Transcript Document

The State of CKD, ESRD
and Mortality in the First
Year on Dialysis: Are We
Doing Enough?
Allan J. Collins, MD, FACP
Professor of Medicine
University of Minnesota
Director, USRDS Coordinating Center
Patient counts,
by modality
Figure p.3 (Volume 2)
Incident & December
31 point prevalent
patients.
USRDS 2008 ADR
Counts of new & returning
dialysis patients
Figure p.2 (Volume 2)
Data obtained from
CMS’s annual EndStage Renal Disease
Facility Survey.
USRDS 2008 ADR
Projected growth of prevalent
dialysis & transplants populations to 2020
Figure 2.2 (Volume 2)
counts projected
using a Markov
model. Original
projections used
data through 2000;
new projections
use data through
2006.
USRDS 2008 ADR
Adjusted incident rates
& annual percent change
Figure 2.3 (Volume 2)
Incident ESRD patients; rates adjusted for age, gender, & race.
USRDS 2008 ADR
Incident counts & adjusted
rates, by age
Figure 2.5 (Volume 2)
Post WW II
“Baby Boomers”
Incident ESRD patients; rates adjusted for gender & race.
USRDS 2008 ADR
Incident counts & adjusted rates,
by race
Figure 2.6 (Volume 2)
Incident ESRD patients; rates adjusted for age & gender.
USRDS 2008 ADR
Incident counts & adjusted rates,
by primary diagnosis
Figure 2.8 (Volume 2)
Incident ESRD patients; rates adjusted for age, gender, & race.
USRDS 2008 ADR
Adjusted incident rates of ESRD due to
diabetes, by age & race/ethnicity: age 20-39
Figure 2.12 (continued) USRDS 2006 ADR
Increasing disparities
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USRDS 2008 ADR
Rates are increasing in African and
Native Americans ages 30-39!
Trends in Incident cases of ESRD
• Overall, incidence rates appear to have stabilized, however,
the absolute number of new cases ESRD patients is driven
by the “Baby Boomer” generation age 45-64 years old
which has major budgetary implications.
• ESRD rates due to Diabetes have stabilized overall and
declined in older Racial groups, However,
• There is a marker increase in ESRD due to Diabetes in the
younger African and Native Americans which is in marked
contrast to the younger White population!
• These findings continue into the most recent data to be
released in September 2009 which demonstrate a growing
health disparity issue for the African and Native American
Populations
USRDS 2008 ADR
Public Health Programs needed to
address ESRD due to DM
• The racial disparity issues in the younger African and
Native American population needs a broad base effort
• In 2009 with all the attention on the Economic and Health
care stimulus package, these racial disparities are “Shovel
Ready” for efforts from
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By government: NIDDK, CDC, DHHS, State Departments of
Health, Health Caucuses in Congress
NGOs across all domains including foundations, patient
advocacy groups should engage these issues
Media: Including Medical Journals, Editorials and the lay press
etc.
• World Kidney Day, at least in the US, should have a theme
on kidney disease and diabetes focusing on the growing
disparity issues for a call to action!
USRDS 2008 ADR
Adjusted prevalent rates
& annual percent change
Figure 2.11 (Volume 2)
December 31 point prevalent ESRD patients; rates adjusted for age, gender, & race.
USRDS 2008 ADR
Growth of the Prevalent ESRD and
dialysis population
• The prevalent population continues to grow at 34% per year
• The growth is now driven by the falling death
rates since the incidence rate has slowed
• The growth, however, places increased demands
on the health care budget such that more cost
effective treatment is needed.
• The proposed new dialysis “Bundled” payment
system is an attempt to contain cost in the same
way as in 1982 when the original composite rate
payment system was created.
USRDS 2008 ADR
Quality indicators: percent of patients
meeting clinical & preventive care guidelines
Figure 5.1 (Volume 2)
Kt/V & vascular access data: incident & prevalent dialysis patients; from 2005 CPM report—patient data from 2004. URR: prevalent hemodialysis patients,
2005; from Medicare claims. Hemoglobin: prevalent dialysis patients, 2005; from Medicare claims. Anemia management: Diabetic care: point prevalent patients
initiating ESRD 90 days prior to January 1, 2004, age 18–75 on December 31, 2005, & alive through December 31, 2005, with diabetes as the primary cause of
ESRD or a comorbidity on the Medical Evidence form, or with diabetes diagnosed during the first year; HbA1c & lipid tests are at least 30 days apart.
Comprehensive monitoring includes at least four HbA1c tests per year, at least two lipid tests per year, & at least one diabetic eye examination per year.
Influenza vaccinations: ESRD patients initiating therapy at least 90 days before September 1, 2005, & alive on December 31, 2005; vaccinations tracked between
the two dates. Pneumococcal pneumonia vaccinations: ESRD patients initiating therapy at least 90 days before January 1, 2004, & alive on December 31, 2005;
vaccinations tracked during entire period. Hepatitis B vaccinations: ESRD patients initiating therapy at least 90 days before January 1, 2005, & alive on
December 31, 2005. Vaccinations tracked during entire period.
USRDS 2008 ADR
Arteriovenous fistula use in
incident hemodialysis patients
Figure hp.11 (Volume 2)
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Incident patients initiating dialysis between January 1 & August 31 of the year of data collection; 1999–2006 ESRD
CPM data. Access represents the current access used as of the latest data collection for that year. Includes only patients
for whom an access is known.
USRDS 2008 ADR
Arteriovenous fistula placement rates in
prevalent hemodialysis patients, by age
& race/ethnicity
Figure hp.12 (Volume 2)
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Period prevalent hemodialysis patients with or without simple fistulas. Data from physician/supplier claims. Some
patients may have more than one access at a given point in time. Some patients may have more than one access at a
given point in time. For Hispanic patients we present data beginning in 1996, the first full year after the April 1995
introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity.
USRDS 2008 ADR
Access procedures in prevalent
hemodialysis patients, by diabetic status
Figure hp.13 (Volume 2)
Transition to cuffed catheters
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Period prevalent hemodialysis patients with or without simple fistulas. Data from physician/supplier claims. Some
patients may have more than one access at a given point in time.
USRDS 2008 ADR
Vascular access utilization
• The Fistula First Initiative has led to the largest
growth in fistulas in the history of the dialysis
program reaching 50% of the new patients within
the first year!
• Placement rates for fistulas has increased 150%
over the last 13 years
• Placement rates for catheters initially increased
significantly but have fallen since 1999, however,
cuffed catheters are being used which may
reduce placement rates but still expose patients
to risks of infections.
USRDS 2008 ADR
Preventive care for infectious
complications
• Influenza Vaccinations
• Pneumococcal pneumonia vaccinations
• Variations in delivered care
USRDS 2008 ADR
Influenza vaccination rates,
by age, race/ethnicity, & modality
Figure 5.18 (Volume 2)
ESRD patients initiating therapy at least 90 days before September 1 of each year & alive on December 31; vaccinations
tracked between September 1 & December 31 of each year.
USRDS 2008 ADR
Influenza vaccinations,
by unit affiliation
Figure 10.24 (Volume 2)
dialysis patients initiating therapy at least 90
days before September 1 of each year & alive
on December 31; vaccinations tracked
between September 1 & December 31 of each
year.
Patients with Medicare inpatient/outpatient &
physician/supplier primary payor coverage
during entire period.
USRDS 2008 ADR
Pneumococcal pneumonia vaccination
rates, by age, race/ethnicity, & modality
Figure 5.20 (Volume 2)
ESRD patients initiating therapy at least 90 days before the start of the period & alive on the period’s last day;
vaccinations tracked during entire period.
USRDS 2008 ADR
Pneumococcal pneumonia
vaccinations, by unit affiliation
Figure 10.25 (Volume 2)
dialysis patients initiating therapy at least 90
days before the start of the period/year & alive
on the period or year’s last day; vaccinations
tracked during entire period/year.
Patients with Medicare inpatient/outpatient &
physician/supplier primary payor coverage
during entire period.
USRDS 2008 ADR
Preventive care for infectious
complications
• The variation is vaccination rates for influenza and
pneumococcal pneumonia are considerable and
unexplained.
• These vaccinations are very inexpensive compared to the
cost of a single hospitalization for pneumonia yet universal
adoption is lacking.
• In fact, there has been no progress in influenza vaccination
rates for the last 5 years!
• Pneumococcal pneumonia vaccinations have increase to a
greater degree in some providers!
• Providers need to be held accountable for the lack of
performance is this area.
USRDS 2008 ADR
Morbidity and Mortality trends: Areas
of concern
• Prevalent mortality rates have been declining since the mid1990s
• Incident based mortality rates have declined modestly in
the 2nd to 5th years under treatment
• First year death rates have not changed in 12 years which
is a major concern
• Hospitalization rates in the first year have increased in most
categories with infections generating the largest growth.
• Vascular access infectious hospitalization have almost
doubled in the last 10 which is a major concern.
USRDS 2008 ADR
Adjusted mortality rates, by vintage:
All Dialysis
Figure 6.9 (Volume 2)
Dallas Morbidity and Mortality Conference
Period prevalent
dialysis patients;
adjusted for age,
gender, race, &
primary diagnosis.
Dialysis patients, 2005,
used as reference
cohort.
USRDS 2008 ADR
Mortality rates,
by modality
Figure 6.1 (Volume 2)
Incident ESRD
patients; adjusted
for age, gender,
race, & primary
diagnosis. Incident
ESRD patients,
2005, used as
reference cohort.
USRDS 2008 ADR
All-cause & cause-specific mortality
in the first months of ESRD
Figure 1.1 (Volume 2)
incident dialysis
patients, 1993–1998 &
1999–2005 combined,
adjusted for age,
gender, race, &
primary diagnosis.
Incident dialysis
patients, 2005, used as
reference.
USRDS 2008 ADR
Change in all-cause & cause-specific
hospitalization rates, by modality: prevalent
Figure p.22
Period prevalent ESRD
patients; adjusted for
age, gender, race, &
primary diagnosis.
ESRD patients, 2005,
used as reference
cohort. Vascular access
hospitalizations are
“pure” inpatient
vascular access events,
as described in
Appendix A. New
vascular access codes
for peritoneal dialysis
patients appeared in
late 1998; therefore,
peritoneal dialysis
vascular access values
are shown as changing
since 1999 rather than
1993.
USRDS 2008 ADR
Summary
• The ESRD incident counts exceeded 110,000 in 2006 with
the prevalent ESRD population exceeding 506,000
• Many aspects of cardiovascular care have improved with
increased use of diagnostic tests and interventions
• Prevalent deaths continue to fall, however, death rates in
the first year have changed little over the last 12 years in
hemodialysis
• Death rates in the first months of dialysis are high and need
to be addressed
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Later referral is a persistent problem: This is a primary care
and nephrology issue!!!!
High rates of catheter utilization at initiation of hemodialysis
lead to complications that are avoidable
Hospitals are not held accountable for a vascular access plan
and have a conflict of interest since they are highly paid for
vascular access DRGs
Hospitals have the ability to regulate the medical staff under
their bylaws and extension of practice privileges
USRDS 2008 ADR
Conclusions
• ESRD incidence rates have slowed considerably since the
early 1990s
• ESRD rates due to diabetes is a major concern particularly
in the younger African and Native American populations
which needs attention on a public health level
• Prevalence rates have grown based on lower death rates
• The use of fistulas in the prevalent population has
increased which is an important achievement
• Morbidity and mortality in the first year of dialysis is a
major concern particularly related to poor planning of
transition to dialysis
• The new CKD stage 4 education benefit needs to be
implemented and providers monitored for effectiveness
• Survival of the ESRD and dialysis population has improved
but challenges remain particularly in CKD to ESRD
transition and first year death and hospitalization rates.
USRDS 2008 ADR