The number of patients who receive a kidney transplant as their first ESRD therapy reached 2,424 in 2005, and since 1995 has grown an average of 7.6 percent each year. In the prevalent population, the number of patients waiting to receive a transplant increased from 9,447 in 1988 to 64,942 in 2005, with an annual growth of 6.5 percent over the last ten years.

Hemodialysis patients are older than those on peritoneal dialysis. Transplant patients, as expected, are youngest, with 50 percent age 45–64.

In the incident hemodialysis population, Medicare only, Medicare plus Medicaid, and Medicare under HMOs or managed care plans cover 75 percent of patients, while employer group health plans (EGHPs) and Medicare as secondary payor cover the remaining 25 percent. In the peritoneal dialysis population, in contrast, the distribution in 2005 was 65 and 35 percent. Medicare covers only 38 percent of transplant patients; 29 percent have EGHP coverage, and 33 percent are covered by other insurers. These differences may significantly affect both patient benefits, particularly those related to prescription drugs, and provider revenue streams from services such dialysis therapy, injectables, treatments and medications for transplantation, and diagnostic testing.

Maps of incident rates by modality illustrate nationwide changes since 1995, changes which may reflect the recent consolidation of ESRD providers, their varying policies regarding therapy, and their individual likelihoods of using dialytic and transplant therapies in the incident population. The rates may also reflect changes in access to organs for transplantation. Changes in peritoneal dialysis use, for example, show distinct geographic patterns that are different from the distribution of the hemodialysis population. Although there has been a general decline in use of this therapy, there are notable exceptions, including the Dakotas, Oklahoma, Louisiana, Mississippi, and Alabama, where use has increased.

Trends similar to those in the incident population are noted for prevalence as well. The rate of decline of the prevalent peritoneal dialysis population has slowed, with an overall increase of 1.3 percent per year between 2004 and 2005, while growth in the prevalent transplant population has grown 5.5–6.0 percent per year since 2001. Differences in payor distribution continue here, but are less dramatic than those seen with incident patients. Eighty-one percent of hemodialysis patients have Medicare as their primary payor, compared to 77 percent of those on peritoneal dialysis and 53 of those in the transplant population.

As shown in maps of ESRD prevalence, use of peritoneal dialysis has fallen across the U.S. since 1994–1995—as much as 67 percent in some areas. Similar to patterns seen in the incident peritoneal dialysis distribution, rates of prevalence are highest in the south central U.S.

The growing consolidation of providers into larger chains has long been clear; chains represented less than 10 percent of patients in the early 1990s, but more than 60 percent by 2005. Two large chains now treat the great majority of U.S. patients. Hospital-based and independent units have been quite stable, treating some 20 percent of new hemodialysis patients in the last ten years. Their number of peritoneal dialysis patients, however, has fallen, and use of this therapy varies considerably by provider group. Further consolidation may raise concerns over modality choice and its relation to provider practices.

With peritoneal dialysis long the dominant home therapy, home hemodialysis has received little attention in the past 15 years. Its use peaked in 1985, with 5,814 prevalent patients. A number of government programs, paying home aids to help deliver the therapy, ended soon afterwards, contributing to a steady decline in use until by 2002 there were only 1,759 patients. Now, however, there appears to be renewed interest in the use of daily home therapy. The home hemodialysis population reached 2,105 in 2005, and new products are being introduced for the delivery of this therapy. And a new NIH study is comparing daily or overnight home hemodialysis to in-center therapy, testing safety and efficacy.

During the past decade, then, modality use has changed considerably. Hemodialysis is still dominant, while use of peritoneal dialysis rises in fewer areas of the country. Differences in the accumulation of patients on different modalities need to be carefully considered, not only from the vantage point of quality of care, but in terms of payor distribution and incentives, which may influence modality choice and the availability of services. Use of home hemodialysis appears to be resurging, based on new applications of daily home therapies such as short treatments of 2–3 hours instead of overnight therapy. These trends will require increased evaluation in the future.

Incident modality  

In 2005, more than 97,000 new ESRD patients began therapy on hemodialysis, 6,875 were placed on peritoneal dialysis, and 2,424 received a preemptive transplant (Table 4.a). Patients age 45–64 make up 36 percent of the hemodialysis population, 42 percent of those on peritoneal dialysis, and more than half of those with a preemptive transplant. Primary diagnoses of diabetes and hypertension together account for 72.5 percent of patients starting on hemodialysis, but only one-fourth of those with a transplant.

The incidence of ESRD per million population reached 317 in 2005 for hemodialysis, 22.5 for peritoneal dialysis, and 7.1 for transplant (Table 4.b). By race, the 2005 rate for patients starting therapy on hemodialysis was 241 among whites compared to 941 among African Americans; for peritoneal dialysis, 19.4 compared to 42.9. For those beginning with a transplant, in contrast, the rate among African Americans was lower, at 7.5 compared to 5.7. In the hemodialysis and transplant populations the annual rate of growth has slowed since 1997–2001.

Forty-four percent of new hemodialysis patients are covered by Medicare only, 22.5 percent are dually-enrolled (Medicare/Medicaid), and 8.1 percent are covered by a Medicare HMO provider—a slight increase from the 7.5 percent enrolled in 2004, which may in part be due to a more attractive payment rate structure available in the Medicare Advantage program (Figure 4.3). Medicare covers 48.5 and 31.5, percent, respectively, of peritoneal dialysis and transplant patients, while 11.8 and 5.1 percent are dually-enrolled and 4.6 and 1.5 percent have HMO coverage.

The use of initial modalities continues to vary across the country (Figure 4.4). The incident rate for patients starting therapy on hemodialysis, for example, is highest along the East Coast, in the southeastern states, and through the Gulf Coast. The pattern for preemptive transplants is reversed, with rates greatest in the Upper Midwest and in the northeastern states. In the hemodialysis population, the mean rate in the upper quintile is 2.4 times greater than in the lower; regions with the highest transplant rates have a mean rate 3.9 times greater than those with the lowest.

More than thirteen hundred children initiated therapy in 2005. Of these, 17.7 received a preemptive transplant—up from 15.3 percent in 2004 (Table 4.c). Twenty-six percent of children were placed on CCPD, far more than the rate of 3 percent or less found in all other age categories. ½

Prevalent modality  

At the end of 2005, more than 314,000 ESRD patients were receiving hemodialysis therapy, 25,895 were being treated with peritoneal dialysis, and 143,693 had a functioning graft (Table 4.d). By age, patients 45–64 constitute the largest part of the prevalent population, from 40.4 percent of those on hemodialysis to 51 percent of those with a transplant. Racial disparities, as in past years, continue to be dramatic. Fifty-five percent of hemodialysis patients are white, and 38 percent African American. In the transplant population, in contrast, whites account for three in four patients, and African Americans fewer than one in five.

In 2005, the prevalence of ESRD reached 1,016 per million population for hemodialysis, 84 for peritoneal dialysis, and 466 for transplant (Table 4.e). The rate for African Americans reached 3,879, six times that found among whites, and nearly twice as high as the rate in the Native American population. Since 1997–2001, the annual percent change in ESRD prevalence has dropped in the hemodialysis and transplant populations, from 4.4 to 1.7, and from 4.7 to 3.8, respectively.

Slightly more than 90 percent of prevalent hemodialysis patients had some type of Medicare coverage in 2005; close to 42 percent were covered solely by Medicare, while 33.7 percent were under Medicare/Medicaid—a population that continues to grow slowly (Figure 4.5). Among transplant patients, in contrast, 69 percent have some form of Medicare insurance, but only 34 percent are covered by Medicare alone. 

Rates by modality in the prevalent population show the same geographical patterns as those for new ESRD patients (Figure 4.6). For hemodialysis, rates are highest in the south and southeastern parts of the country, while in the transplant population rates remain highest in the northern states.

Nearly 70 percent of prevalent pediatric patients had a functioning graft in 2005, while in-center hemodialysis was provided to 17.3 percent, and 11 percent received therapy through CCPD (Table 4.f). Only 4.5 percent of patients age 75 and older had a functioning graft; 91 percent, in contrast, were on hemodialysis. Slightly more males than females had a functioning graft in 2005, at 31.5 versus 27.3 percent, and transplants were twice as likely in whites compared to African Americans.

Modality & provider characteristics  

With further consolidation of the largest dialysis providers during the past two years, and divestiture of numerous units to satisfy requirements of the Federal Trade Commission, the provider landscape continues to change. A visual illustration of how the providers existing in 1995 have merged and changed over the last decade is provided in Figure 10.1, on page 209.

Data on the distribution of dialysis patients shows the continued increase in market share of the chain-owned providers (Figure 4.7). These providers treated nearly 60,000 incident hemodialysis patients in 2005—61.5 percent of new patients treated with this modality, and up from 55.3 percent in 2000. This rise has been concurrent with a drop in the percentage of new hemodialysis patients treated in hospital-based units, from 21.0 percent in 2000 to 16.2 percent in 2005. The non-chain environment, in contrast, has remained relatively steady, accounting for 19.5–19.6 percent of incident hemodialysis patients in both 2000 and 2005.

Similar changes have occurred for the incident peritoneal dialysis population. In 2005, 58.3 percent were treated in chain-owned units, 22.7 percent in non-chain units, and 15.7 percent in hospital-based units—compared to 52.8, 23.4, and 20.6 percent in 2000. As noted in the 2006 ADR, Gambro and Renal Care Group have been the providers most likely to place their patients on peritoneal dialysis. With the recent acquisition of Gambro by DaVita, and of RCG by Fresenius, the future use of this therapy is in question.

Incident patient distribution by provider type continues to differ slightly by race (Figure 4.8). In the African American and Native American populations, for example, 64–65 percent of new hemodialysis patients are treated in chain-owned units, compared to 60.7 percent of white patients and 54.9 percent of Asians.

As compared to their counterparts living in rural areas, new ESRD patients living in urban settings are 32 percent more likely to be placed on hemodialysis, and 24 percent less likely to start therapy on peritoneal dialysis (Figure 4.9).

Changes in providers are visible in the prevalent population as well. The percentage of prevalent hemodialysis patients treated in chain-owned units has grown from 58.1 in 2000 to 65.8 in 2005 (Figure 4.10). Hospital-based units, in contrast, now treat just 8.2 percent of both the hemodialysis and peritoneal dialysis populations, down from 15.6 and 18.0 percent, respectively.

In the prevalent African American population, 71–72 percent of both hemodialysis and peritoneal dialysis patients receive therapy through chain-owned providers, compared to 54–55 percent of Asian patients, 63 percent of whites, and 60–63 percent of Native Americans (Figure 4.11).

A prevalent patient living in an urban area is 28 percent more likely than a rural patient to be treated with hemodialysis, and 22 percent less likely to receive peritoneal dialysis therapy (Figure 4.12).

Home hemodialysis  

On this spread we focus on the use of home hemodialysis, a therapy receiving increased attention in recent years.

In 2005, 428 incident dialysis patients began therapy on home hemodialysis (Table 4.g). For the younger age groups, their distribution is similar to that of the in-center hemodialysis population, with 12.4 percent age 20–44, and 34.1 percent age 45–64. Patients age 75 and older account for a higher percentage of the home hemodialysis population, at 35.3 compared to 27.4 percent. Distribution by gender is almost the same, while, by race and ethnicity, Hispanic patients account for a lower proportion of those on home hemodialysis, at 8.2 compared to 13.2 percent.

Overall, 7.2 percent of incident dialysis patients began treatment on home therapy in 2004–2005 (Figure 4.13). The therapy is popular in several states with widely dispersed populations, including Alaska and Idaho, each with more than 20 percent of their new dialysis patients treated with this therapy. It is also used frequently, however, in Connecticut and West Virginia, at 16.0 and 12.4 percent, respectively.

In the prevalent dialysis population, 2,105 patients were treated with home hemodialysis during 2005 (Table 4.h). Close to one in five were age 20–44, compared to 14.2 percent in the center hemodialysis population. Fewer, however, were age 75 or older, at 17.3 compared to 22.2 percent. Prevalent home hemodialysis patients are less likely to be African American or Hispanic, at 29.6 and 6.2 percent of the population, compared to 38.2 and 15.0 percent for in-center hemodialysis patients.

By state, use of home hemodialysis therapy among prevalent patients is similar to that of the incident population (Figure 4.14). One in four prevalent dialysis patients in Alaska is treated with this therapy, one in five living in Idaho, and 15–16 percent of those living in Connecticut, Montana, and West Virginia.