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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 facility medical directors, nurse managers and administrators. We encourage facilities to use the reports in quality improvement activities. These reports currently consist of three standard reports, developed by CMS, plus two Network 8 specific reports. The reports are described below:

  1. Fistula Use and Placement Rates in Incident Patients – describes the number of incident patients (new patients starting dialysis that month) and type of access used for dialysis, plus other access types present, but not used. This report depicts the percentage of incident patients beginning dialysis with an AVF in place, whether used or not.
  2. Vascular Accesses Used in Prevalent Patients – describes the number of prevalent (current) patients and type access used for dialysis on the last treatment day of each month. Categories described include: % AVF only, % AVG only, % Catheter or port (Patient may have catheter only or with maturing AVF or AVG, but used catheter.) This report also describes the % AVF placed (used or not) as above, plus the % of patients with no access reported.
  3. Fistula Rate Comparison, Prevalent Patients: Facility, Network, US – describes the number and percentage of prevalent patients using an AVF for dialysis on the last treatment day of each month, compared to the number and percentage of prevalent patients in the Network and US using an AVF.
  4. Facility Prevalence Rates for Catheters – NW 8 specific report describing the number and percentage of prevalent patients dialyzing with catheters in the following categories: catheter > 90 days, catheter < 90 days, catheter with AVF present, and catheter with AVG present.
  5. Catheter Prevalence Rates Comparison - NW 8 specific report describing the number and percentage of prevalent patients dialyzing with a catheter for > 90 days compared to number and percentage of patients in state and Network 8 using long-term catheters.

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 2007 Dialysis Facility Reports were mailed the week of August 10, 2007. To view the guide for these reports, click here. (230 KB pdf file opens in a new browser.)

ESRD Clinical Performance Measures (CPM) Project Annual Report

A report prepared annually by CMS for the Clinical Performance Measures Project. The report describes patient outcomes and practice patterns, by Network, on a number of clinical measures selected by CMS. Measures include dialysis adequacy, vascular access, anemia management, and nutrition.  The reports are no longer printed and distributed, but are posted on the CMS website.  To view the 2006 Annual Report, click here. (link opens in new browser)