2016 ANNUAL REPORT HSAG: The Florida ESRD Network (Network 7)

Transcription

1 2016 ANNUAL REPORT HSAG: The Florida ESRD Network (Network 7) Together we can spread positive change to make healthcare better. Centers for Medicare & Medicaid Contract Number: HHSM C HSAG: The Florida ESRD Network (Network 7) 3000 Bayport Dr., Suite 300 Tampa, FL

2 Table of Contents Contents Report Highlights... 3 Introduction... 4 CMS End Stage Renal Disease Network Organization Program... 4 Medicare Coverage for Individuals with ESRD... 4 History of CMS ESRD Network Organization Program... 4 ESRD Network Geography and General Population... 5 ESRD Population... 5 Providers... 6 Network Goals... 6 Profile of Patients in the Network s Service Area... 8 Improving Care for ESRD Patients... 9 Patient Safety: Reducing Rates of Healthcare-Acquired Infections... 9 Vascular Access: Reducing Rates of Long-Term Catheters Patient Engagement & Satisfaction: Improving Patients Understanding of Lab Values Facilities that Consistently Failed to Cooperate with Network Goals Recommendations to CMS for Additional or Facilities Grievances and Access to Care Grievance Cases Referred to State Survey Agencies Emergency Preparedness and Response List of Tables Appendix. Data Tables This material was prepared by HSAG: ESRD Network 7, under contract with the Centers for Medicare & Medicaid (CMS), an agency of the U.S. Department of Health and Human. The contents presented do not necessarily reflect CMS policy. FL-ESRD-7G Page 2 of 65

3 Report Highlights The End Stage Renal Disease Network Organization Program (ESRD Network Program) is a national quality improvement program funded by the Centers for Medicare & Medicaid (CMS). As part of the Health Advisory Group, Inc. (HSAG) team, HSAG: The Florida ESRD Network (Network 7) collaborates with patients and providers in the state of Florida to improve the quality of care and quality of life for ESRD patients. HSAG has held the Network 7 contract for 14 years. In 2016, Network 7 partnered with key stakeholders from the renal community, including patients, family members, advocacy organizations, and providers, to improve the quality of life and quality of care of 30,504 individuals with ESRD. As of December 31, 2016, the Network s service area included 457 ESRD dialysis and transplant providers. Successful quality improvement activities (QIAs) conducted with dialysis providers during 2016 included: Improving hemodialysis vascular access management by reducing the long-term use (90 days or longer) of catheters for vascular access. Reducing the rate of healthcare-associated infections (HAIs) among ESRD patients, specifically by reducing the rate of bloodstream infections (BSIs). Improving patient understanding of dialysis lab values through the implementation of chairside patient education. Network QIAs conducted with dialysis providers in the Network service area during 2016 are described in detail throughout this report. A foundation of Network 7 s work throughout 2016 involved working closely with patients, family members, and other caregivers to incorporate their perspective into all quality improvement activities. For example, through the Patient Advisory Committee (PAC), Patient Subject Matter Experts (SMEs) assisted the Network in planning and developing activities, and attended facility QIA calls so they could share their stories, troubleshoot barriers to interventions, and discuss areas for improvement at the patient and facility level. Page 3 of 65

4 Introduction CMS End Stage Renal Disease Network Organization Program The ESRD Network Program is a national quality improvement program funded by CMS. CMS is a federal agency, part of the U.S. Department of Health and Human (HHS). CMS defines ESRD as permanent kidney failure in an individual who requires dialysis or kidney transplantation to sustain life. Under contract with CMS, 18 ESRD Network Organizations, or ESRD Networks, carry out a range of activities to improve the quality of care for individuals with ESRD. The 18 ESRD Networks serve the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, American Samoa, Guam, and the Northern Mariana Islands. Medicare Coverage for Individuals with ESRD Medicare coverage was extended to most ESRD patients in the U.S. under the Social Security Act Amendments of 1972 (Public Law ). Individuals with irreversible kidney failure are eligible for Medicare if they need regular dialysis or have had a kidney transplant and they meet (or their spouse or parent meets) certain work history requirements under the Social Security program, the railroad retirement system, or federal employment. History of CMS ESRD Network Organization Program Following passage of the 1972 Amendments to the Social Security Act, in response to the need for effective coordination of ESRD care, hospitals and other health care facilities were organized into networks to enhance the delivery of services to people with ESRD. In 1978, Public Law modified the Social Security Act to allow for the coordination of dialysis and transplant services by linking dialysis facilities, transplant centers, hospitals, patients, physicians, nurses, social workers, and dietitians into Network Coordinating Councils, one for each of 32 administrative areas. In 1988, CMS consolidated the 32 jurisdictions into 18 geographic areas and awarded contracts to 18 ESRD Network Organizations, now commonly known as ESRD Networks. The ESRD Networks, under the terms of their contracts with CMS, are responsible for: supporting use of the most appropriate treatment modalities to maximize quality of care and quality of life; encouraging treatment providers to support patients vocational rehabilitation and employment; collecting, validating, and analyzing patient registry data; identifying providers that do not contribute to the achievement of Network goals; and conducting onsite reviews of ESRD providers as necessary. Page 4 of 65

5 ESRD Network 7 As part of the HSAG team, Network 7 works with patients and providers in the state of Florida to improve the quality of care and quality of life for ESRD patients. HSAG has held the Network 7 contract for 14 years. Geography and General Population The state of Florida covers 54,090 square miles and is bordered by Alabama, Georgia, the Gulf of Mexico, and the Atlantic Ocean. According to the United States (U.S.) Census Bureau, Florida s population was estimated at 20,271,272 in This represented a 7.8% increase from the 2010 census. In addition, the state of Florida ranked as third largest in population in the nation. ESRD Population Network 7 worked in collaboration with key stakeholders from the renal community in the Network s service area to improve the quality of life and quality of care of 29,169 individuals with ESRD in This section describes the characteristics of the ESRD patient population in the Network 7 service area. From December 31, 2015, to December 31, 2016, the ESRD patient census increased by 1,335 patients (4.6%), for a total of 30,504 prevalent patients in the Network s service area as of December 31, 2016). The number of incident patients increased by 336, for a total of 8,405 individuals newly diagnosed with ESRD in This represents a 4.0% increase compared to Race and Ethnicity 2 The demographics of the ESRD population in the Network 7 service area are similar to that of the United States ESRD population, with 58.4% of Florida s ESRD population characterized as White and 38.9% as African American. The third largest racial group in Florida was the Asian group, representing 1.6% of the entire ESRD population in Florida as of December 31, Per the U.S. Census Bureau, individuals who identified as Hispanic or Latino accounted for 24.1% of Florida s general population as of July 1, 2016 Error! Reference source not found.. As of December 31, 2016, 17.1% of Florida ESRD patients were reported as Hispanic or Latino. Gender and Age Forty-two percent of Florida s ESRD population was female and 58.1% was male as of December 31, Additionally, 49.2% of Florida s ESRD population was age 65 or older as of December 31, This figure is also disproportionately large when compared to Florida s general population, in which only 27.9% of residents were age 65 or older as of July 1, 2016 Error! Reference source not found Data on "ethnicity" and "race" should be interpreted with caution because of the inherent instability of race/ethnicity data. Page 5 of 65

6 Dialysis Treatment Options Dialysis patients in Florida utilized four main modalities of dialysis treatment in 2016: 1. In-center hemodialysis: As of December 31, 2016, 87.6% of dialysis patients used this modality. 2. Continuous cycling peritoneal dialysis: As of December 31, 2016, 8.8% of dialysis patients used this modality. 3. Continuous ambulatory peritoneal dialysis: As of December 31, 2016, 1.4% of dialysis patients used this modality. 4. Home hemodialysis: As of December 31, 2016, 2.2% of dialysis patients used this modality. Primary Cause of ESRD/Co-Morbidities Network data reflected that in 2016, 75.7% of ESRD patients on dialysis in the Network 7 service area had a primary cause of ESRD that fell into either the largest category, diabetes (41.0%), or the second largest category, hypertension (34.7%). Providers As of December 2016, Network 7 s service area included a total of 448 dialysis providers (including Veterans Administration providers), representing 12 different corporate affiliations. The majority of Florida s dialysis providers were owned by the three large dialysis organizations (LDOs), DaVita, Fresenius, and DCI. These three corporations owned and/or operated 71.8% of Florida s 448 dialysis facilities at the end of Within the LDO facilities, 43.1% were affiliated with DVA, 27.4% with FMC, and 1.3% with DCI. Table A. Dialysis Facilities and Transplant Centers in the Network s Service Area, as of December 31, 2016 Category Number Number of Dialysis Facilities in the Network s Service Area 448 Number of Transplant Centers in the Network s Service Area 9 Source of data: CROWNWeb. Table B. Number of Medicare-Certified Dialysis Facilities in the Network s Service Area and Number and Percent of Dialysis Facilities Offering Dialysis Shifts Starting after 5 PM, as of December 31, 2016 Category Number Percent Number of Dialysis Facilities in the Network s Service Area 448 Dialysis Facilities in the Network s Service Area Offering Dialysis Shifts Starting after 5 PM % Source of data: CROWNWeb. Network Goals CMS establishes priorities for the ESRD Network contractors annually in the Statement of Work section of each Network s contract with the agency. These priorities support CMS and Department of HHS national quality improvement goals and priorities. In 2016, the ESRD Network contractors were tasked with meeting the following goals: Improving care for ESRD patients in the Network s service area by: o Promoting patient- and family-centered care. o Responding to grievances about ESRD-related services filed by, or on behalf of, ESRD patients. Page 6 of 65

7 o Supporting improvement in patients experience of care. o Working with dialysis facilities to ensure that all dialysis patients have access to appropriate care. o Promoting best practices in vascular access management. o Helping dialysis facilities reduce the incidence of healthcare-associated infections. Improving the health of the ESRD patient population in the Network s service area through activities designed to reduce disparities in ESRD care. Reducing the costs of ESRD care in the Network s service area by supporting performance improvement at the dialysis facility level and supporting facilities submission of data to CMS-designated data collection systems. Page 7 of 65

8 Profile of Patients in the Network s Service Area The ESRD Network Program collects data on incident (new) ESRD patients, prevalent (currently treated) dialysis patients, and renal transplant recipients. The Network uses data on patients clinical characteristics including primary cause of ESRD, treatment modality, and vascular access type to focus its outreach and quality improvement activities. Table C. Clinical Characteristics of the ESRD Population in the Network s Service Area, Calendar Year 2016 Category Number Percent Incident (New) ESRD Patients 8,405 Number of Incident ESRD Patients, Calendar Year ,405 Prevalent Dialysis Patients Number of Prevalent Dialysis Patients as of December 31, ,504 Treatment Modality of Prevalent Dialysis Patients as of December 31, 2016 In-Center Hemodialysis or Peritoneal Dialysis 26, % In-Home Hemodialysis or Peritoneal Dialysis 3, % Total 30, % Vascular Access Type at Latest Treatment among Prevalent In-Center and In-Home Hemodialysis Patients as of December 31, 2016 Arteriovenous Fistula in Use 16, % Arteriovenous Graft in Use 4, % Catheter in Use for 90 Days or Longer 2, % Other 2, % Total 27, % Renal Transplants Number of Renal Transplant Recipients* Calendar Year ,001 Total 1, % Source of data: CROWNWeb. *Count of unduplicated individuals receiving renal transplantation during the calendar year. Page 8 of 65

9 Improving Care for ESRD Patients The Network works closely with ESRD patients, patients family members and friends, nephrologists, dialysis facilities and other healthcare organizations, ESRD advocacy organizations, and other ESRD stakeholders to improve the care for ESRD patients in the Network s service area. Under its contract with CMS, the Network is responsible for: Identifying opportunities for quality improvement and developing interventions to improve care for ESRD patients in the Network service area. Identifying opportunities for improvement at the facility level and providing technical assistance to facilities as needed. Promoting the use of best practices in clinical care for ESRD patients. Encouraging use of all modalities of care, including home modalities and transplantation, as appropriate, to promote patient independence and improve clinical outcomes. Promoting the coordination of care across treatment settings. Ensuring accurate and timely data collection, analysis, and reporting by facilities in accordance with national standards. Throughout 2016, Network 7 worked with individual facilities, as well as groups of facilities, to initiate QIAs focused on improving patient outcomes and experience of care. The following section provides highlights of three noteworthy activities focused on reducing HAIs, improving vascular access rates, and increasing patient understanding of dialysis lab values conducted by the Network during Patient Safety: Reducing Rates of Healthcare-Acquired Infections Infection is a leading cause of morbidity in the ESRD population, second only to cardiovascular disease as the leading cause of death for the chronic uremic patient on hemodialysis. According to the National Action Plan to Prevent HAIs, the incidence of sepsis in ESRD patients can be up to 100 times as high as that in the general population, and sepsis is responsible for a 43% higher rate of mortality in the ESRD population. 3 Quality Improvement Activity In 2016, Network 7 conducted an HAI Reduction QIA to improve infection control practices with the intent of reducing BSI rates. Selection of the project facilities was accomplished using the National Healthcare Safety Network (NHSN) BSI pooled mean rate per 100 patient-months for All Access Types, which compares a facility s pooled mean BSI rate to all dialysis facilities in NHSN. The Network was required to include at least 20% of Florida dialysis facilities as participants in the QIA. 3 Page 9 of 65

10 Sixty-three dialysis facilities were targeted for inclusion in the QIA, with approximately 4,529 hemodialysis patients, which represented 14.9% of the Network area hemodialysis patient population. Affiliations for the 63 QIA facilities were: DaVita 29 Fresenius Medical Care 14 American Renal Associates 9 Central Florida Kidney Centers 1 Independent 10 The 63 targeted facilities had BSI rates per 100 patient-months ranging from 0.9 to 3.3, compared to the NHSN BSI mean rate of 1.3 and Network-area BSI mean rate of 0.7. The baseline mean BSI rate per 100 patient-months for the targeted facilities was 1.5. The primary intervention for the QIA was to promote, monitor, and increase the correct use of the CDC BSI prevention audit tools. The CDC approaches for preventing HAIs were reviewed during an orientation webinar, and facilities were required to implement the CDC Recommended Interventions for Dialysis BSI Prevention and take the CDC training course, Infection Prevention in the Dialysis Setting. Additionally, facilities were required to conduct a specified number of monthly audits and report completion of audits to NHSN and the Network. In a final analysis of project data for June 2015 to June 2016, the QIA facilities aggregate BSI rate per 100 patient-months had decreased to 0.8 per 100 patient-months. Patient Engagement The 2016 HAI Reduction QIA also included interventions that fostered patient and family engagement in infection prevention practices in dialysis facilities in order to empower patients to speak up and help to improve hand hygiene compliance. The 63 QIA facilities provided patients with education materials on hand hygiene practices and vascular access care. Once educated, patients were asked to sign a pledge to assist with infection prevention in the facility. Facilities were also tasked with having a small number of patients complete the CDC audits for staff hand hygiene monthly. The goal was for a partnership to develop between patients and staff, in which both understood the appropriate protocols and worked together to create a safer dialysis environment. As of project completion, 83.0% of patients in the QIA facilities had signed pledges that they would assist with infection prevention. In addition, facilities reported that, as a result of the QIA, there was increased communication between patients and staff regarding hand hygiene opportunities, and that patients were more compelled to engage in dialogue addressing infection control concerns. Vascular Access: Reducing Rates of Long-Term Catheter Use According to clinical guidelines, arteriovenous fistulas (AVFs) remain the preferred vascular access as they require less rework and fewer interventions, have demonstrated the ability to last longer, and are associated with lower rates of infections, hospitalizations, and death. 4 4 National Kidney Foundation Kidney Disease Outcomes Quality Imitative Guidelines Updates, 2006). Page 10 of 65

11 In comparison, catheters have proven to have a significant association with morbidity and mortality in chronic hemodialysis patients. 5 Based on this information, both the ESRD Conditions for Coverage and the Fistula First Catheter Last (FFCL) Workgroup Coalition state that each patient should be evaluated for the most appropriate vascular access, with catheters being the last option. Quality Improvement Activity The 2016 Vascular Access QIA was aimed at reducing long-term catheter (LTC) use in facilities with baseline rates above 10%. Using September 2015 CROWNWeb data for the baseline, the Network identified 184 facilities with an aggregate baseline LTC rate of 16.2%. The QIA goal was to achieve a two percentage point reduction among QIA facilities, or to reach 14.2% by September The objectives of the QIA were to create a foundation of sustainable facility processes for catheter reduction and to promote timely and accurate vascular access reporting in CROWNWeb. Of the 184 facilities with LTC rates above 10%, the Network targeted a focus group of 35 facilities that received more intensive interventions, as well as being provided with a stretch goal of achieving a 3 percentage point reduction from their September 2015 baseline. The Network provided one-on-one technical assistance to the 35 focus group facilities each month, first initiating a root cause analysis (RCA) plan using the Plan-Do-Study-Act (PDSA) cycle, then providing ongoing feedback to assist in developing individualized facility processes and resources. The results of the RCA and PDSA cycles were also shared with other QIA facilities that were not in the focus group. In addition, the Network held monthly calls for the focus group to discuss challenges and best demonstrated practices, and invited patient SMEs to share the patient perspective on each call. At the end of the QIA, the 184 subset group reached their QIA goal with an LTC rate of 14.2%. The 35 focus group facilities were able to reduce their aggregate LTC rate from 18.9% to 16.0%, a decrease of 2.9 percentage points. Patient Engagement and Satisfaction: Improving Patients Understanding of Their Lab Values In 2016, the Network was tasked with improving the experience of care for patients by conducting a QIA to improve the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey scores for a Network-selected question in a targeted group of dialysis facilities. Based upon analysis of the Spring 2015 ICH CAHPS survey results, the Network determined the best question to focus on for the QIA was, In the last three months, how often did your dialysis center staff explain your blood test results in a way that was easy to understand? For this question, the Spring 2015 ICH CAHPS survey results indicated that 74.8% (415/555) of respondents answered Usually or Always to the selected question. The Network s QIA goal was to demonstrate at least a 5% improvement, relative to the baseline, in the percentage of positive responses ( Usually or Always ) to this question. 5 National Kidney Foundation Kidney Disease Outcomes Quality Imitative Guidelines Updates, 2006). Page 11 of 65

12 In total, 20 dialysis facilities were targeted for inclusion in the QIA, with approximately 2,362 hemodialysis patients. Affiliations for the 20 QIA facilities were: DaVita 10 Fresenius Kidney Care 8 American Renal Associates 1 US Renal Care 1 Feedback obtained from Network patient SMEs about the possible reasons why a patient might answer the selected question with Never or Sometimes identified that frequently patients do not understand the term blood test results because the dialysis center staff use the term labs or lab results. Based on this feedback, the Network developed the Learn About Blood Test Results (or L.A.B.) QIA intervention. As part of the intervention, the 20 focus group facilities used laminated educational cards (in both English and Spanish) to educate patients about their blood test results. The cards were given to patients to keep and refer to on an ongoing basis. Shortly after being educated and receiving the laminated cards, the patients were given a survey card which asked the ICH CAHPS question selected for this project. Patient survey cards were sealed and mailed to the Network for analysis. The QIA was conducted from March to September The baseline for the QIA was 74.7% and the goal was 75.9% (5% relative improvement). In the final analysis of the project s outcome, 95.7% (201/210) of survey respondents answered Usually or Always to the selected question. Best practices identified by focus facilities included keeping a laminated card deck in each pod and giving each patient card deck for personal reference. Facilities that Consistently Failed to Cooperate with Network Goals Section 1881(c) of the Social Security Act states that the ESRD Network can recommend to CMS the imposition of a sanction when an ESRD provider is not cooperating in achieving Network goals. The Federal Regulations that implement this statute are found in 42 CFR Network 7 strived to maintain a cooperative and collaborative partnership with ESRD providers in all activities in The Network regularly interacted with facilities related to quality improvement activities and projects, patient grievances, data reporting, and the provision of technical assistance and education. In 2016, Network 7 did not identify any facilities in its service area that consistently failed to cooperate with Network goals. Recommendations to CMS for Additional or Facilities Network 7 did not recommend to CMS additional facilities in its Network area in Page 12 of 65

13 Grievances and Access to Care The Network responds to grievances filed by or on behalf of ESRD patients in its service area. Grievances may focus on staff issues, quality of care issues, or environmental issues. Grievances are addressed through Immediate Advocacy, in which the Network contacts the facility to resolve the issue within seven calendar days, through a General Grievance process, in which the Network addresses more complex non-quality of care issues over a 60-day period, or through a Quality of Care Review, in which records are requested and a grievant receives a final outcome letter. In 2016, the Network responded to 97 grievances. Table D. Grievance Data for Calendar Year 2016 Category Number Number of Grievance Cases Opened by the Network in Calendar Year Number of Grievance Cases Involving Access to Care 0 Number of Grievance Cases Involving Involuntary Transfer 0 Number of Grievance Cases Involving Involuntary Discharge 0 Number of Grievance Cases Involving Failure to Place 0 Number of Non-Grievance Cases Involving Access to Care 85 Number of Non-Grievance Cases Involving Involuntary Transfer 0 Number of Non-Grievance Cases Involving Involuntary Discharge 61 Number of Non-Grievance Cases Involving Failure to Place 24 Total Number of Grievance and Non-Grievance Cases Involving Access to Care 85 Number of Grievance Cases Closed by the Network in Calendar Year Number of Non-Grievance Access to Care Cases Closed by the Network in Calendar Year Source of data: Patient Contact Utility. Grievance Cases Referred to State Survey Agencies Of the 97 grievances received by the Network in 2016, 17 (17.5%) were referred to the SA for further investigation. Thirteen cases (76.5%) were related to clinical quality of care issues such as staff-to-patient ratios, water issues, and poor hand hygiene or poor infection prevention practices. Four cases (23.5%) were related to physical environment issues. Of the 17 cases referred to the SA, 10 (58.8%) of the facilities received citations. The Network monitored all cases referred to the SA for their outcomes and provided technical assistance in development of an action plan for facilities that were cited for a deficiency. Page 13 of 65

14 Emergency Preparedness and Response The Network responded to two weather-related emergencies in 2016, both hurricanes that impacted Florida s coastlines and prompted the Emergency Operations Center (EOC) to move to Full Activation. Throughout each emergency, the Network provided technical assistance to both patients and providers regarding facility schedule changes and facility closures, and contacted affected facilities daily to confirm altered schedules, necessary closures, and planned reopenings. Hurricane Hermine Hermine made landfall along the Gulf Coast of Florida on September 2, 2016, becoming the first hurricane to hit the state in 11 years. The Network issued Severe Weather Alerts to all facilities on August 30 and August 31, 2016, providing links to pertinent information and reminders to inform the Network of any changes to facility operational status or of any patient access to care issues. The Network also made direct contact with facilities in the counties forecasted to be in Hermine's path. Of these facilities, 21 reported implementing emergency preparations, such as dialyzing patients ahead of planned closures. Following the storm, four facilities closed due to power outages. Each of the four was able to successfully notify patients and staff of the closure/scheduling change, and all reopened the next day. Hurricane Matthew Hurricane Matthew moved slowly up Florida s East Coast for several days before making landfall in South Carolina on October 8, As the storm approached, the Network issued daily Severe Weather Alerts to all facilities, providing links to pertinent information and reminders to inform the Network of any changes to facility operational status or patient access to care. In addition, the Network collaborated with the Florida Department of Health via daily status updates. In total, the Network monitored 164 facilities, with a combined census of 12,425 patients, that reported planned closures and altered schedules to provide treatment ahead of the storm. For each emergency, facility operation status was shared with the Kidney Community Emergency Response (KCER) Program via daily reporting and participation on daily KCER Emergency Status Calls. No Florida dialysis facilities experienced any permanent closures, nor were any patients without access to care due to either storm. Page 14 of 65

15 List of Tables Table 1, Incident (New) ESRD Patients in Network 7's Service Area, by Patient Characteristics. Page 16 Table 2, Prevalent Dialysis Patients in Network 7's Service Area, by Patient Characteristics. Page 18 Table 3, In-Home Dialysis Patients in Network 7's Service Area, by Dialysis Facility and Modality....Page 20 Table 4, In-Center Dialysis Patients in Network 7's Service Area, by Dialysis Facility and Modality....Page 32 Table 5, Number of Transplants Performed in Network 7's Service Area, by Transplant Center and Donor Type and Number of Patients on Transplant Waiting List* in Network 7's Service Area, by Transplant Center Page 44 Table 6, Renal Transplant* Recipients in Network 7 s Service Area, by Patient Characteristics.....Page 45 Table 7, Deaths among Dialysis Patients in Network 7 s Service Area, by Patient Characteristics Page 47 Table 8A, Vocational Rehabilitation Status, Employment Status, and School Attendance of Prevalent Dialysis Patients Age Years in Network 7 s Service Area... Page 50. Table 8B, Vocational Rehabilitation Status, Employment Status, and School Attendance of Prevalent Dialysis Patients Age Years in Network 7 s Service Area... Page 62 Table 9A, Incident ESRD Patients in Network 7 s Service Area, by Ethnicity and Race.....Page 64 Table 9B, Prevalent Dialysis Patients in Network 7 s Service Area, by Ethnicity and Race.....Page 65 Table 9C, Renal Transplant Recipients* in Network 7 s Service Area, by Ethnicity and Race.....Page 66 Page 15 of 65

16 Appendix. Data Tables Table 1. Incident (New) ESRD Patients in Network 7's Service Area, by Patient Characteristics January 1, December 31, 2016 Network 7's Service Area Number Percent Age Group 4 Years % 5-9 Years 9 0.1% Years % Years % Years % Years % Years % Years % Years % Years % Years % Years % Years % Years 1, % Years 1, % Years % Years % 85 Years % Network-Level Total 8, % Median Age 67 Gender Female 3, % Male 5, % Network-Level Total 8, % Ethnicity* Hispanic or Latino 1, % Not Hispanic or Latino 6, % Not Specified % Network-Level Total 8, % Page 16 of 65

17 Network 7's Service Area Number Percent Race* American Indian/Alaska Native % Asian % Black or African American 2, % Native Hawaiian or Other Pacific Islander % White 5, % More Than One Race Reported % Not Specified % Network-Level Total 8, % Primary Cause of ESRD* Diabetes 3, % Glomerulonephritis % Secondary Glomerulonephritis/Vasculitis % Interstitial Nephritis/Pyelonephritis % Transplant Complications % Hypertension/Large Vessel Disease 3, % Cystic/Hereditary/Congenital/Other Diseases % Neoplasms/Tumors % Disorders of Mineral Metabolism 3 0.0% Genitourinary System % Acute Kidney Failure % Miscellaneous Conditions % Not Specified % Network-Level Total 8, % Source of data: CROWNWeb. *Categories are from the CMS-2728 form. NOTES: 1. This table includes data on dialysis and transplant patients whose initial Admit Date in CROWNWeb was within the calendar year. Excludes patients with a "Discharge Reason" of acute kidney failure. 2. This table may include data on some patients receiving dialysis services from U.S. Department of Veterans Affairs (VA) facilities. 3. Data on "ethnicity" and "race" should be interpreted with caution because of the inherent instability of race/ethnicity data. Page 17 of 65

18 Table 2. Prevalent Dialysis Patients in Network 7's Service Area, by Patient Characteristics As of December 31, 2016 Network 7's Service Area Number Percent Age Group 4 Years % 5-9 Years % Years % Years % Years % Years % Years % Years % Years 1, % Years 1, % Years 2, % Years 3, % Years 3, % Years 4, % Years 3, % Years 3, % Years 2, % 85 Years 1, % Network-Level Total 30, % Median Age 64 Gender Female 12, % Male 17, % Network-Level Total 30, % Ethnicity* Hispanic or Latino 5, % Not Hispanic or Latino 25, % Not Specified % Network-Level Total 30, % Page 18 of 65

19 Network 7's Service Area Number Percent Race* American Indian/Alaska Native % Asian % Black or African American 11, % Native Hawaiian or Other Pacific Islander % White 17, % More Than One Race Reported % Not Specified % Network-Level Total 30, % Primary Cause of ESRD* Diabetes 12, % Glomerulonephritis 2, % Secondary Glomerulonephritis/Vasculitis % Interstitial Nephritis/Pyelonephritis % Transplant Complications % Hypertension/Large Vessel Disease 10, % Cystic/Hereditary/Congenital/Other Diseases 1, % Neoplasms/Tumors % Disorders of Mineral Metabolism 5 0.0% Genitourinary System % Acute Kidney Failure % Miscellaneous Conditions 1, % Not Specified % Network-Level Total 30, % Source of data: CROWNWeb. *Categories are from the CMS-2728 form. NOTES: 1. This table includes data on all patients identified in CROWNWeb as alive and receiving dialysis services as of December 31 of the calendar year. 2. This table may include data on some patients receiving dialysis services from U.S. Department of Veterans Affairs (VA) facilities. 3. Data on "ethnicity" and "race" should be interpreted with caution because of the inherent instability of race/ethnicity data. Page 19 of 65

20 Table 3. In-Home Dialysis Patients In Network 7's Service Area, by Dialysis Facility and Modality As of December 31, 2016 Other Total In-Home State HD CAPD CCPD Modalities Patients Total In-Center and In- Home Patients FL , ,779 30,532 Network Total , ,779 30,532 Facility CCN HD CAPD CCPD Other Modalities Total In-Home Patients Total In-Center and In- Home Patients F F F F Page 20 of 65

21 Facility CCN HD CAPD CCPD Other Modalities Total In-Home Patients Total In-Center and In- Home Patients Page 21 of 65

22 Facility CCN HD CAPD CCPD Other Modalities Total In-Home Patients Total In-Center and In- Home Patients Page 22 of 65

23 Facility CCN HD CAPD CCPD Other Modalities Total In-Home Patients Total In-Center and In- Home Patients Page 23 of 65

24 Facility CCN HD CAPD CCPD Other Modalities Total In-Home Patients Total In-Center and In- Home Patients Page 24 of 65

25 Facility CCN HD CAPD CCPD Other Modalities Total In-Home Patients Total In-Center and In- Home Patients Page 25 of 65

26 Facility CCN HD CAPD CCPD Other Modalities Total In-Home Patients Total In-Center and In- Home Patients Page 26 of 65

27 Facility CCN HD CAPD CCPD Other Modalities Total In-Home Patients Total In-Center and In- Home Patients Page 27 of 65

28 Facility CCN HD CAPD CCPD Other Modalities Total In-Home Patients Total In-Center and In- Home Patients Page 28 of 65

29 Facility CCN HD CAPD CCPD Other Modalities Total In-Home Patients Total In-Center and In- Home Patients Page 29 of 65

30 Facility CCN HD CAPD CCPD Other Modalities Total In-Home Patients Total In-Center and In- Home Patients Page 30 of 65

31 Facility CCN HD CAPD CCPD Other Modalities Total In-Home Patients Total In-Center and In- Home Patients FL0ORP FL Total , ,779 30,532 Source of data: ESRD Facility Survey (CMS-2744A) as recorded in CROWNWeb. HD = Hemodialysis CAPD = Continuous Ambulatory Peritoneal Dialysis CCPD = Continuous Cycling Peritoneal Dialysis NOTE: This table may include data for some U.S. Department of Veterans Affairs (VA) facilities. Page 31 of 65

32 Table 4. In-Center Dialysis Patients in Network 7's Service Area, by Dialysis Facility and Modality As of December 31, 2016 State HD PD Total In-Center Patients Total In-Center and In- Home Patients FL 26, ,753 30,532 Network Total 26, ,753 30,532 Facility CCN HD PD Total In-Center Patients Total In-Center and In- Home Patients F F F F Page 32 of 65

33 Facility CCN HD PD Total In-Center Patients Total In-Center and In- Home Patients Page 33 of 65

34 Facility CCN HD PD Total In-Center Patients Total In-Center and In- Home Patients Page 34 of 65

35 Facility CCN HD PD Total In-Center Patients Total In-Center and In- Home Patients Page 35 of 65