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Dialysis Facility Compare (DFC) Website Evaluation. ESRD Stakeholders Meeting March 25, 2004 Michael Trisolini, PhD, MBA RTI International. Presentation outline. 1. Project Overview 2. Website Presentation & Navigation 3. Facility Characterisics 4. Quality Measures

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Dialysis Facility Compare (DFC) Website Evaluation

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Dialysis facility compare dfc website evaluation l.jpg

Dialysis Facility Compare (DFC) Website Evaluation

ESRD Stakeholders Meeting

March 25, 2004

Michael Trisolini, PhD, MBA

RTI International

Presentation outline l.jpg

Presentation outline

1. Project Overview

2. Website Presentation & Navigation

3. Facility Characterisics

4. Quality Measures

5. Dialysis and Kidney Disease Information & Links

6. Next Steps

1 project overview l.jpg

1. Project overview

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CMS Project Officer

Eileen Zerhusen, RN, BSN

DFC Evaluation Project Staff


Michael Trisolini, PhD, MBA

Amy Roussel, PhD

Shelly Harris, MPH

Karen Bandel, MPH

Philip Salib, BA


Dorian Schatell, MS

Kristi Klicko, BS

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Project timetable

Sept. 2002 – Nov. 2002 - Planning, recruiting participants

Dec. 2002 – June 2003 - Qualitative data collection with 6 types of respondents

July 2003 – Oct. 2003 - Reports and recommendations, begin mock-ups of revised DFC

Nov. 2003 – Nov. 2004 - Develop and test mock-ups of revised DFC, develop new content

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General objectives

  • Gain feedback on current DFC content and features from patients, family members, and professionals

  • Investigate current patterns of DFC use

  • Study information needs of potential DFC users

  • Identify ways to improve the DFC

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Qualitative data collection

  • Focus groups

  • Triads (small focus groups)

  • In-person interviews

  • Telephone interviews

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Locations for data collection

  • Site visits (about 1 week each)

    • Washington, DC

    • Atlanta

    • Chicago

    • Phoenix

  • Telephone interviews

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Respondent types


  • Dialysis patients & family members98

  • Dialysis professionals & technicians98

  • Pre-ESRD (CKD) patients & family members42

  • Pre-ESRD professionals 8

  • Senior staff of dialysis chains, MCOs & DMOs18

  • Senior staff of national renal organizations 6

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Dialysis patients & family


  • Hemodialysis patients 63

  • Peritoneal dialysis patients12

  • Family Members23



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Dialysis professionals & techs


  • Nephrologists 9

  • Nurses22

  • Social workers29

  • Dietitians25

  • Technicians 9

  • Renal administrators 4



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General findings - 1

  • Few respondents currently using the DFC

  • HD & pre-ESRD patients pleased to have access to the data on DFC, saw it as relevant, but wanted more data and more user-friendliness

  • Dialysis family members & PD patients less satisfied

  • All respondents had many ideas for improvements to DFC

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General findings - 2

  • Dialysis patients perceived to have less choice among facilites when starting, but more later

  • Variation by site

  • Pre-ESRD patients & family have many learning needs

  • Pre-ESRD educational programs are in early stages of development

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General findings - 3

  • Internet access less of a problem than expected

  • Public reporting of quality data perceived by professionals to have value for quality improvement

  • MCOs & DMOs saw applications for DFC

  • CMS perceived as honest broker for dialysis & facility information

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RTI Recommendations

  • Based on findings from research

  • Currently proposals being evaluated by CMS staff

  • Implementation now under consideration

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2. Website presentation & navigation

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  • Aim for 5th grade reading level

  • Settle for 7th – 9th grade reading level

  • Provide button to increase font size

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Reduce density of text

  • Break long text sections into manageable pieces - “chunking”

    • Short sentences & paragraphs

    • Bulleted lists

    • Columns to limit line length to 30-50 characters

    • Subheadings

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Example – current DFC

  • Read This: The information in Dialysis Facility Compare should be looked at carefully. Use it with the other information you gather about dialysis facilities as you decide where to get dialysis. You should visit any facility in which you are interested and talk with the dialysis facility staff. You may also want to contact your doctor, local ESRD Network or State Survey Agency for more information before you choose a dialysis facility. The telephone number for the local ESRD Network and State Survey Agency can be found in the Helpful Contacts section of this website.

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Revised DFC Mockup

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  • Create a Spanish language version of DFC

  • Use model from Nursing Home Compare

    • “Vea en Espanol” button on each page in English

    • “View in English” button on each page in Spanish

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Increase non-text content

  • Graphics, photographs, diagrams, cartoons

  • Mapping function with “zoom” (like MapQuest)

  • Animation

  • Audio clips, video clips

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Revised DFC Mockup

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Concerns with non-text content

  • Section 508 – accessibility for visually impaired beneficiaries

  • Load time

  • Hardware, software requirements

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Reduce scrolling

  • Add headings with hyperlinks

  • Add tabs and sub-tabs for results

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Revised DFC Mockup

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Add user-friendly features for those with little web experience

  • Tabs or hyperlinks for special populations

    • PD patients

    • Family members

    • CKD patients

    • Pediatric patients and their parents

  • Clarify context, “why to use DFC”

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Revised DFC Mockup

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Facility characteristics table

  • Enable facility characteristics table to show 4-6 facilities per screen versus 2

  • Reduce font size if needed, with option to switch back to larger font and 2 facilities per screen

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3. Facility Characteristics

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Current DFC

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Participants suggested many new facility characteristics

  • Patient issues

  • Staffing issues

  • Organizational issues

  • Policy issues

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PD patients have special information needs

  • Number of PD staff

  • Number of PD patients

  • PD patients per PD nurse

  • PD training

  • PD supplies and equipment

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Pre-ESRD patients and family made fewer suggestions

  • Don’t know enough to know what they need to know

  • Very interested in the experience of receiving dialysis care

  • Patient checklists would be very helpful

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Add patient checklists

  • DFC cannot offer everything

  • Encourage patients to contact dialysis facilities and providers with specific questions

  • Provide detailed list of potential areas of inquiry

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Consider facility characteristics from SIMS database

  • Review available data elements

  • Add relevant facility characteristics

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Consider information on state surveys and inspections

  • Follows Nursing Home Compare (CMS exploring similar approach for DFC)

  • Most recent Medicare certification (initial certification date already posted on DFC)

  • Most recent state survey date

  • Deficiencies cited

  • Add to checklist

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Information on amenities

  • Topics highlighted by respondents:

    • Support groups

    • Visitor policy

    • Accessibility for people with disabilities

    • Televisions

    • Data ports

    • Cleanliness

  • Add to checklist

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Information on scheduling

  • Shift times

  • Hours and days of operation

  • Add to checklist

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Offer more information about modalities

  • Availability

  • How many patients are receiving various modalities

  • Add to checklist

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Staffing information

  • Staffing ratios

  • Certification or training of technicians

  • Number staff on site

  • Clinical staff availability

  • Add to checklist

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Revised DFC Mockup

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3. Quality measures

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Adequacy & Anemia

3. Quality measures

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Presentation – very appealing

  • Colored bar graphs

  • Comparisons to national & state averages

  • Multiple facility comparisons

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  • Patients & family members liked comparing facilities

  • Kt/V & hemoglobin preferred by professionals

  • But URR & hematocrit considered acceptable

  • Professionals had some casemix concerns

  • Age of the quality data was not a major concern for patients & family members, but was for professionals

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Text explanations – problematic

  • Glossary definitions too complicated, too long

  • Explanations above the bar graphs better, but not great

  • Reading level too high

  • Too much text – patients & family usually skip over it

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Patient survival

3. Quality measures

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Patients & family

  • Statistical language hard to understand – “better than expected”

  • Explanation above the results table unclear to many

  • FAQs better

  • Most prefer bar graphs (adequacy & anemia) to the check marks in the patient survival results table

  • Most still wanted to see survival data

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  • Concern that non-facility factors affect survival

    • Percent elderly & nursing home residents

    • Percent poor nutrition or non-compliant

    • Percent comorbidities

  • Some understood existing casemix adjustments (age, race, gender, diabetes) but many missed it

  • Also liked FAQs

  • Suggested text explanations too complex for patients & family

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3. Quality measures

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  • Add (a few) more quality measures

  • Consider PD-specific quality measures

  • Replace “Not Available” with specific reasons

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Current DFC

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Revised DFC Mockup

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  • Revise text explanations

    • Reduce amount of text

    • Highlight links to FAQs & expand them

    • Lower reading level

    • More use of non-text methods – diagrams, pictures, graphics

  • Consider presenting quality data as trends over time

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Recommendations for new measures - 1

  • Patient satisfaction (experience of care)

    • STRONG preference of patients (they want to hear from other patients)

    • A way to have their “voice” heard

    • Also supported by professionals

    • Most dialysis facilities already collect these data

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Recommendations for new measures - 2

  • Transplant waiting list

  • Vascular access

  • State survey results

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Recommendations for new measures - PD

  • PD-only adequacy (Kt/V)

  • Albumin levels

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Recommendations for changing measures

  • Kt/V versus URR

  • Hemoglobin versus hematocrit

  • Follow Clinical Performance Measures

  • Most facilities already collect these data

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5. Dialysis and kidney disease information & links

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Uses of DFC for patient education

  • Patients would like more information on a range of topics

  • Professionals saw potential for use in educating patients

  • CKD educators could add to their resource lists and classroom exercises

  • Currently limited applicability to PD patients

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Additional information sought - 1

  • Patient experience of treatment. E.g., “What’s it like to be on PD?”

  • Information on clinical aspects of dialysis & renal disease

  • Information on dialysis and CKD self-care (e.g., nutrition, vascular access)

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Additional information sought - 2

  • More on transplantation

  • More on PD

  • Explanations of medical terms (e.g., “necrotic”)

  • Meaning of lab results – link to quality measures

  • Implications of patient non-adherence to treatment

  • Rights and responsibilities of patients

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Develop checklists for patients

  • Reinforce message that patients should seek information from facilities and providers directly

  • Patients often don’t know what to ask

  • Support patient involvement in decision-making and in managing their own care

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Make Web links more prominent and more extensive

  • Other federal and state resources

  • Renal organizations

  • External information sources

  • Patient education resources

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Consider special needs of new dialysis and CKD patients

  • Would like better understanding of kidney function and renal disease

  • Adjusting to dietary changes

  • Facing choices:

    • how to delay need for dialysis

    • vascular access

    • dialysis modality

    • transplant

    • dialysis facility

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Consider information needs of other special populations

  • PD patients

  • Family members

  • Pediatric patients & their parents

  • Non-English-speaking patients

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6. Next Steps

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To provide input

  • Eileen Zerhusen, CMS

    • [email protected]

  • Michael Trisolini, RTI

    • [email protected]

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Questions & comments

  • Comment form in conference notebooks

  • Microphones in aisles

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RTI Next Steps

  • Assist development of Next Generation DFC

  • Test new language and text

  • Develop and test checklists

  • Plan additional revisions to DFC

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CMS Next Steps

  • Consider additional quality measures for public reporting

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