1. Alyssa Chase, MHA Core Prevention Manager Q-Source, TNs QIOMay 6, 2010 Fistula Interventions:An Awareness-driven Approach

2. TN Diabetes Facts 2007

Prevalence

• 2008 - Statewide rate 10.9% /higher than national rate of 8%

• 2007 - 517,000 adults diagnosed w/Type 2

• 2006 - 480,000 adults diagnosed w/Type 2

Mortality

• 1,827 deaths related to DM between 2002 2004, a 92% increaseover 1990- 1992

Hospitalizations

• 8,995 inpatients on average per year w/principal diagnosis of DM

Diabetic End Stage Renal Disease Incidence

1990 349 new cases of DM-related ESRD

• • 2003 928 new cases of DM-related ESRD

Sources:Tennessee Behavioral Risk Factor Surveillance Survey (BRFSS), 2007, TN Dept. of Health,Tennessee Hospital Discharge Data System (HDDS), and U.S. End Stage Renal Data System (USRDS) 3. In Tennessee July 2008 - June 2009

• Total Medicare Beneficiaries = 1,055,178

• Total Diabetic Medicare Beneficiaries = 150, 155

• Total Hypertensive Medicare Beneficiaries = 264,687

• Total CKD Medicare Beneficiaries = 22,254

4. Cost of CKD to the Medicare Fund 2006 CKD costs comprised22.1%of general Medicare costs --(CMS data) 5. Estimated Costs for CKD in the Medicare/Medicaid population, by State, 2005 TN 2007 USRDS 6. 2007 USRDS ADR Costs of the ESRD & Medicare Programs 7. Goalsof the CKD initiative

• Decrease the incidence of CKD amongdiabetic patients

• Slow progressing of CKD through

early intervention

• Encourage timely counseling forRenalReplacement Therapy (RRT)

• Promote fistula placement andmaturation as first choice for accesswhere medically appropriate

8. CKD ProjectMeasures

• Increase CKD screening in Medicare

patients with diabetes (annualmicroalbumin screening)

• Increase use of ACEI/ARBS in CKDpatients with diabetes

• Increase Use of AV fistulas for dialysis

• Increase participation in PQRI for CKD/Diabetes

• Increase use of Computerized records for CKD care management

9. Benefits to Patients Early detection and treatment means delayed disease progression AV fistula as first choice for hemodialysis means fewer access complications 10. Providers Involved 11. Providers Involved 12. Focus counties in Tennessee, selected based on Medicare claims data, 2007 Shelby 14,313 diabetic beneficiaries Davidson 8,144 diabetic beneficiaries Hamilton 6,936 diabetic beneficiaries Knox 6,847 diabetic beneficiaries (auxiliary areas also if resources allow) 13. 14. Medicare Beneficiaries with CKD in Tennessee, by Stage July 2008 - June 2009 15. CKD Medicare Benes per County Top 10 Counties:July 2008 - June 2009 # CKD Any Stage/# Medicare Benes in County 16. Interventions

• Systems Changes:

• Save Your Veins

• Exercise Your Fistula Toolkits

• Dialysis CKD Educators

• Opt-out Referrals

• Accessories:

• Nephrology/Vascular Surgeon Focus Groups

• Fistula First Coalitions

• Referrals from Nephrologists

• RPA Vascular Passports

17. Save Your Veins 18. SYV Pilot Testing

Posters

Patient Comments:

• "I wont take it off

• "It's a good thing

• "I want diamonds in it, but I guess I will wear it

• "Great Idea" (wife of patient)

ED Staff

EMT/Firemen

Nephrology vs. Vascular Surgery (FFBI)

19. Exercise Your Fistula 20. Interventions

• Systems Changes:

• Save Your Veins

• Exercise Your Fistula Toolkits

• Dialysis CKD Educators

• Opt-out Referrals

21. 22. 23. Interventions

• Accessories:

• Nephrology/Vascular Surgeon Focus Groups

• Fistula First Coalitions

• RPA Vascular Passports

• Cannulation Camps

• AAKP Kidney Beginnings Live!

24. How Are We Doing? 25. Memphis Fistula Data Data Courteousy ofNetwork 8 26. Effectiveness & Sustainability

Data

Patient-level Outcomes

Literature/evidence based

Spread within QIO community and national

Awareness plus tangible interventions

27. Where Do We Go From Here

Fistulas placed 6 to 12 months prior to requiring hemodialysis

Identify other best practices for upcoming 10SoW

28. Questions and Comments? This material was prepared by QSource, The Medicare Quality Improvement Organization (QIO) for Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (CHHS).This content presented does not necessarily reflect (CMS) policy.QSOURCE- TN-CKD-2008-00009 2007 USRDS ADR United States Renal Data System (USRDS)Annual Data Report (ADR) 29. Alyssa Chase, MHA Core Prevention Manager Q-Source, TNs QIOStacy Jowers Dorris, MBA, RHIA, CPHQ CKD Program Manager, QSource [email_address]