Minor revisions were also made to Objective 4.6, originally a goal of increasing “the proportion of patients with treated chronic kidney failure who receive a transplant within three years of registration on the waiting list,” but now looking at transplants in the first three years after initiation of ESRD therapy; baseline years and target levels have also been adjusted.

Until this year, issues of data availability made it difficult to adequately address Objective 4.3, on nutrition, treatment choices and cardiovascular care in the year prior to ESRD initiation. New fields on the revised Medical Evidence form, however, provide information related to this objective, and we present results this year.

The adjusted rate of ESRD incidence has been stable, rising no more than 0.5 percent per year since 2001, and reaching 347 per million population in 2005. But the HP2010 goal is a rate of 221, so more strategies are clearly needed to reduce the progression of CKD to ESRD.

Incident diabetic ESRD has also remained fairly stable since 2001, although the prevalence of diabetes in the general population is rising slightly. It is heartening to see that diabetic ESRD among Native Americans has declined more than 26 percent since 2000. The overall rate of ESRD due to diabetes, however, is well above the HP2010 goal. Diabetes prevention programs should continue to target all populations—particularly minorities and obese individuals.

Cardiovascular death rates continue to fall—from a high of 94 deaths per 1,000 patient years in 1999 to 76 in 2005. A continued decline in deaths due to ASHD and myocardial infarction in the ESRD population may indicate that management of cardiovascular disease and cardiovascular risk factors is continuing to improve. Rates of mortality due to CHF deaths, in contrast, are still growing, and in light of multiple new strategies for treating CHF in the general population, reasons for this growth are unclear.

New evidence shows that nearly two-thirds of new dialysis patients receive care from a nephrologist prior to starting ESRD therapy, and 73 percent are informed of their transplant options. Only 13 percent of patients, unfortunately, receive counseling from a dietitian prior to therapy.

The HP2010 objective for vascular access is that 50 percent of new hemodialysis patients use arteriovenous (AV) fistulas as their primary access. In 2004, CMS funded the Fistula First Initiative, a national initiative to reduce barriers for placement of AV fistulas in U.S. hemodialysis patients. Although the rate of fistula use in incident hemodialysis patients in 2004 was only 38 percent, it did increase from 29 percent in 2002. In addition, fistula placement in prevalent hemodialysis patients has been rising steadily, reaching a high of 122 placements per 1,000 patient years in 2005. The initiative thus seems to be producing positive results.

After a slight decline (most likely reflecting the 2004 vaccine shortage), influenza vaccination rates in ESRD patients rose to nearly 58 percent in 2005—still far from the goal of 90 percent, though it should be noted that patients may receive vaccinations through programs not tracked in the Medicare data. Dialysis programs need to initiate quality improvement programs to increase vaccination rates across age groups.

Today’s major challenge for kidney transplantation is the shortage of organ donors. The number of kidney transplants has grown, but the number of ESRD patients is rising at an even greater rate. The proportion of dialysis patients registered on the wait list for transplantation or who receive a transplant within three years of ESRD registration has remained stable, and both are far below targets.

Prevention and optimal management of diabetes is the logical way to reduce cases of ESRD due to diabetes, addressed in Objective 4.7. The percentage of Medicare diabetic CKD patients who receive recommended screening and evaluation—including two or more glycosylated hemoglobin tests per year and annual lipid and eye examinations—grew from 21 to 31 percent between 2000 and 2005, just short of the 36 percent goal. New data on medication use show that almost 70 percent of Medicare patients with CKD and diabetes were treated with either ACE-Is or ARBs in both 2000 and 2003. (Sample numbers are quite small, so results should be viewed with caution.)

Kidney disease is common, costly, and preventable, and remains underdiagnosed and undertreated. It is our hope that data showing progress—and the lack of it—toward HP2010 goals will help increase awareness of issues related to this disease, and promote positive changes in the healthcare system.

Incident rates & cardiovascular disease  

The adjusted rate of new ESRD cases has remained stable since 2001, rising less than 0.5 percent each year to reach 347 per million population in 2005 (Table hp.a and Figure hp.2). While the rate does seem to have plateaued, it shows no sign of falling toward the HP2010 target of 221.

By age, rates have fallen slightly since 2001 for children and those age 45–74, while rising 3.6 and 7.8 percent for those age 20–44 and 75 and above; rates for Native Americans have fallen 12 percent (Figure hp.3). Like the overall rates, rates of ESRD due to diabetes or hypertension have been quite stable since 2001, reaching 152 and 94 per million population, respectively (Figure hp.4). Diabetes in the general population, however, rose slightly between 2004 and 2005, to 7.3 percent.

Rates of cardiovascular mortality in prevalent ESRD patients fell 6.4 percent in 2005, to 76.1 deaths per 1,000 patient years—still a distance from the HP2010 target of 62.1 (Table hp.b and Figure hp.5). By race and ethnicity, cardiovascular mortality rates range from a low of 59–60 in Native Americans and Asians to a high of 81.4 in whites. Rates remain relatively close by gender, and increase dramatically with age, from 7.5 deaths per 1,000 patient years in the pediatric population to 187 in patients age 75 and older.

Since 2000, rates of cardiovascular mortality have fallen 15.5 percent overall, and nearly 26 percent among Native American patients; this is in contrast to only a 5.4 percent drop in the overall rate of all-cause mortality (Figure hp.6).

Mortality due to congestive heart failure rose nearly 9 percent between 2000 and 2005 (Figure hp.7). Mortality due to atherosclerotic heart disease and acute myocardial infarction, in contrast, fell 42 and 37 percent, respectively, and the rate of death due to other cardiovascular causes fell 10.4 percent.

Pre-ESRD counseling & fistula use  

New fields on the revised Medical Evidence form show that nearly two-thirds of incident dialysis patients receive nephrologist care prior to initiation; 13 percent receive counseling from a dietitian, and 73 percent are informed of their transplant options (Table hp.c and Figure hp.8).

Older patients are the most likely to see a nephrologist, while children (age 0–19) are 2–3 times more likely to have dietitian counseling and are most likely to be informed of transplant options. By race/ethnicity, Asian/Pacific Islanders are the most likely to be under the care of a nephrologist pre-initiation, at 70.7 percent. And a greater proportion of Asians receive pre-ESRD diabetic counseling as well.

Backcasted data on patients age 67 and older at the initiation of ESRD show that the proportion of these patients who see a nephrologist during the two years prior to starting therapy reached 85.5 percent in 2005, up from 75 percent in 1996 (Figure hp.9). The rate does not vary by age, and by race and ethnicity is just slightly higher in whites and lower in Asian patients.

Albumin testing in the two years before initiation—an indication that patients may be under the care of a dietitian—has grown from just 3.1 percent in 1996 to 17.8 percent in 2005 (Figure hp.10). Testing rates are highest among Hispanic patients, and lowest in the Native American population. ½

Nearly 38 percent of new hemodialysis patients had an arteriovenous (AV) fistula as their primary mode of vascular access in 2004, up slightly from 36.3 percent in 2003, but still a distance away from the HP2010 goal of 50 percent (Table hp.d and Figure hp.11). Nearly 53 percent of new patients age 20–44 have an AV fistula, and fistulas are considerably more common in males than females—45.4 versus 28.7 percent. By race/ethnicity, 51.7 percent of Asian or Pacific Islanders use fistulas compared to 41.9 and 39.7 percent, respectively, in Hispanics/Latinos and whites. The lowest use occurs in African Americans, at 33.7 percent.

Placement rates of arteriovenous fistulas in prevalent patients have more than doubled since 1991, rising from 54.0 placements per 1,000 patient years to 122.4 in 2005 (Figure hp.12). Children have the highest rates, at 151, and rates for those age 20–44, 45–64, and 65–74 are 140.6, 120.7, 121.8, respectively. The lowest placement rates, of 114.5, are found in patients age 75 and older. Since 1991, rates in Asians have grown the most, from 41.4 per 1,000 to 105.8—a 155.2 percent increase.

By diabetic status, fistula placements in 2005 differed by only 3.6 percent between diabetic and non-diabetic patients, while rates for both grafts and catheters were 13–14 percent higher in the diabetic population (Figure hp.13).

Transplantation  

The percentage of patients registered on the transplant wait list or receiving a deceased-donor kidney transplant within one year of beginning ESRD therapy grew slightly for new patients in 2004, reaching 15.4; this is still, however, only half way to the Healthy People 2010 goal of 30 percent (Table hp.e and Figure hp.14).

The pediatric population, and that of patients with cystic kidney disease as the cause of their ESRD, continue to come closest to meeting the HP2010 goal, with 42.3 and 44.7 percent, respectively, placed on the wait list or receiving a deceased-donor transplant in the year after their initiation in 2004 (Figure hp.15). This is compared to only 15.4 percent of all patients, and 9.0 percent of those age 60–69. Percentages vary little by gender, but by race and ethnicity range from 10.6 percent of Native Americans to 30.0 percent of Asian patients, and are only 12–13 percent for patients with diabetes or hypertension.

For patients starting ESRD therapy in 2002, the percentage receiving a transplant within three years of intiation remained stable, at 18.4, perhaps slowing the progression,  since 1991, away from the HP2010 goal of 30.5 percent. (Table hp.f and Figure hp.16).

Variations here are similar to those seen for Objective 4.5. The percentage of patients transplanted falls by age, from 68 percent of pediatric patients beginning therapy in 2002 to 9.4 percent of those age 60–69 (Figure hp.17). It varies little by gender, with rates for men and women each less than two percentage points from the overall rate. By race and ethnicity, whites remain most likely to be transplanted, at 23.8 percent, and African Americans least likely, at only 9.8 percent. And by primary diagnosis, only 12.3 percent of those with diabetes or hypertension receive a transplant in this period, compared to 51.1 percent of those with cystic kidney disease.

Diabetes & care of CKD patients with diabetes  

Like the overall incident rates, those of ESRD due to diabetes have recently stabilized, and have indeed fallen slightly in three of the past four years (Table hp.g and Figure hp.18). The 2005 rate of 152 per million population, however, remains well above the HP2010 target of 90.

By age, rates of diabetic ESRD among new patients age 45–64 and 65–74 have fallen 6.2 and 4.5 percent, respectively, since 2001 (Figure hp.19). Among patients age 20–44, in contrast, the rate has grown 3.6 percent, to 37.3 per million population. Since 2000, when the revised U.S. Census form allowed respondents to identify themselves by more than one race, the true rate of decline in diabetic ESRD among Native Americans has been more than 26 percent, the most dramatic change by race or ethnicity (Figure hp.20).

Patients with Type 1 or 2 diabetes and chronic kidney disease are at high risk for progression to chronic renal insufficiency. Preventive screening such as glycosylated hemoglobin testing (HbA1c), lipid testing, and diabetic retinopathy monitoring, and subsequent treatment such as the use of angiotensin coenzyme inhibitiors or angiotensin II receptor blockers (ACE-Is/ARBs), are designed to slow or prevent this progression.

In 2005, 31.0 percent of diabetic CKD patients received all three of the recommended screening tests—short of the 36.0 percent goal established following a mid-course review of the HP2010 objectives (Table hp.h and Figure hp.21). Nearly 70 percent of patients were prescribed ACE-Is/ARBs in 2000 and 2003—a somewhat encouraging outcome, but one that should be viewed with caution due to a low sample size of patients.

By age, the percent of patients receiving all three tests is 32–34 percent in those age 65–79, but falls to only 26 percent in patients age 80 and older (Figure hp.22).

Asians are the most likely to be tested, at 36.5 percent, followed by whites, Hispanics, African Americans, and Native Americans, at 31.5, 31.1, 27.5, and 19.4 percent, respectively. The noticeably low testing rate in Native Americans is disturbing, and should be evaluated further.

Vaccinations, & network achievement of HP2010 objectives  

Influenza vaccinations among prevalent ESRD patients rose 6 percent in 2005, with nearly 58 percent of patients vaccinated (Table hp.i and Figure hp.23). Since 2002, however, little progress has been made toward the HP2010 goal of 90 percent.

The percent of patients vaccinated again influenza continues to vary little by race or ethnicity, and widely by age, ranging from 28.6 percent of pediatric ESRD patients to 68 percent of those age 75 and older (Figure hp.24).

Two-year rates of pneumococcal pneumonia vaccinations nearly doubled between the 2000–2001 and 2004–2005 periods, reaching 19.2 percent (Figure hp.25). The rate is highest for patients age 75 and older, at 22.8 percent. ½

Progress toward HP2010 objectives continues to vary widely by ESRD network. The target incident rate, for example, is 221 per million population. Network 16 comes closest to meeting this goal, with a rate of 272, while Network 14 has the highest rate, of 416 (Figure hp.26).

Mortality rates due to cardiovascular disease range from a low of 57.4 per 1,000 patient years in Network 10—more than meeting the goal of 62—to 104.3 in Network 13 (Figure hp.27).

By 2010, 50 percent of new hemodialysis patients should be using arteriovenous fistulas. Network 16 is close to meeting this goal, with 47.7 percent (Figure hp.29). In Network 5, in contrast, only 21.6 percent of patients are using this recommended access at initiation.

Network 11 is the only one to achieve the objective of having at least 30 percent of patients transplanted within three years of initiation (Figure hp.31). The lowest percentage, of 11.5, occurs in Network 6.

As with overall incident rates, rates of new ESRD due to diabetes remain far from the HP2010 goal—here of 90 per million population (Figure hp.32). Rates range from 115 in Networks 1 and 16 to 218 in Network 14.

Figure 2.56 Contains a map of the ESRD networks; a list of network contacts can be found on page 258 of Appendix A.