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PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 (CONTINUED)

INSTRUCTIONS FOR COMPLETING QUESTIONS 18 THROUGH 20 (continued from page 1): To answer questions 18 through 20

review the patient’s clinic or facility medical record FOR EACH TWO-MONTH TIME PERIOD: OCT 1, 2004 through NOV 30, 2004,

DEC 1, 2004 through JAN 31, 2005, and FEB 1, 2005 through MAR 31, 2005. Do not leave any items blank. Enter NF/NP if the follow-

ing information cannot be located.

18A: Enter the patient’s FIRST hemoglobin (Hgb) value determined by the laboratory for EACH two-month time period. Include the date the

lab was drawn. If not found or not performed during the two-month time period, enter NF/NP.

18B.1: Check the appropriate box to indicate if the patient had a prescription for EPOETIN or DARBEPOETIN (Aranesp

) at anytime during

the 28 days BEFORE the date of the hemoglobin value in 18A. If the answer is NO to both, skip to question 18C.

18B.2: If Epoetin was prescribed, enter the TOTAL PRESCRIBED 4-WEEK Epoetin dose, not the administered dose, in units/28 days

given prior to the 28 days before the date of the hemoglobin value in 18A, even if the patient did not receive the dose. This includes any

prescribed dose not given because of an error or the patient missed a dose, etc. Enter “0” if the patient was on “Hold”. (For the purposes

of this collection, a “Hold” order will be considered a 0 unit prescribed dose.)

If Darbepoetin (Aranesp

) was prescribed, enter the TOTAL PRESCRIBED 4-WEEK Darbepoetin dose, not the administered dose,

in micrograms/28 days prior to the 28 days before the date of the hemoglobin value in 18A, even if the patient did not receive the dose.

This includes any prescribed dose not given because of an error or the patient missed a dose, etc. Enter “0” if the patient was on “Hold”.

(For the purposes of this collection, a “Hold” order will be considered a 0 mcg/month prescribed dose.)

18B.3: Enter the number of doses per month (28 days) that Epoetin was prescribed OR the number of doses per month (28 days) Darbepoetin

was prescribed.

18B4: Check the appropriate box to indicate the prescribed route of administration for Epoetin or for Darbepoetin (intravenous [IV] or

subcutaneous [SC]). If the patient received Epoetin or Darbepoetin IV and SC during the month, please check both boxes.

18C: Enter the patient’s FIRST serum ferritin concentration recorded EACH two-month time period. Include the date the lab was drawn. If a

serum ferritin concentration test was not found or not performed every two-month time period, enter the value for the time period when

performed and record NF/NP for the other time period(s).

18D: Enter the patient’s FIRST % transferrin saturation (TSAT) recorded EACH two-month time period. Include the date the lab was drawn. If

a % transferrin saturation (TSAT) test was not found or not performed every two-month time period, enter the value for the time period

when performed and record NF/NP for the other time period(s).

18E: Check either “Yes”, “No”, or “Unknown” to indicate if iron was prescribed at any time during the two-month time periods.

18F: If the answer to 18E is “Yes”, please check the appropriate space to indicate the route of iron administration (intravenous [IV] or by mouth

[PO]) for each two-month time period. Check every route of administration that was prescribed each time period.

18G: If the patient was prescribed IV iron, add together all doses that were given during each two-month time period OCT-NOV 2004, DEC

2004-JAN 2005, FEB-MAR 2005 and enter the TOTAL dose of IV iron (in mg) administered.

19A: Enter the patient’s FIRST serum albumin value recorded EACH two-month time period. Include the date the lab was drawn.

19B: Check the method used by the laboratory to determine the serum albumin levels (bromcresol green or bromcresol purple). If you do not

know what method the laboratory used, call the laboratory to find out this information.

20A: Check the appropriate response (yes or no) for each two-month time period, indicating whether this patient was on peritoneal dialysis at any

time during each of the specified two-month time periods.

20B: Check the appropriate response (yes or no) for each two-month time period, indicating whether this patient was on hemodialysis or received

a transplant at any time during each of the specified two-month time periods.

INSTRUCTIONS FOR COMPLETING QUESTIONS 21 THROUGH 24: To answer questions 21 through 24 review the patient’s clinic

or facility medical record and provide the requested data for each of the first two adequacy measurements and PD prescriptions in

effect at the time the adequacy measurements were done during the months OCTOBER 2004 through MARCH 2005. DO NOT record

more than one adequacy measurement done for any one month.

21.

Check “yes”, “no”, or “unknown” to indicate if a PD adequacy measurement was done between OCT 1, 2004 through MAR 31, 2005.

21A: Enter the first date on which PD adequacy of dialysis was assessed for the first measure obtained between OCT 1, 2004 through MAR 31,

2005. DO NOT record more than one PD adequacy measurement done for any one month.

21B: Check the modality of peritoneal dialysis this patient was on at the time the corresponding adequacy of dialysis measure was obtained.

CHECK either CAPD or Cycler. CAPD includes patients with one overnight exchange using an assist device. Cycler includes patients using

an automated device for exchanges.

21C: Enter the patient’s weight (with abdomen empty) at the clinic/facility visit when the adequacy measurements were obtained, circle lbs or kgs

as appropriate.

21D: Enter the TOTAL WEEKLY Kt/V

for the first adequacy measurement indicated on 21A between OCT 1, 2004 through MAR 31, 2005.

urea

NOTE: Whether or not you have a value for weekly Kt/V

for this adequacy assessment, please complete the corresponding values for

urea

questions 21H-21I for 24-hour dialysate volume, 24-hour dialysate urea and question 21K for 24-hour urine volume. If the patient

is not anuric, complete the corresponding value for question 21L, the 24-hour urine urea, if this value is available. Enter NF/NP for all

values when not found or not performed. If your unit calculates a daily Kt/V

, multiply this result by 7.0 and enter the result in the

urea

appropriate space(s). If this patient did not dialyze each day of the week, then multiply the daily Kt/V

by the number of days the

urea

patient did dialyze.

CMS – 821 (Rev.1/20/05)

Form Cms-821 - Peritoneal Dialysis Clinical Performance Measures Data Collection - 2005 Page 5

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