As the ESRD program enters its third decade, it continues to grow both in terms of patient census and cost.  The development of improved and expanded quality assurance and improvement mechanisms for the program are vital due to the recent reimbursement changes as a result of bundling.  The purpose of a Quality Management program is to identify and apply techniques for assessing and improving care quality to achieve the best possible outcomes for all patients.

RRC has implemented the structure and process for the Quality Management program.  The Quality Management program is chaired by Dr. Edward Jones, who is the Medical Officer of RRC.  Dr. Jones monitors clinic level quality management programs, and works with individual clinics and physicians to improve outcomes.  This effort has resulted in demonstrated improvements in clinical outcomes as demonstrated below.

Practice patterns and protocols for Epogen and Iron have changed as a result of the FDA black box warning, and implementation of the fully bundled end-stage renal disease prospective payment system. The Dialysis Outcomes and Practice Patterns Study (DOPPS) launched a new initiative known as the DOPPS Practice Monitor (DPM). The DPM aims to analyze and report changes in U.S. clinical practices, facility services offered, and performance measure achievement. The ability to monitor trends in care as the fully bundled PPS is implemented will be of great importance to patients, provider, and the dialysis community. The DPM preliminary findings through December 2010 note a small drop in mean hemoglobin with a possible decline in the percentage of patients with hemoglobin >12 gm/dL. RRC’s hemoglobin > 12 gm/dL has trended downward from 30% to 24% over 12 months.

The DOPPS Practice Monitor found that there has been an increase in the percentage of patients receiving IV iron, as well as an increased proportion of patients receiving higher doses of iron. RRC has seen an increase in the number of patients receiving iron and an increase in the dosage administered. Both TSATs and Serum Ferritin levels have increased as well.

Within RRC centers, EPO usage has been decreased over the past 12 months from an average of 8200 units/EPO treatment to 5200 units/EPO treatment, however, hemoglobin levels have remained stable. In 2010 RRC hired a Nurse Practitioner as a Virtual Outcome Manager. The NP has worked with the Medical Officer and individual physicians to develop Anemia Protocols from which the NP can evaluate real time lab results and modify EPO and iron dosages.

RRC continues to improve the adequacy of the delivered dialysis treatment. The DOPPS Practice Monitor outcome for December 2010 indicated that Non Large Dialysis Organizations experienced 90% of patients achieving a delivered single session spKt/V >=1.2. RRC has achieved a consistently higher Kt/V's ranging from 92% to 93%.

The Fistula First Program includes CMS, Networks, the Institute of Healthcare Improvement and the Kidney Community joined together in a partnership in launching the National Vascular Access Improvement Initiative in 2003. The goal of the program is to increase the use of fistulas with rates on average of 70-80%. The National 2008 ESRD Clinical Performance Project reported that AV Fistulas represented 49% of all accesses, Grafts represented 24% and Catheters represented 27%. The DOPPS DPM report from December 2010 indicated the AV Fistulas represented 56% of all accesses, Grafts represented 17% and Catheters represented 27% (no improvement from the 2008 CPMs). RRC has improved vascular access trending as noted in the slide and continues to work on this goal.

RRC’s Strategic Plan to increase patients on home therapy has been realized in 2011. Currently 11% of the patient population is dialyzing at home; either on home hemodialysis or peritoneal dialysis. A Director of Self Care Therapy was hired to drive these programs. By the end of 2011, the goal is to have at least 15% of the patient population on home therapy. In addition, the Director has initiated an in-center self care program for patients who either do not have the confidence or support at home but wish to manage their care.

Summary

The Mission of RRC is to deliver the best quality of care possible for our patients, provide support for our physician partners and create a rewarding work environment for our employees. Clinical practice and focused outcomes can only improve if physicians, nurses, technicians, dieticians and social workers sit side by side and work to explore their unique role and contribution in shaping the future care for our patients.