Dialysis Laboratory Services and Reports December 2012 January 2013

Dialysis Laboratory Services and Reports December 2012 January 2013 Excerpted Analyses From Full Report Prepared for NNI March 6, 2013 NCS Research NCSResearchCouncil@gmail.com

Executive Summary Research Objectives and Methodology Survey Respondent Demographics Overall Satisfaction With Laboratory Provider Key Attributes in Selecting a Laboratory Provider Deep Dive on Laboratory Reporting Application Current Satisfaction With Reporting Application Evaluation of Reporting Application Functions Potential Satisfaction If Main Issued Addressed 2

Executive Summary (1 of 3) The Dialysis Laboratory Services and Reports Questionnaire was fielded from December 2012 to January 2013 with 166 qualified respondents (64% respond rate) representing All major dialysis laboratories All dialysis organization segments (size and profit status) Dialysis facility settings (Free-standing and hospital) Dialysis modality (Home and in-center) Years of nephrology experience Degrees and backgrounds The following analyses are selected excerpts from the full report and are presented across all respondents as well as by laboratory provider in certain cases. Other subgroup analyses such as by influence level, practice setting, dialysis modality, and size of dialysis organization are not presented. Customized analyses upon request 3

Executive Summary (2 of 3) The research objectives were as follows: 1. Evaluate general overall satisfaction with dialysis laboratory provider Half of respondents are very satisfied with their lab provider and only 10% noting dissatisfaction Of respondents representing organizations that can choose their laboratory provider, Ascend Clinical ranks #1 in overall satisfaction. Across all respondents, DCI respondents were most satisfied. 2. Understand the top criteria when selecting a dialysis laboratory provider Unsurprisingly, Speed was rated the number one important attribute of dialysis laboratory provider with 75% of respondents highlighting this criteria Of the 9 attributes evaluated, the next top attribute selected by almost 2/3 of respondents was Laboratory Reports. This research effort attempts to understand perceptions of laboratory reports and the various functions with the reporting application 4

Executive Summary (3 of 3) The research objectives were as follows (continued): 1. 2. 3. Identify relative strengths and development areas of the various laboratory providers reporting applications Across all respondents, top 3 functions with the highest satisfaction were Patient Report Cards, Data Integrity, Water and Dialysate Results. The 3 functions with the lowest satisfaction were Filtering, Medication Management, and Disease Management Reporting Areas of strength and development vary by individual provider 4. Evaluate potential improved overall satisfaction with laboratory reports if areas of dissatisfaction were addressed If the functions with the lowest satisfaction were addressed, satisfaction with laboratory reports jumps from ~50% being very satisfied to ~75% being very satisfied 5

Executive Summary Research Objectives and Methodology Survey Respondent Demographics Overall Satisfaction With Laboratory Provider Key Attributes in Selecting a Laboratory Provider Deep Dive on Laboratory Reporting Application Current Satisfaction With Reporting Application Evaluation of Reporting Application Functions Potential Satisfaction If Main Issued Addressed 6

Dialysis Laboratory Reports and Services Research Objectives 1. Evaluate general overall satisfaction with dialysis laboratory provider 2. Understand the top criteria when selecting a dialysis laboratory provider 3. Identify relative strengths and development areas of the various laboratory providers reporting applications 4. Evaluate potential improved overall satisfaction with laboratory reports if areas of dissatisfaction were addressed These research objectives were evaluated across all respondents and various sub-groups: Influence level: Decision Maker, Influencer, User Laboratory Provider: Spectra, DaVita, Ascend, DCI, Nationwide, etc Dialysis Org Size: LDOs (>1000 facilities), MDO/SDOs, and Independents (1-10 facilities) Dialysis Setting: Free-standing vs hospital based dialysis centers Dialysis Modality: Home vs In-center dialysis Profit Status: For-profit vs non-profit Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012-January 2013 7

Dialysis Laboratory Reports and Services Methodology SCHEDULE The Dialysis Laboratory Services and Reports Survey is scheduled to field semi-annually and compare trends in dialysis laboratory services and reports in the US dialysis market First round: December 2012-January 2013 Second round: June-July 2013 Third round: Timing TBD ANALYSIS Data were collected via internet survey tools and analyzed in Excel Frequency tables, means, median, and other values were calculated Means/proportions between groups were tested for significant differences at the 95% confidence interval Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012-January 2013 8

Dialysis Laboratory Reports and Services Methodology (continued) QUANTITATIVE INTERNET QUESTIONNAIRE Of over 2000 healthcare professionals, invitations to the December 2012/ January 2013 Dialysis Laboratory Services and Reports Survey were sent to 261 qualified healthcare professionals with 166 respondents (64% response rate). The following screening criteria were applied: Nephrology Healthcare Professional US setting Dialysis as the primary practice setting In practice greater than 1 year in nephrology Representation Home and In-Center Dialysis Patient Interaction Time LDOs, MDOs, SDOs, and Independents For-Profit and Non-Profit Hospital-based and Free-standing Dialysis Facilities Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012-January 2013 9

Executive Summary Research Objectives and Methodology Survey Respondent Demographics Overall Satisfaction With Laboratory Provider Key Attributes in Selecting a Laboratory Provider Deep Dive on Laboratory Reporting Application Current Satisfaction With Reporting Application Evaluation of Reporting Application Functions Potential Satisfaction If Main Issued Addressed 10

Respondent Demographics The December 2012-January 2013 Dialysis Laboratory Services and Reporting Survey had 166 respondents in the US dialysis practice setting. The respondents were well represented across Education degrees Years of nephrology experience Work time spent interfacing with patients Roles in the dialysis facility Size of dialysis organization Home and In-Center dialysis For-Profit and Non-Profit status Hospital and Free-standing dialysis centers Dialysis Laboratory Providers (not shown) Influence level in selecting the Laboratory Provider (not shown) Employers (not shown) Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012 - January 2013 11

Respondents represent a variety of education backgrounds Degree of Respondents Percent of Respondents, Totals > 100% as some with multiple degrees (n=166) Bachelor Degree in Nursing 37 Associate of Arts (AA) Diploma Nurse 24 28 Masters Degree in Nursing Bachelor Degree (other) 14 17 Other (please specify) 9 Masters Degree (other) 6 LVN/LPN Doctorate (Ph.D) Degree (other) Doctorate Degree in Nursing Doctor of Medicine (MD/DO) 3 1 1 1 Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012 - January 2013 12

75% of Respondents Have Over 10 Years of Dialysis Experience Respondent Years in Nephrology Percent of Respondents (n=166) 30 45 13 12 0-5 Yrs 6-10 Yrs 11-20 Yrs >20 Yrs n = 22 20 50 74 Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012 - January 2013 13

Percent of work time spent interfacing with patients Work Time Spent Interfacing with Patients Percent of Respondents (n=166) 33 31 23 13 >75% 50-75% 25-49% <25% n = 55 51 38 22 Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012 - January 2013 14

Vast Majority of Respondents are Nurses in the Dialysis Facility Respondent Primary Role Percent of Respondents (n=166) Home Dialysis Nurse/PD Nurse Clinical Nurse Manager 23 27 Facility Administrator 9 Corporate Staff* 8 Other responses Nurse Practitioner Staff Nurse Anemia Manager Professor/Instructor (Academics) 2 1 7 7 Regional manager roles Clinical roles Education roles Coordinator roles QA and Compliance roles CKD Clinic Nurse 1 Vascular Access Manager 1 Other 15 * Clinical Services, Operations, Research, Finance, etc. Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012 - January 2013 15

Equal representation across all sizes of dialysis organizations Respondent Dialysis Organization Size Percent of Respondents (n=166) 34 33 33 Independents MDO/SDO LDO 1-10 dialysis facilities 10-1000 dialysis facilities >1,000 dialysis facilities n = 57 54 55 Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012 - January 2013 16

2/3 of Respondents are In-Center and ~60% Work in For- Profit Organizations Dialysis facility type and status Percent of Respondents Type of Dialysis Facility Primary Dialysis Facility Profit Status 64 36 59 41 In-center hemodialysis Home dialysis For-profit Non-profit n = 103 59 n = 94 65 Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012 - January 2013 17

74% of Respondents Cite Freestanding as Their Primary Dialysis Setting Dialysis Facility(ies) Setting Percent of Respondents (n=152) 74 26 n = Freestanding facility 112 Hospital-based facility 40 Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012 - January 2013 18

Executive Summary Research Objectives and Methodology Survey Respondent Demographics Overall Satisfaction With Laboratory Provider Key Attributes in Selecting a Laboratory Provider Deep Dive on Laboratory Reporting Application Current Satisfaction With Reporting Application Evaluation of Reporting Application Functions Potential Satisfaction If Main Issued Addressed 19

Overall Satisfaction All Respondents Overall Satisfaction with Laboratory Provider By Provider Respondents Average Score* (n=166) Lab Provider Average score* DCI Ascend DaVita 2.50 2.48 2.80 Above average Hospital Lab 2.40 Nationwide Spectra 2.33 2.30 Below average Do not know 1.67 Total average 2.39 * Very Satisfied = 3; Somewhat Satisfied = 2; Somewhat Dissatisfied = 1; Very Dissatisfied = 0; Direct comparisons across groupings are not valid given that responses from each respondent was assigned to only one grouping and respondents experiences with other grouping categories likely vary widely; Caution should be applied in interpreting results extrapolated from small number of respondents as results may not be representative Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012-January 2013 20

Of Respondents Representing Organizations That Can Choose Their Laboratory Provider, Ascend Ranks #1 in Overall Satisfaction Overall Satisfaction with Laboratory Provider External Respondents Only 1 Respondents Average Score 2 and Percent Dissatisfied (n=47) Average score 2 Ascend Non Satellite 2.5 Spectra Labs 4 2.3 Nationwide 3 2.3 DaVita Labs 3 1.7 1 Responses from Satellite, DaVita, FMC, and DCI respondents were excluded as well as those identifying hospital or do not know as their lab 2 Very Satisfied = 3; Somewhat Satisfied = 2; Somewhat Dissatisfied = 1; Very Dissatisfied = 0; Direct comparisons across groupings are not valid given that responses from each respondent was assigned to only one grouping and respondents experiences with other grouping categories likely vary widely 3 <10 respondents in this category; Caution should be applied in interpreting results extrapolated from small number of respondents as results may not be representative 4 Inclusive of long-term care facilities Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012-January 2013 21

Executive Summary Research Objectives and Methodology Survey Respondent Demographics Overall Satisfaction With Laboratory Provider Key Attributes in Selecting a Laboratory Provider Deep Dive on Laboratory Reporting Application Current Satisfaction With Reporting Application Evaluation of Reporting Application Functions Potential Satisfaction If Main Issued Addressed 22

Speed and Laboratory Reports are the Most Important Attributes in Selecting a Lab Provider Most Important Attributes in Selecting a Laboratory Provider* Percent of Respondents (n=166) Speed of lab values availability 78 Laboratory reports 63 Customer service support by phone 54 Ease of shipping samples EMR interface 33 33 Cost 20 Billing system interface In-person support 7 9 Geographic coverage 2 * Sub analyses by influence level and by individual lab provider not shown here Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012-January 2013 23

Speed, Reports, and Cust Service Were Top 3 Attributes By Influence Level With Cost Also A Top 3 for Decision Makers Most Important Attributes in Selecting Lab Provider by Influence Level* Percent of respondents (n=166) Top 3 attributes Decision-Makers Influencers Users Speed of lab values avail. 71 74 78 Laboratory reports 57 58 64 Cost 50 22 15 Phone cust. service support 50 46 57 EMR interface 36 42 27 Ease of shipping samples 14 36 33 Billing system interface 14 8 9 In-person support 7 2 10 Geographic coverage 0 0 3 * Caution should be applied in interpreting results extrapolated from small number of respondents as results may not be representative; Direct comparisons across groupings are not valid given that responses from each respondent was assigned to only one grouping and respondents experiences with other grouping categories likely vary widely Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012-January 2013 24

Executive Summary Research Objectives and Methodology Survey Respondent Demographics Overall Satisfaction With Laboratory Provider Key Attributes in Selecting a Laboratory Provider Deep Dive on Laboratory Reporting Application Current Satisfaction With Reporting Application Evaluation of Reporting Application Functions Potential Satisfaction If Main Issued Addressed 25

Half of Respondents are Very Satisfied with Their Laboratory Reports with Only ~10% Noting Dissatisfaction Satisfaction with Laboratory Reports Percent of Respondents (n=163) 50 41 9 0 Very satisfied Somewhat satisfied Somewhat dissatisfied Very dissatisfied n = 81 67 15 0 * Very Satisfied = 3; Somewhat Satisfied = 2; Somewhat Dissatisfied = 1; Very Dissatisfied = 0 Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012 - January 2013 26

Executive Summary Research Objectives and Methodology Survey Respondent Demographics Overall Satisfaction With Laboratory Provider Key Attributes in Selecting a Laboratory Provider Deep Dive on Laboratory Reporting Application Current Satisfaction With Reporting Application Evaluation of Reporting Application Functions Potential Satisfaction If Main Issued Addressed 27

Analysis of Laboratory Report Functions Suggests A Variety of Strengths and Weaknesses Satisfaction with Laboratory Report Functions* Respondents Average Score** (n=166) Average score** Patient Report Card Data Integrity Water and Dialysate Results Microbiology and Infection Speed QAPI Reporting Ease / User-Friendly QIP Tracking Disease Management Reporting Medication Management Filtering Average Overall 2.15 2.11 2.31 2.30 2.29 2.27 2.26 2.24 2.28 2.43 2.37 2.37 Above average Below average * Sub analyses by influence level and by individual lab provider not shown here ** Very Satisfied = 3; Somewhat Satisfied = 2; Somewhat Dissatisfied = 1; Very Dissatisfied = 0 Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012-January 2013 28

Top 4 Functions That Users are Unaware Of/Do Not Use: Medication Mgmt, Disease Mgmt Reporting, QIP Tracking, and QAPI Reporting Satisfaction with Laboratory Report Functions All Respondents Percent of Respondents (n=153) Very Satisfied Somewhat Satisfied Somewhat Dissatisfied Very Dissatisfied Not applicable/do Not Use Patient Report Card 38 33 5 0 24 Data Integrity 51 34 12 12 Water and Dialysate Results Reporting 41 25 5 4 24 Microbiology and Infection Reporting 43 38 9 3 7 Speed 46 37 9 4 4 QAPI Reporting 29 33 6 1 31 Ease/User-Friendly 42 37 14 1 5 QIP Tracking 30 3 27 7 33 Disease Management Reporting 27 27 7 3 36 Medication Management 18 21 7 2 52 Filtering 24 40 11 2 24 Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012-January 2013 29

Executive Summary Research Objectives and Methodology Survey Respondent Demographics Overall Satisfaction With Laboratory Provider Key Attributes in Selecting a Laboratory Provider Deep Dive on Laboratory Reporting Application Current Satisfaction With Reporting Application Evaluation of Reporting Application Functions Potential Satisfaction If Main Issued Addressed 30

Almost ¾ of Respondents Would Be Very Satisfied with Their Laboratory Reports If Main Issues Were Addressed If Issues Addressed, Potential Satisfaction with Laboratory Reports* Percent of Respondents (n=166/151) 72 Current Satisfaction Potential Satisfaction 50 41 25 9 3 Very Satisfied Somewhat Satisfied Somewhat Dissatisfied * Sub analyses by influence level and by individual lab provider not shown here Source: NCS Research Dialysis Laboratory Reports and Services Survey, December 2012-January 2013 31