|Sections this chapter:|
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 program addresses chronic kidney disease 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, as Objective 4.8 was reworded and expanded with two sub-objectives that could be addressed with available data. New fields on the revised Medical Evidence form now make it possible to provide information on Objective 4.3. And 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 objective related to kidney disease is the continued decline in cardiovascular mortality in prevalent ESRD patients. Rates dropped 5.9 percent in 2008, to 64.1 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. A continued decline in deaths due to atherosclerotic heart disease and myocardial infarction may indicate that management of cardiovascular disease and risk factors in the ESRD population is continuing to improve. Rates of death due to CHF, however, have remained stable over the past three years. All-cause mortality rates continue to fall, but to a lesser degree than seen with cardiovascular mortality, suggesting that a focus on non-cardiovascular deaths is merited.
After a slight increase in 2006, the adjusted rate of ESRD incidence fell in 2008 for the second year, reaching 351 per million population. And after an uptick in 2006, the incidence of diabetic ESRD also fell for a second 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 continue to show mixed results. Only 3.9 percent of Medicare ESRD patients have seen a dietitian for at least a year prior to initiation, and just 28.4 percent have seen a nephrologist for that period. Among older patients, use of albumin testing in the two years prior to ESRD continues to rise, while 76.3 percent receive lipid monitoring. 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 21.4 percent in 2000. Three of four Medicare patients with CKD and diabetes were treated with an ACEI, ARB, or renin inhibitor in 2008, up from 68.2 percent in 2000. And the use of annual urinary microalbumin testing in older patients with diabetes has almost tripled, from 12.3 percent in 2000 to 35.6 percent in 2008, 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 Initiative advocates secondary AV fistulas in AV graft patients, and AV fistula evaluation and placement in patients with catheters. The percentage of new dialysis patients using a fistula increased from 2004 to 2005, then fell to about 41 percent in both 2006 and 2007, suggesting that the 2005 uptick was an anomaly. In prevalent hemodialysis patients, fistula placement rates increased slightly from 2007 to 2008, most notably in patients younger than 44. CMS implemented a stretch goal of increasing fistula use in prevalent hemodialysis patients to 66 percent by 2009, but reaching it seems unlikely given the small gain from 41.1 to 41.3 percent between 2006 and 2007.
Mixed news continues to be reported in the transplant arena. 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 from 14.1 percent in 2001 to 17.1 percent in 2007; 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 declined slightly, to 17.3 percent, further from the goal of 30.5 percent.
In 2008, 62.4 percent of prevalent ESRD patients received an influenza vaccination, an increase of 4.8 percent from 2007. This is below the goal of 90 percent, but patients may receive vaccinations through programs not tracked in the Medicare data. Of note, influenza vaccinations among pediatric patients have increased slightly, good news given the recent downward trend. The rate of pneumococcal pneumonia vaccinations has grown from 16 percent in 2003–2004 to 22 percent in 2007–2008.
New and revised Healthy People objectives for 2020 are being formulated for CKD and other areas to reflect new data and recent trends in healthcare. We will report data focused on these new HP2020 CKD objectives in the 2011 ADR. Information on the proposals for HP2020 can be found at www.healthypeople.gov/hp2020.
Figure hp.1 Healthy People 2010 targets &achieved levels (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
Figure hp.2 Adjusted incident rates of ESRD
Figure hp.3 Adjusted incident rates of ESRD, by age &race/ethnicity
Figure hp.4 Adjusted incident rates of ESRD, by primary diagnosis, &diabetes in the general population
Figure hp.a Adjusted incident rates of ESRD (per million population)
The adjusted rate of new ESRD cases decreased 1.1 percent in 2008, to 351 per million population; this remains far from the HP2010 target of 221.
Rates in 2008 declined slightly in all age groups with the exception of age 0–19, in which the rate had a one-year growth of 2.5 percent, and has increased 3.8 percent since 2003. By race and ethnicity, declines in rates of new ESRD cases are evident for all groups, yet rates among African Americans remain nearly four times higher than those in the white population.
Incident rates of ESRD due to diabetes and glomerulonephritis fell 1.5 and 3.0 percent in 2008, respectively, while those for hypertension remained unchanged. The median percentage of the general population ever told by a doctor that they had diabetes rose to 8.2 percent, up slightly from 8.1 percent in the prior year.
Figures hp.2–4 &table hp.a; see page 469 for analytical methods. Incident ESRD patients. Adj: overall, age/gender/race; rates by age, gender/race; rates by gender, age/race; rates by race/ethnicity, age/gender. Ref: 2005. 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
Figure hp.5 Unadjusted cardiovascular mortality rates in prevalent ESRD patients
Figure hp.6 Unadjusted all-cause &cardiovascular mortality rates in prevalent ESRD patients, by race ðnicity
Figure hp.7 Unadjusted cardiovascular mortality rates in prevalent ESRD patients, by cause of death, gender, &race/ethnicity
Figure hp.b Unadjusted cardiovascular mortality rates in prevalent ESRD patients (deaths per 1,000 patient years at risk)
After reaching a peak in 1999 of more than 94 deaths per 1,000 patient years at risk, the overall rate of cardiovascular mortality in the period prevalent ESRD population has continued to decline. In 2008 the rate fell 5.9 percent, to 64.1 — coming close to the HP2010 goal of 62.1.
By race and ethnicity, cardiovascular mortality in 2008 was highest in whites, at 68.2 deaths per 1,000 patient years, compared to 49–53 in Asian, Native American, and Hispanic patients; the rate for African Americans was 59.6. Rates continue to fall at a greater rate than those of all-cause mortality. Since 2000, for example, the rate of cardiovascular mortality among white patients has fallen 30.1 percent, while all-cause mortality has declined 12.9 percent; among Asian patients, rates have fallen 32 and 14.6 percent, respectively.
In 2003, cardiovascular mortality was higher in women than in men; in 2008, however, rates were nearly identical, at 64.0–64.1 deaths per 1,000 patient years at risk. Rates increase by age, from just 3.8 in the pediatric population to nearly 153 in patients age 75 and older.
Figures hp.5–7 &table hp.b; see page 469 for analytical methods. Period prevalent ESRD patients; unadjusted.
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
Figure hp.8 Patients receiving pre-ESRD counseling &care for greater than 12 months, by age &race/ethnicity, 2008
Figure hp.9 Patients receiving an albumin test in the two years prior to ESRD, by age &race/ethnicity
Figure hp.10 Patients receiving a lipid test in the two years prior to ESRD, by age &race/ethnicity
Figure hp.c Percentage of patients receiving pre-ESRD counseling or care for greater than 12 months
Just 28.4 percent of incident dialysis patients receive more than 12 months of pre-ESRD nephrologist care, and only 3.9 percent have seen a dietitian for a year or more. Seventy-two percent, in contrast, have been informed of their transplant options. Compared to younger adults, a slightly higher percentage of older patients receives pre-ESRD nephrologist care, while the likelihood of receiving transplant information falls with age. By race and ethnicity, the proportion of patients with pre-ESRD nephrology care ranges from 21.4 percent in Hispanics to 30.1 percent in whites; Native Americans have the highest level of dietary care, at 7.0 percent, and Asians are the most likely to receive transplant information, at 78.1 percent.
Albumin — an important measure of nutrition and inflammation — is used as a marker to identify early risk of mortality. Testing rates continue to increase, with 23.6 percent of 2008 incident patients age 67 and older receiving albumin testing in the two years prior to ESRD. The likelihood of testing falls with age, from 28 percent in those age 67–69 to 21.8 percent in those 75 and older. By race, rates range from 18.2 percent among Native Americans to 28.8 percent in the Asian population.
Lipid testing is important in detecting dyslipidemia, which contributes to cardiovascular disease. In 2008, three in four incident patients age 67 and older received pre-ESRD testing. Rates remain highest among Asian patients, at nearly 80 percent, and continue to be low in Native Americans, at just 46.6 percent. These latter patients, however, may obtain care through the Indian Health Service; this care is not tracked in Medicare claims.
Figures hp.8–10 &table hp.c; see page 469 for analytical methods. Incident dialysis patients, 2008 (hp.8); incident ESRD patients age 67 &older at initiation (hp.9–10); incident dialysis patients (hp.c).
hp2010 Objective 4.4 Increase the proportion of new hemodialysis patients who use arteriovenous fistulas as their primary mode of vascular access
Figure hp.11 Arteriovenous fistula use in hemodialysis patients within the first year of dialysis (ESRD CPM data)
Figure hp.12 Arteriovenous fistula placement rates in prevalent hemodialysis patients, by age &race/ethnicity
Figure hp.13 Access placements in prevalent hemodialysis patients, by diabetic status
Figure hp.d Percentage of incident hemodialysis patients using an arteriovenous fistula (ESRD CPM data)
Identified through the ESRD CPM dataset, the percentage of new dialysis patients using an arteriovenous (AV) fistula in the first year of therapy was 41.3 in 2007 — unchanged from that in the previous year, and seeming to confirm that the sharp rise reported in the 2005 ESRD CPM data was an anomaly. Use of AV fistulas in incident patients now varies little by age, but by race/ethnicity ranged in 2007 from 35–36 percent among Hispanic and African American patients to 47.6 percent among Native Americans.
After a decade-long increase, the rate of AV fistula placements in prevalent hemodialysis patients has flattened since 2005. Between 2007 and 2008, the overall rate rose just 0.5 percent, to 126 placements per 1,000 patient years at risk. Rates fall with age and, by race, range from 108 among Asian patients to 135 among whites.
Fistula placement rates among prevalent hemodialysis patients are 5.6 percent higher among patients with diabetes than in those without; rates of catheter and graft placement are 11 percent greater. Catheter and graft placement rates have fallen 41 and 48 percent, respectively, since 2000. The rate of fistula placements has increased 66 percent but has, as mentioned, stabilized since 2005. Programs such as HP2010 and the Fistula First Initiative continue to work to increase the use of fistulas and promote early placement prior to initiation of ESRD therapy.
Figures hp.11–13 &table hp.d; see page 469 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.12–13). "." Zero values in this cell.
hp2010 Objective 4.5 Increase the proportion of dialysis patients registered on the wait list for transplantation
Figure hp.14 Patients wait-listed or receiving a deceased-donor kidney transplant within one year of ESRD initiation
Figure hp.15 Patients wait-listed or receiving a deceased-donor kidney transplant within one year of ESRD initiation, by age, gender, race/ethnicity, &primary diagnosis
Figure hp.e Percentage of patients wait-listed or receiving a deceased- donor kidney transplant within one year of ESRD initiation
After a 7 percent growth in 2006, the proportion of incident ESRD patients registered on the transplant wait list or receiving a deceased donor kidney within one year of ESRD initiation grew just 1.2 percent in 2007, reaching 17.1 percent. It has, however, increased each year since 2001. The Healthy People 2010 goal is 30 percent.
This target is currently met only among pediatric ESRD patients, Asian patients, and those with a primary diagnosis of glomerulonephritis or cystic kidney disease, at 50, 32, 33, and 50 percent, respectively. This is compared to rates of 11–14 percent among those age 60–69, Native Americans and African Americans, and those with a primary diagnosis of diabetes or hypertension.
Figures hp.14–15 &table hp.e; see page 470 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
Figure hp.16 Incident ESRD patients receiving a transplant within three years of ESRD initiation
Figure hp.17 Incident ESRD patients receiving a transplant within three years of ESRD initiation, by age, gender, race/ethnicity, &primary diagnosis
Figure hp.f Percentage of incident ESRD patients receiving a transplant within three years of ESRD initiation
The goal of HP2010 Objective 4.6 is to have 30.5 percent of ESRD patients transplanted within three years of initiating therapy. Results, however, continue to fall further away from this goal, with 17.3 percent of new patients in 2005 receiving a transplant in their first three years of therapy — a slight decrease from 17.9 percent for 2004 incident patients.
The percentage of pediatric ESRD patients transplanted within three years remains quite steady, at 68–70. Among patients age 20–39, in contrast, the percentage has fallen from nearly 47 in 1991 to 29 in 2005. Rates are lowest among the oldest patients, among African Americans and Native Americans, and among those with a primary diagnosis of diabetes or hypertension.
Figures hp.16–17 &table hp.f; see page 470 for analytical methods. Incident ESRD patients younger than 70.
hp2010 Objective 4.7 Reduce kidney failure due to diabetes
Figure hp.18 Adjusted incident rates of ESRD due to diabetes
Figure hp.19 Adjusted incident rates of ESRD due to diabetes, by age
Figure hp.20 Adjusted incident rates of ESRD due to diabetes, by race/ethnicity
Figure hp.g Adjusted ESRD incident rates due to diabetes (per million population)
After peaking in 2006 at 160 per million population, the adjusted incidence of ESRD due to diabetes fell 3.2 and 1.5 percent in the two following years, reaching 153 in 2008. This is, however, still far from the HP2010 target of 90 per million population.
By age, incident rates of diabetic ESRD ranged in 2008 from 41 per million population among those age 20–44 to 692 in those age 65–74; rates for those age 75 and older were 582 per million. The one-year decline was greatest in patients age 65–74, at 3.5 percent, while declines of 0.7 and 1.9 percent were seen for those age 45–64 and those 75 and older, respectively. Rates rose 0.2 percent in patients age 20–44.
African Americans, Native Americans, and Hispanics continue to have the highest rates of ESRD due to diabetes, at 425, 333, and 310 per million population, respectively, in 2008 — far greater than the rate of 117.8 seen in the white population.
Figures hp.18–20 &table hp.g; see page 470 for analytical methods. Incident ESRD patients. Adj: overall, age/gender/race; rates by age, gender/race; rates by gender, age/race; rates by race/ethnicity, age/gender. Ref: 2005. *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
Figure hp.21 CKD patients with diabetes receiving medical evaluation &treatment
Figure hp.22 CKD patients with diabetes receiving medical evaluation &treatment, by age &race/ethnicity
Figure hp.h Percentage of CKD patients with diabetes receiving medical evaluation &treatment
Patients with diabetes in addition to 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 2008, 34.2 percent of general Medicare patients with both diabetes and CKD received the recommended screening tests — two or more glycosylated hemoglobin (A1c) tests, at least one lipid test, and at least one diabetic eye examination. This was close to the 36 percent target established during the HP2010 mid-course review, and 1.4 percent greater than in 2007. By race, rates for comprehensive testing remain greatest among Asian/Pacific Islanders and whites, at 36.3 and 35.1 percent, respectively, in 2008, compared to just 17.6 percent among Native Americans. Similar patterns are seen with A1c and lipid testing, with rates in the Native American population far lower than for patients of other races. Testing in Native Americans, however, may be done through the Indian Health Service, and not reported through Medicare.
In 2006, nearly three in four diabetic CKD patients in the MCBS database were treated with angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), up from 67 percent the previous year.
Figures hp.21–22 &table hp.h; see page 470 for analytical methods. Evaluation: Medicare patients age 66 &older with diabetes &CKD. "All three tests" include at least two glycosylated hemoglobin (A1c) tests, at least one lipid test, &at least one diabetic eye examination. Treatment: patients age 66 &older with diabetes &CKD; from Medicare Current Beneficiaryt Survey (MCBS) Cost &Use file.
hp2010 Objective 5.11 Increase the proportion of adults with diabetes who obtain an annual urinary microalbumin measurement
Figure hp.23 Patients with diabetes receiving an annual urinary microalbumin measurement
Figure hp.24 Patients with diabetes receiving an annual urinary microalbumin measurement, by age
Figure hp.25 Patients with diabetes receiving an annual urinary microalbumin measurement, by race/ethnicity
Figure hp.i Percentage of patients with diabetes receiving an annual urinary microalbumin measurement
hp2010 Objective 14.29 Increase the proportion of adults vaccinated annually against influenza &ever vaccinated against pneumococcal disease
In the diabetic population age 66 and older, the percentage of patients receiving an annual urinary microalbumin measurement has increased from 12.3 in 2000 to 35.6 in 2008 — 2.5 times greater than the 14 percent recommended by the Healthy People 2010 guidelines.
Rates of annual urinary microalbumin testing fall with age, with 40.9 percent of those age 66–69 tested in 2008, compared to 28.2 percent of those age 80 and older. By race and ethnicity, testing rates are lowest in Native American patients with diabetes, at 20.9 percent, and highest in their Asian counterparts, at 37.5 percent. Testing may, however, be under-reported 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 36.6 percent for men and 34.8 percent for women. ? Figures hp.23–25 &table hp.i; see page 470 for analytical methods. Medicare patients with diabetes, age 66 &older.
Figure hp.26 Prevalent ESRD patients receiving influenza vaccinations
Figure hp.27 Prevalent ESRD patients receiving influenza vaccinations, by age &race/ethnicity
Figure hp.28 Prevalent ESRD patients receiving pneumococcal pneumonia vaccinations, by age &race/ethnicity
Figure hp.j Percentage of prevalent ESRD patients receiving influenza &pneumococcal pneumonia
In 2008, 62.4 percent of prevalent ESRD patients were vaccinated against influenza — up 4.8 percent from the previous year. Rates by age vary from 27.8 percent of patients age 0–17 to nearly 71 percent of patients age 75 and older; rates by race and ethnicity have a narrower range, from 58.9 percent of African Americans to 64.5 percent among whites. Since 2000, the rate has increased nearly 42 percent overall, doubling in the pediatric population, and rising 68 percent among patients age 18–39. While reported rates remain far from the HP2010 target of 90 percent, patients may receive vaccinations through non-Medicare programs.
The two-year rate of pneumococcal pneumonia vaccinations has grown from 16.2 percent in 2003–2004 to 22.3 percent in 2007–2008. The rate rises by age, from 7.3 percent in pediatric patients to 24–25 percent in patients age 65 and older, and by race and ethnicity is greatest among Native Americans, at 24.7 percent.
Figures hp.26–28 &table hp.j; see page 470 for analytical methods. Point prevalent ESRD patients.
Figure hp.29 Objective 4.1 Adjusted incident rates of ESRD, 2008
Figure hp.30 Objective 4.2: Unadjusted cardiovascular mortality rates, 2008
Figure hp.31 Objective 4.3: Patients receiving more than 12 months of pre-ESRD nephrologist care, 2008
Rates of incident ESRD in Networks 1 and 16 come closest to meeting the target of 221 per million population, at 280 and 269, respectively; rates in Networks 14 and 18 reached 422 and 428 in 2008. The HP2010 goal related to cardiovascular mortality was met by nine networks in 2008, each with a rate below the targeted 62.1 deaths per 1,000 patient years at risk. The percentage of patients who see a nephrologist for more than 12 months prior to ESRD ranges from 14.1 in Network 18 to 42.5 in Network 16.
Figures hp.29–31; see appendix a for analytical methods. Incident ESRD patients, 2008, adj: age/gender/race; ref: 2005 (hp.29). Period prevalent ESRD patients, 2008 (hp.30). Incident dialysis patients, 2008 (hp.31).
Figure hp.32 Objective 4.4: Arteriovenous fistula use, 2007
Figure hp.33 Objective 4.5: Patients on the transplant wait list or receiving a deceased-donor kidney transplant, 2007
The HP2010 goal related to vascular access states that 50 percent of new hemodialysis patients should be using a fistula as their primary access. In 2007, among patients in the ESRD CPM database, this goal was met only by Network 8. The lowest rates — of 30 to 33 percent — occurred in Networks 5 and 9. Networks 6, 10, and 11, which had rates less than 30 percent in 2006, had rates greater than 40 percent in 2007.
HP2010 Objective 4.5 is currently met only by Network 17, in which nearly 39 percent of incident patients in 2007 were wait-listed for or received a deceased donor kidney within one year of initiating ESRD therapy. Rates in the remaining networks are below the target of 30 percent, and in Networks 6, 7, and 13 just 11.3–12.5 percent of patients are wait-listed or transplanted during the first year.
Figures hp.32–33; see appendix a for analytical methods. Incident patients, 2007, initiating hemodialysis between January 1 &August 31, 2007, from 2008 ESRD CPM data (hp.32). Incident ESRD patients younger than 70 ®istered on the transplant wait list on December 31, 2007 (hp.33).
Figure hp.34 Objective 4.6: Patients transplanted within three years of ESRD registration, 2005
Figure hp.35 Objective 4.7: Adjusted incident rates of ESRD due to diabetes, 2008
HP2010 Objective 4.6 states that 30.5 percent of patients should receive a transplant within three years of initiating ESRD therapy. Network 11 is closest to this goal, with 28.3 percent of 2005 incident patients transplanted within three years; Network 6, in contrast, has a rate of just 11.3 percent.
The rate of new cases of ESRD due to diabetes ranges from 110.2 per million in Network 1 to 228.5 in Network 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, 2005 (hp.34). Incident ESRD patients, 2008; adj: age/gender/race; ref: 2005 (hp.35).
Figure hp.36 Objective 4.8: Incident ESRD patients with diabetes, 2008 (age 67+), receiving preventive care (A1c, lipid test, &eye exam) prior to ESRD
Figure hp.37 Objective 5.11: Incident ESRD patients with diabetes, 2008 (age 67+), receiving a urinary microalbumin test in the year prior to ESRD
Figure hp.38 Objective 14.29: Prevalent ESRD patients, 2008, receiving influenza vaccinations
In all ESRD networks, the rate of preventive care testing in diabetic patients prior to ESRD is close to or exceeds the HP2010 target of 36 percent, ranging from 35.7 percent in Network 13 to 58.8 percent in Network 1. The goal of 14 percent for urinary microalbumin testing in the year prior to ESRD is also exceeded across the country, with rates of 37–53 percent. The target of 90 percent for influenza vaccinations, however, remains elusive, with rates ranging from 56 percent in Network 2 to 67 percent in Networks 6 and 11. (Not all vaccinations may be reported through Medicare.)
Figures hp.36–38; see appendix a for analytical methods. Incident ESRD patients, 2008, age 67 or older at initiation (hp.36–37). Prevalent ESRD patients, 2008 (hp.38).