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Quality Improvement Reports

The following information describes the current CMS/Network 8 quality improvement reports distributed to facilities. Facilities must make the information contained in the following reports available to patients or inform patients on how to contact the Network to obtain this information.

Fistula First Reports

Fistula First data feedback reports are distributed quarterly to all facility medical directors, nurse managers and administrators and MONTHLY to facilities with AVF rate < 50%. We encourage facilities to use the reports in quality improvement activities. These reports currently consist of four standard reports developed by Network 8. The reports are described below:

  1. Vascular Access Outcomes: Overview—bar chart snapshot of current number of patients with long-term catheter (> 90 days), AV graft, and AV fistula. New feature for this report is “AVF needed” which reports number of fistulas that must be added in order for facility to meet current Network contract goal of 52.8%. Caveats: (1) This report does not include other/short-term catheters (<90 days) so access total may not equal total population; (2) Network 2009-2010 stretch goal for AVF rate is 55% and contract goal changes annually. REMEMBER, Fistula First goal is 66% of prevalent patients dialyzing via AV fistula, not having AVF. Fistulas that are placed but not in use DO NOT COUNT towards facility AVF rate until in use.
  2. Vascular Accesses Outcomes: AVF – 6 month trend of AV fistula rates for facility. Aim for 66%!
  3. Vascular Accesses Outcomes: AVG – 6 month trend of AV graft rates for facility.
  4. Vascular Accesses Outcomes: Long-term catheter (LTC) – 6 month trend of LTC rates for facility. Remember, Measures Assessment Tool (MAT) notes that <10% of patients should dialyze with LTC in keeping with KDOQI recommendations.

Dialysis Facility Reports (DFR)

The Dialysis Facility Reports are prepared by the University of Michigan Kidney Epidemiology and Cost Center (UMKECC) annually, and distributed by the Network to facility medical directors and administrators. The reports contain facility-specific patient characteristics, treatment patterns, transplantation rates, hospitalization rates, and mortality rates, and compare them to state, Network and national data.

The report is based on data from Medicare dialysis and hospitalization claims, Medical Evidence Forms (CMS-2728), Death Notification Forms (CMS-2745), Annual Facility Survey Reports (CMS-2744), other CMS data and Social Security Administration data.

The purposes of the report are:

The 2009 Dialysis Facility Reports were mailed July 31,2009. To view the guide for these reports, click here.

ELAB Reports

Patient-specific lab data by facility are collected annually, through electronic submission from Large Dialysis Organizations (LDOs) to CMS and through manual data submission from non-LDO facilities to the Networks. Non-LDO facilities are notified by mail and are supplied with a data collection tool and instructions for data submission. Lab data is collected for 100% of the defined patient population. Once data is analyzed, reports are developed by Network 11 and distributed by Network 8. Elab reports were distributed to each participating facility in the Network 8 region on July 31, 2009. The 2008 National Trends Report can be viewed here.