HP2010 - Healthy People 2010

Since 1979, the Healthy People program has developed and evaluated national health objectives to address preventable threats to health and encourage collaborations across sectors. The HP2010 program addresses chronic kidney disease (CKD) as one of 28 focus areas, and includes the goal of “reducing new cases of CKD and its complications, disability, death, and economic costs.” As the decade moved towards 2010, the program conducted a mid-course review of each focus area, modifying original objectives. Only one major change was made in those related to CKD. Objective 4.8 was reworded and expanded with two sub-objectives that could be addressed with available data. Minor revisions were also made to Objective 4.6, which now looks at transplants in the first three years after initiation of end-stage renal disease (ESRD) therapy instead of relative to registration on the transplant wait list; baseline years and target levels were adjusted. Until 2007, 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 from this source. Added in 2008 was an assessment related to HP2010 Objective 5.11, which looks at diabetic patients receiving an annual urinary microalbumin test. The most impressive gain toward achieving an HP2010 CKD objective is the continued decline in cardiovascular mortality in prevalent ESRD patients. Rates dropped 5.5 percent in 2007, to 68.1 deaths per 1,000 patient years — approaching the HP2010 goal of 62.1. This is particularly notable because declines have occurred across all race, ethnicity, and gender groups. All-cause mortality rates have also fallen, but to a lesser degree. A continued decline in deaths due to atherosclerotic heart disease, congestive heart failure, and myocardial infarction in the ESRD population may indicate that management of cardiovascular disease and cardiovascular risk factors is continuing to improve. After a slight increase in 2006, the adjusted incident rate of ESRD fell 2.1 percent in 2007, reaching 354 per million population. In a parallel pattern, the incidence of diabetic ESRD also fell in 2007 after an uptick the prior year. Although this reversal seems encouraging, it is difficult, given continued growth in the prevalence of diabetes in the general population, to envision the trend continuing. The overall rate of ESRD due to diabetes remains well above the HP2010 goal. Diabetes prevention programs should continue to target all populations, but focus particularly on minorities and obese individuals. Data on pre-ESRD and preventive care show mixed results. Only 3.6 percent of Medicare ESRD patients have seen a dietitian for at least a year prior to initiation, and just 27 percent have seen a nephrologist for that period. Among older patients, use of albumin testing in the two years prior to ESRD continues to increase, while 76 percent receive lipid monitoring. Just one in three older CKD patients with diabetes now receives all three preventive care measures — two or more glycosylated hemoglobin (A1c) tests per year, and annual lipid tests and eye examinations — up from 27.1 in 2002. Two of three Medicare patients with CKD and diabetes were treated with either ACE-Is or ARBs in 2007, down from 71 percent in 2002. And the use of annual microalbumin testing in older patients with diabetes (with or without CKD) has almost tripled, from 12.3 percent in 2000 to 33.6 percent in 2007, far surpassing the HP2010 goal of 14 percent. The HP2010 objective for vascular access is that 50 percent of new hemodialysis patients use an arteriovenous (AV) fistula as their primary access. In 2004, CMS funded the national Fistula First Initiative to reduce barriers for the placement of AV fistulas. The percentage of new dialysis patients using an AV fistula increased sharply from 2004 to 2005, then fell to 41 percent in 2006, suggesting that the uptick in 2005 may have been an anomaly. In prevalent hemodialysis patients, AV fistula placement rates declined 2.6 percent in 2007, most notably in whites and in patients 65 and older. CMS has a stretch goal of increasing fistula use in prevalent hemodialysis patients to 66 percent by 2009. The Fistula First Initiative advocates secondary AV fistulas in AV graft patients, and AV fistula evaluation and placement in patients with catheters. There is some good news in the transplant arena, as the proportion of incident ESRD patients registered on the transplant wait list or receiving a deceased-donor kidney with one year of ESRD initiation grew 7.7 percent in 2006, to 17.1 percent; this is still far lower, however, than the HP2010 goal of 30 percent. The percentage of ESRD patients receiving a kidney transplant within three years of ESRD registration remained steady at 17.9 percent, still a distance from the goal of 30.5 percent. In 2007, almost 60 percent of prevalent ESRD patients received an influenza vaccination. This appears low, but patients may receive vaccinations through programs not tracked in the Medicare data. Of note, influenza vaccinations among pediatric patients have declined, a trend that should be carefully evaluated. Pneumococcal pneumonia vaccinations, in contrast, have grown from 13.6 percent in 2002–2003 to 19.1 percent in 2006–2007. The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives is currently working on objectives for 2020. The framework — vision, mission, goals, and focus areas — will be released in 2009, followed by the launch of the specific objectives in 2010. Public comment meetings will be held in the fall of 2009. See www.healthypeople.gov/HP2020 for more information.

Figure hp.1 For patient populations, see figure captions for the individual objectives on the following pages.

HP2010 Objective 4.1

Reduce the rate of new cases of end-stage renal disease

The rate of new ESRD cases (adjusted for age, gender, and race) fell 2.1 percent in 2007, to 354 per million population — a significant distance from the Healthy People 2010 target of 221. With the exception of the uptick in 2006, the rate has been stable for the past seven years.

Rates for each age group have also been quite stable, as have those for most races. In the Native American population, however, the incident rate has declined 25 percent since 2000. At 998 per million population, the rate among African Americans remains 3.7 times higher than that of whites. Incident rates of ESRD due to glomerulonephritis, diabetes, and chronic kidney disease fell 7.0, 3.3, and 2.5 percent, respectively, while ESRD due to hypertension rose 0.8 percent. The median percentage of the general population ever told by a doctor that they have diabetes rose to 8.1, up from 7.5 the prior year. Figures hp.2, hp.3, & hp.4 & table hp.a; see page 363 for analytical methods. Incident ESRD patients. Data on diabetes in the general population obtained from the CDC’s Behavioral Risk Factor Surveillance System, at www.cdc.gov/brfss. *Census data not available for non-Hispanic African Americans & whites, so rates cannot be calculated.

HP2010 Objective 4.2

Reduce deaths from cardiovascular disease in persons with chronic kidney failure

Rates of cardiovascular (CV) mortality continue to decline since their peak in 1999, falling 5.5 percent in 2007, to 68.1 deaths per 1,000 patient years, and approaching the Healthy People 2010 goal of 62.1.

By race and ethnicity, CV mortality rates in 2007 were highest in whites, at 72.9 per 1,000 patient years, compared to 53–55 percent in Native Americans, Asians, and Hispanics; the rate for African Americans was 62.6. Noteworthy is the continuing decline in CV deaths in the Native American population — particularly the 28.5 percent decrease since 1991, and the fall of 33.7 percent since 2000. In contrast to CV mortality rates, all-cause rates have fallen as well, but to a lesser degree. In Native Americans, for example, all-cause rates have decreased 10 percent since 1991, and 19 percent since 2000. All-cause rates have fallen more slowly in other racial and ethnic groups.

Cardiovascular mortality rates in 2007 were similar in men and women, at 67.5 and 68.9 per 1,000 patient years, respectively, 21–25 percent lower than in 2002. Figures hp.5, hp.6, & hp.7 & table hp.b; see page 363 for analytical methods. Period prevalent ESRD patients.

HP2010 Objective 4.3

Increase the proportion of treated chronic kidney failure patients receiving counseling on nutrition, treatment choices, & cardiovascular care twelve months before the start of renal replacement therapy

Just 27 percent of incident dialysis patients receive more than 12 months of pre-ESRD nephrologist care, and only 3.6 percent have seen a dietitian for a year or more; 70.6 percent, in contrast, are informed of their transplant options. Older patients are more likely to receive nephrology care prior to ESRD than their younger adult counterparts, with the opposite true for being informed of transplant options. By race and ethnicity, the proportion of patients with pre-ESRD nephrology care ranges from 20.5 percent in Hispanics to 28.5 in whites; Native Americans are the most likely to receive dietary care and transplant information, at 5.2 and 78.7 percent, respectively.

Albumin — an important measure of nutrition and inflammation — is used as a marker to identify early risk of mortality. Overall, 21.8 percent of patients in 2007 received albumin testing in the two years prior to ESRD initiation. Patients age 75 and older are far less likely to be tested, at 19.4 percent compared to 27.0 and 24.8 percent in those age 67–69 and 70–74, respectively. Asians and Hispanics had the highest testing rates in 2007, at 29.3 and 28.6 percent, and Native Americans were far less likely to be tested, at 15.2 percent.

Lipid testing is important in detecting high cholesterol levels, which can often contribute to cardiovascular disease. In 2007, three of four patients received a pre-ESRD lipid test: testing rates were highest in Asians, at 80.5 percent, and remarkedly low in Native Americans, at 41.3 percent. Figures hp.8, hp.9, hp.10 & table hp.c; see page 363 for analytical methods. Incident dialysis patients, 2005–2007 (hp.8 & hp.c); incident ESRD patients age 67 & older at initiation (hp.9–10).

HP2010 Objective 4.4

Increase the proportion of new hemodialysis patients who use arteriovenous fistulas as their primary mode of vascular access

Identified through the CPM dataset, the percentage of new dialysis patients using an arteriovenous (AV) fistula in the first year of dialysis was 41.1 in 2006 — in line with the annual growth seen in most recent years, and suggesting that the sharp rise reported in the 2005 CPM data may have been an anomaly.

After showing steady upward progress since the middle 1990s, AV fistula placement rates in prevalent hemodialysis patients decreased 2.6 percent in 2007. The greatest decline (6–7 percent) occurred in patients age 65 and older, while for those younger than 65 placement rates fell less than one percent. By race and ethnicity, rates decreased most in whites, at 4.2 percent, compared to 1.5 and 1.2 percent, respectively, in African Americans and Hispanics. Native American patients saw a slight increase of 1.7 percent.

Fistula placement rates vary little by diabetic status. Rates for arteriovenous grafts and catheters, however, are 12.4 and 10.4 percent higher in patients with diabetes compared to those without the disease. Overall, graft and catheter placement rates have fallen 61 and 16 percent, respectively, since 1991, and catheter rates have fallen 39 percent since 2000. It is to early to predict if the decline in fistula placements will continue into future years. Programs such as HP2010 and the Fistula First Initiative are designed to increase fistula use and promote early placement prior to ESRD. Figures hp.11–13 & Table hp.d; see page 363 for analytical methods. ESRD CPM data: patients initiating dialysis between January 1 & August 31 of the year of data collection (hp.11 & hp.d); access represents current access used at time of data collection. Medicare physician/supplier data: period prevalent hemodialysis patients (hp.12 & hp.13). “.” Zero values in this cell.

HP2010 Objective 4.5

Increase the proportion of dialysis patients registered on the wait list for transplantation

The proportion of incident ESRD patients registered on the transplant wait list or receiving a deceased-donor kidney within one year of beginning ESRD therapy grew 7.7 percent in 2006, to reach 17.1 percent. This is the highest rate recorded in the last 16 years, though still a distance from the HP2010 goal of 30 percent.

The Healthy People goal is currently met only among Asian ESRD patients, those with glomerulonephritis or cystic kidney disease, and pediatric patients, with rates of 31, 34, 50, and 48 percent, respectively. This is compared to rates of 11–14 percent among patients age 60–69, African American and Native American patients, and those with a primary diagnosis of diabetes. Figures hp.14, hp.15 & table hp.e; see page 363 for analytical methods. Incident ESRD patients younger than 70.

HP2010 Objective 4.6

Increase the proportion of patients with treated chronic kidney failure who receive a transplant within three years of end-stage renal disease (ESRD)

Just over 30 percent of incident ESRD patients should receive a transplant within three years of starting therapy, according to the Healthy People 2010 objective. Progress toward this goal, however, continues to remain elusive, with 17.9 percent of new patients in 2004 transplanted in the first three years — a number essentially unchanged from the prior year.

The percentage transplanted in this period falls by age, from 68 percent of pediatric patients to 9.5 percent of those age 60–69. And it varies from 10–11 percent of African Americans and Native Americans to nearly 23 percent of whites, and from 11.7 percent of those with ESRD due to diabetes to more than 50 percent among those with ESRD caused by cystic kidney disease. Figures hp.16 & hp.17 & table hp.f; see page 364 for analytical methods. Incident ESRD patients younger than 70.

HP2010 Objective 4.7

Reduce kidney failure due to diabetes

In 2007, the incidence of ESRD due to diabetes (adjusted for age, gender, and race) fell 3.3 percent, to 155 per million population — a distance from the HP2010 target of 90. This decline is in contrast to a rise in diagnosed diabetes in the general population, which rose from a median of 7.5 to 8.1 percent between 2006 and 2007 (Figure hp.4).

By age, rates of diabetic ESRD range from 41 per million population among those age 20–44 to 594 among those age 75 and older. This latter rate remained steady between 2006 and 2007; rates for those age 45–64 and 65–74, in contrast, fell 4.6 and 3.3 percent, respectively. The African American and Native American populations continue to have far greater rates of diabetic ESRD than that seen in the white population — in 2007, 3.6 and 2.8 times greater, respectively. But while the rate has remained relatively steady for African Americans, it has fallen dramatically among Native American patients — nearly 18 percent since 2004, to 333 per million population. Figures hp.18, hp.19, hp.20 & table hp.g; see page 364 for analytical methods. Incident ESRD patients. *Census data are not available for non-Hispanic African Americans & whites, so rates cannot be calculated.

HP2010 Objective 4.8

Increase the proportion of persons with Type 1 or Type 2 diabetes & chronic kidney disease receiving recommended medical evaluation & treatment to reduce progression to chronic renal insufficiency

Patients with diabetes and CKD are at increased risk of progression to ESRD. Preventive screenings for indications of developing disease, combined with associated follow-up treatments, are designed to slow or prevent this progression.

In 2007, 33.8 percent of general Medicare patients with both diabetes and CKD received all three recommended screening tests — glycosylated hemoglobin (A1c) testing, lipid monitoring, and a diabetic eye examination. This was close to the 36 percent target established during the HP2010 mid-course review, and 3.6 percent higher than in 2006. By race, Asian/Pacific Islanders and whites are the most likely to receive all three tests, at 36.0 and 34.5 percent, respectively, compared to just 13.2 percent of Native Americans. Likewise, A1c tests are received by 60–67 percent of African Americans, whites, and Asians, but only 32 percent of Native American patients. Testing in Native Americans, however, may be done through the Indian Health Service, and not reported through Medicare.

In 2005, two in three diabetic CKD patients were treated with angiotensin converting enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs), down from nearly 73 percent the prior year. Treatment differs dramatically by gender, at 78.3 percent in men and 57.6 percent among women. Figures hp.21 & hp.22 & table hp.h; see page 364 for analytical methods. Evaluation: Medicare patients age 65 & older with diabetes & CKD. “All three tests” include at least two glycosylated hemoglobin tests, at least one lipid test, & at least one diabetic eye examination. Treatment: Medicare Current Beneficiary Survey (MCBS) Cost & Use file, patients age 65 & older with diabetes & CKD.

HP2010 Objective 5.11

Increase the proportion of adults with diabetes who obtain an annual urinary microalbumin measurement

In the diabetic population, the percentage of patients receiving an annual urinary microalbumin measurement has increased from 12.3 in 2000 to nearly 34 in 2007 — almost three times greater than the 14 percent recommended by the Healthy People 2010 guidelines.

Among diabetic patients age 66 and older, the use of an annual microalbumin test falls with age, with 38.6 percent of those age 66–69 being tested in 2007, compared to 26.4 percent of those age 80 and older. By race and ethnicity, testing rates are lowest in Native American patients with diabetes, at 20.8 percent, and highest in the Asian population, at 35.2 percent. Testing may, however, be underreported in Native Americans, as the Indian Health Service does not report claims through the Medicare system. There is little difference by gender in testing rates, at 34.7 percent for men and 32.8 percent for women. Figures hp.23, hp.24, hp.25 & table hp.i; see page 364 for analytical methods. Medicare patients with diabetes, age 66 & older.

HP2010 Objective 14.29

Increase the proportion of adults vaccinated annually against influenza & ever vaccinated against pneumococcal disease

In 2007, 59.4 percent of prevalent ESRD patients were vaccinated against influenza — up slightly from 56.6 percent the previous year. Rates by age range from 27 percent of patients age 0–17 to 68 percent of those age 75 and older; rates by race and ethnicity have a narrower range, from 55.4 percent among African Americans to nearly 62 percent among whites and Native Americans. Since 2000, the rate has increased 35 percent overall, with growth of 95 percent in the pediatric population, and of 71 and 56 percent, respectively, among Native Americans and Asians. Among patients age 0–17, however, rates have been declining since their peak in 2005. While reported rates are low, patients may receive vaccinations through non-Medicare programs.

The two-year rate of pneumococcal pneumonia vaccinations rose from 13.6 percent in 2002–2003 to 19.1 percent in 2006–2007. The rate rises by age, to 21.1 percent among patients age 75 and older, and by race is greatest among Native Americans, at 24.1 percent. Figures hp.26, hp.27, hp.28 & table hp.j; see page 364 for analytical methods. Point prevalent ESRD patients.

Incident rates in Networks 1 and 16 come closest to meeting the target of 221 per million population, at 277–279 in 2007; rates in Networks 14 and 18 reach 419 and 433. The HP2010 goal related to cardiovascular mortality is met by Networks 10, 11, 15, 16, and 17, each with a rate below the targeted 62.1 per 1,000 patient years. The number of patients who see a nephrologist for more than 12 months prior to ESRD ranges from 12.5 percent in Network 18 to 40.6 percent in Network 1. Figures hp.29–31; see Appendix A for analytical methods. Incident ESRD patients, 2007 (hp.29); period prevalent ESRD patients, 2007 (hp.30); incident dialysis patients, 2007, with new (revised edition) Medical Evidence forms (hp.31).

To meet the HP2010 goal related to vascular access, 50 percent of new hemodialysis patients should be using a fistula as their primary access. In 2006, among patients in the CPM database, this goal was met by Networks 1 and 16, with 55 and 56 percent, respectively. The lowest rates — of 30 to 34 percent — were reported in Networks 6, 10, 11, and 13.

HP2010 Objective 4.5 is currently met only by Network 17, in which nearly 40 percent of incident patients in 2006 were wait-listed or received a deceased-donor kidney within one year of initiating ESRD therapy. The remaining networks are below the target of 30 percent, and in Networks 6 and 13 just 10–11 percent of patients are wait-listed or transplanted during the first year. Figures hp.32–33; see Appendix A for analytical methods. Incident patients, 2006, initiating hemodialysis between January 1 & August 31, 2006, from 2007 ESRD CPM data (hp.32); incident ESRD patients younger than 70 & registered on the transplant wait list on December 31, 2006 (hp.33).

No networks currently meet HP2010 Objective 4.6, which states that 30.5 percent of patients should receive a transplant within three years of initiating ESRD therapy. Network 11 comes closest, with a rate of 28.6 percent; Networks 1, 4, and 16 have rates of 24–26 percent. In Network 6, in contrast, only 11.9 percent of patients receive a transplant within the first three years after initiation.

The rate of new ESRD cases due to diabetes ranges from 111 per million population in Network 1 to 198 and 222 in Networks 18 and 14. The Healthy People 2010 goal is 90 new cases per million population. Figures hp.34–35; see Appendix A for analytical methods. Incident ESRD patients younger than 70, 2004, excluding patients with a prior transplant (hp.34); incident ESRD patients, 2007 (hp.35).

In all networks, rates of preventive care testing in diabetic ESRD patients exceed the HP2010 target of 36 percent, ranging from 36.7 percent in Network 8 to 54.3 percent in Network 1. The goal for microalbumin testing in the year prior to ESRD is also met across the country, with 34–48 percent of diabetic patients tested, exceeding the target of 14 percent. Across ESRD networks, influenza vaccination rates remain a distance below the HP2010 goal of 90 percent, ranging from 52.8 percent in Network 2 to 65.5 percent in Network 11. Figures hp.36, hp.37, hp.38; see Appendix A for analytical methods. Incident ESRD patients, 2007, age 67 or older at initiation (hp.36–37); prevalent ESRD patients, 2007 (hp.38).