According to the Centers for Disease Control (CDC) Survey of Dialysis Associated Diseases, California, which includes Network 17 and 18, had one of the lowest hepatitis B vaccination rates in the country for 1994, 1995, and 1996. With 3 outbreaks of hepatitis B (HBV) in California in 1994, hepatitis B vaccination was chosen as a quality improvement project in both Network 17 and 18. With input from both Medical Review Boards and HCFA Region X, a project was formulated which focused on the improvement of the number of facilities which had hepatitis B vaccination rates which are greater than 50%. The overall purpose of both projects was to: (1) achieve access to preventative services for end-stage renal disease (ESRD) Medicare beneficiaries; (2) increase the number of ESRD patients in California who are vaccinated for HBV; (3) eliminate dialysis in California as an independent risk factor for contracting HBV; (4) decrease the number of ESRD facilities with HBV vaccination rates of 0%; and (5) increase the number of ESRD facilities with HBV vaccination rates greater than 50%. In 1998, both Network 17 and 18 denominators were adjusted to reflect the population which is eligible for vaccination. Because of historically low vaccination rate in California, the 1998 data collection sought to ascertain precise numbers for the ESRD patient population. Data were used from the 1996 and 1997 CDC Survey of Dialysis Associated Diseases from baseline measurements of HBV vaccination rates for all facilities in both Network 17 and 18. The CDC did not conduct a survey in 1998, however, Network 17 and 18 conducted a survey of dialysis associated diseases for all of California ESRD facilities. A data collection tool was designed to gather information on processes and outcomes in each facility. This allowed a continuous quality improvement (CQI)-based approach to analyze the problem, where tools like cause/effect and Pareto diagrams provided information on factors and issues affecting low HBV vaccination rates. Interventions were designed to target those specific factors. Interventions included creation of the "Hepatitis Booklet" (Network 18) and the "Hepatitis Resource Guide" (Network 17); mailing of the resource material to all providers (Network 18), and with vaccination rates less than 50% (Network 17); development of facility specific profiles; and policy statements by both Medical Review Boards on Hepatitis B Vaccination. The number of ESRD patients in California who are vaccinated for HBV increased to 53% or 11,412 patients of 21,617 eligible patients in both Networks. The number of ESRD patients in California who are vaccinated plus those in the process of receiving the series brought the California vaccination rate of 72% or 15,653 for 21,617 eligible patients in both Networks. The number of ESRD facilities in California with HBV vaccination rates of 0% decreased to 10 facilities in 1998, from 75 facilities in 1997, and 135 facilities in 1996. The number of ESRD facilities in California with HBV vaccination rates more than 50% increased to 175 facilities, from 87 facilities in 1997, and 52 in 1996. The number of patients developing antibodies post-vaccine was 62% (Network 18). Facilities in Network 17 with vaccination rates exceeding 50% who did not receive the Hepatitis B Resource Guide vaccinated 44% of all patients vaccinated or in progress in Network 17 in 1998. Facilities in Network 17 with vaccination rates less than 50% who did receive the Hepatitis B Resource Guide vaccinated 57% of all patients vaccinated or in progress in Network 17. For the first time, vaccination rates were collected on peritoneal dialysis (PD) patients. In Network 17, 51% of PD patients are vaccinated versus 59% of hemodialysis patients. In Network 18, 48% of PD patients are vaccinated versus 48% of hemodialysis patients. Resource material and feedback reports developed by both Networks facilitated improvements in Hepatitis B vaccination of ESRD patients in California. Rates will continues to be tracked with the new CDC Survey of Dialysis Associated Diseases in 1999. Further interventions will be based on facility performance. (C) 2000 by the National Kidney Foundation, Inc.
