighted by the total number of patients each year in each HSA. CPT codes (36489, 36491, 36533, 36800, and 36835) are obtained from Part B physician/supplier claims data. These maps are smoothed, and weighted by the total number of patients each year in each HSA. CPT codes (36819, 36821, and 36825) are obtained from Part B physician/ supplier claims data.

FULFILLMENT OF K/DOQI GUIDELINES 92 anemia treatment dialysis therapy vascular access

INTRODUCTION ANEMIA TREATMENT hemoglobin levels epo treatment iron treatment FULFILLMENT OF K/DOQI GUIDELINES 2 anemia treatment dialysis therapy vascular access EPO DOSING PATTERNS 4 epo dosing per kg