2010 USRDS Annual Data Report
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Figure List
Figure 7.1Patients with at least one CKD claim prior to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.2Cumulative percent of patients with a CKD claim prior to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.3Cumulative percent of patients with a first physician visit in the year prior to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.4Cumulative percent of patients with a first nephrologist visit in the year prior to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.5Cumulative percent of patients with a first cardiologist visit in the year prior to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.6Cumulative percent of patients with a first primary care physician visit in the year prior to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.7Cumulative percent of patients with a first urine microalbumin test prior to ESRD, by dataset & CKD diagnosis code, 20062008
Figure 7.8Cumulative percent of patients with a first serum creatinine test prior to ESRD, by dataset & CKD diagnosis code, 20062008
Figure 7.9Cumulative percent of patients with a first calcium/phosphorus test prior to ESRD, by dataset & CKD diagnosis code, 20062008
Figure 7.10Cumulative percent of patients with a first parathyroid hormone (PTH) test prior to ESRD, by dataset & CKD diagnosis code, 20062008
Figure 7.11Cumulative percent of patients with a first lipid test prior to ESRD, by dataset & CKD diagnosis code, 20062008
Figure 7.12Cumulative percent of diabetic patients with a first glycosylated hemoglobin (A1c) test prior to ESRD, by dataset & CKD diagnosis code, 20062008
Figure 7.13ACEI/ARB/renin inhibitor use during the transition to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.14Beta blocker use during the transition to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.15Dihydropyridine calcium channel blocker use during the transition to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.16Statin use during the transition to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.17Use of diuretics during the transition to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.18EPO/DPO use during the transition to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.19Use of oral active vitamin D during the transition to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.20Phosphate binder use during the transition to ESRD, by dataset & CKD diagnosis code, 2008
Figure 7.21Medication use prior to & following ESRD initiation: MarketScan patients, 2008
Figure 7.22Medication use prior to & following ESRD initiation: Ingenix i3 patients, 2008
Table 7.aMedication continuity in the transition to ESRD, by dataset, 2008

Chapter Seven
The transition to end-stage renal disease   Top

Sections this chapter: 

From the earliest stages of their disease, patients with chronic kidney disease face many challenges. Control of salt intake, blood pressure, lipid levels, and weight are needed to address the management of cardiovascular risk factors. And the disease's progression, with the potential for accelerating cardiovascular disease and for reaching kidney failure, poses additional issues.

In Chapter Three we give one perspective on these issues, looking prospectively at CKD patients to determine their care in the year following diagnosis. Since progression to ESRD is a rare event, however, compared to death or survival, it is important also to assess the care of patients who do reach ESRD, to determine if they receive comparable services.

At two years prior to the initiation of ESRD therapy, 50 percent of Medicare ESRD patients have no claims for CKD services, and, while recognition grows each quarter, 28 percent still have no claim six months before ESRD. The constellation of reported CKD codes also changes as progressing kidney failure manifests itself in major complications. The proportion of patients with Stage 35 CKD rises, as does the frequency of acute kidney injury, particularly in the quarter before ESRD.

While these findings are consistent across populations, there are important differences in delivered care. Whether or not they have a reported CKD diagnosis code, EGHP patients are far less likely to see any doctor particularly a nephrologist prior to ESRD than are their Medicare counterparts. A planned transition to ESRD, with modality selection, vascular access placement, and work-ups for kidney transplantation, is difficult when visits to the primary physicians who coordinate this care are delayed.

We next address laboratory testing during the transition to ESRD. Compared to the data presented in Chapter Three, on prospectively measured care of identified CKD patients, microalbuminuria testing is less frequent in those who reach ESRD. Creatinine testing, not unexpectedly, is lowest in those without a CKD stage code, even though these individuals are clearly progressing to ESRD. And other testing to identify the usual complications of progressive kidney disease is lacking as well, with low rates of calcium/phosphorus, parathyroid hormone, lipid, and glycemic testing. Among diabetic Medicare patients with Stage 35 CKD who go on to ESRD, nearly 80 percent receive a glycosylated hemoglobin test in the two years prior to initiation, compared to 51 percent of their Ingenix i3 counterparts. Care of patients who reach ESRD is clearly less than recommended, and may contribute to progression of their disease. In addition, testing rates are considerably lower among EGHP patients than for those with Medicare coverage, a major concern.

Information on the pre-ESRD use of prescription medications can also be compared to data in Chapter Three, on the management of the known CKD population. At two years prior to ESRD, 5062 percent of CKD patients are using an ACEI, ARB, or renin inhibitor, and this falls to 3344 percent in the three months before initiation. It is not clear whether this decline arises from concern over rising creatinine levels as kidney failure progresses, or if complications such as hyperkalemia may contribute to these patterns.

Use of beta blockers and dihydropyridine calcium channel blockers rises as patients near ESRD, possibly reflecting increased treatment for hypertension and congestive heart failure (CHF) in the later stages of CKD. The use of thiazide diuretics, known to be relatively ineffective in advanced kidney disease, averages about 10 percent among CKD patients advancing to ESRD. Use of loop diuretics, in contrast, and of the combination of loop plus thiazide diuretics, both increase, indicative of the increasing difficulty in managing fluid overload, pedal edema, hypertension, and CHF. These diuretic combinations can be also used to treat the hyperkalemia which may develop under the use of ACEIs/ARBs.

We conclude by examining medication continuity after ESRD initiation. While use of ACEIs, ARBs, and renin inhibitors appears similar before and after initiation, analysis shows that half the patients using these drugs three months prior to ESRD are taken off them by one month after initiation, and new patients are started on these medications. Findings related to phosphate binders are dramatically different, with just 10 percent on these medications three months before ESRD, and 53 percent at one month after initiation. These data may provide important insights into the high prevalence of hyperparathyroidism at the start of ESRD, as it appears that few patients receive treatment for the control of phosphorus levels. Medication use in the Medicare population will be assessed further when more Part D data becomes available to the USRDS and we can construct a more complete treatment history for the incident population.

Figure 7.1 Patients with at least one CKD claim prior to ESRD, by dataset & CKD diagnosis code, 2008 (see page 171 for analytical methods. Incident Medicare ESRD patients age 67 & older, & incident MarketScan & Ingenix i3 ESRD patients (all ages), 2008.)

Patient care prior to ESRD  Top

Figure 7.2 Cumulative percent of patients with a CKD claim prior to ESRD, by dataset & CKD diagnosis code, 2008

Figure 7.3 Cumulative percent of patients with a first physician visit in the year prior to ESRD, by dataset & CKD diagnosis code, 2008

In 2008, the cumulative percent of Medicare patients with CKD claims in the quarter prior to ESRD initiation reached 98.9 percent, compared to 89.7 and 84.3 percent, respectively, in the MarketScan and Ingenix i3 populations. Nearly all Medicare CKD patients saw a physician a nephrologist, cardiologist, or primary care specialist by the end of the quarter prior to ESRD, compared to 8385 and 8998 percent of MarketScan and Ingenix i3 patients.

Figure 7.4 Cumulative percent of patients with a first nephrologist visit in the year prior to ESRD, by dataset & CKD diagnosis code, 2008

Medicare patients were a]more likely than their MarketScan or Ingenix i3 counterparts to see a nephrologist prior to ESRD. By the end of the quarter prior to ESRD, for example, 93 percent of Stage 35 Medicare CKD patients had visited a nephrologist, compared to 54 and 88 percent in the MarketScan and Ingenix i3 populations. These data show that, while CKD is often recognized by a physician, many privately insured patients do not proceed early enough to the next logical step of seeing a nephrologist. This may have significant impact on theraputic choices, such as access use, as these patients initiate ESRD treatment. As we show in Chapter Three of Volume Two, patients with no pre-ESRD nephrology care are far more likely to use a catheter at dialysis initiation??an access associated with higher rates of infectious complications and early mortality.

Figure 7.5 Cumulative percent of patients with a first cardiologist visit in the year prior to ESRD, by dataset & CKD diagnosis code, 2008

By the end of the quarter prior to ESRD, visits to a cardiologist are more common in the Medicare population, at 8289 percent, compared to 4654 and 5871 percent in MarketScan and Ingenix i3 patients.

Figure 7.6 Cumulative percent of patients with a first primary care physician visit in the year prior to ESRD, by dataset & CKD diagnosis code, 2008

Medicare patients are also more likely to see their primary care physicians than patients in the employed population.

Figures 7.26; see page 171 for analytical methods. Incident Medicare ESRD patients age 67 & older, & incident MarketScan & Ingenix i3 ESRD patients (all ages), 2008.

Laboratory testing prior to esrd  Top

Figure 7.7 Cumulative percent of patients with a first urine microalbumin test prior to ESRD, by dataset & CKD diagnosis code, 20062008

The presence of microalbumin in urine is an indicator of possible kidney damage, and early detection is important in order to slow the progression of chronic kidney disease. In 2008, only 1219 percent of Medicare CKD patients had a first microalbumin test in the fourth quarter prior to ESRD initiation, compared to 1833 percent in the Ingenix i3 population. By the end of quarter one prior to ESRD, 3842 percent of Medicare patients had been tested, compared to 3058 percent in the Ingenix i3 population. More than one in two Ingenix i3 patients with CKD of Stages 12 had been tested for the first time by the third quarter prior to ESRD.

Figure 7.8 Cumulative percent of patients with a first serum creatinine test prior to ESRD, by dataset & CKD diagnosis code, 20062008

Serum creatinine is also an important marker of kidney function. Sixty-nine to 87 percent of Medicare patients have their first serum creatinine test in the fourth quarter prior to ESRD, compared to 3450 percent of Ingenix i3 patients. By the end of the quarter just prior to ESRD, the percentage tested for the first time rises to 9498 and 5675 percent, respectively.

Figure 7.9 Cumulative percent of patients with a first calcium/phosphorus test prior to ESRD, by dataset & CKD diagnosis code, 20062008

Calcium/phosphorus testing can be used to identify bone and mineral disorders. When compared to Ingenix i3 patients, those with Medicare coverage are far more likely to have their first test by the end of the quarter prior to ESRD, at 5081 versus 3448 percent. More than 80 percent of Medicare patients with Stage 35 CKD receive their first calcium/phosphorus test by the end of quarter one.

Figures 7.79; see page 171 for analytical methods. Incident Medicare ESRD patients age 67 & older, & incident Ingenix i3 ESRD patients (all ages), 20062008.

Figure 7.10 Cumulative percent of patients with a first parathyroid hormone (PTH) test prior to ESRD, by dataset & CKD diagnosis code, 20062008

PTH testing is used to determine causes of calcium imbalance. Among Medicare patients with Stage 35 CKD, 68 percent have their first PTH test by the quarter prior to ESRD, compared to 41 percent of those in the employed population.

Figure 7.11 Cumulative percent of patients with a first lipid test prior to ESRD, by dataset & CKD diagnosis code, 20062008

Detection and treatment of elevated lipids is important in order to prevent associated cardiovascular disorders and high blood pressure. Overall, Medicare CKD patients have their first pre-ESRD lipid test earlier than Ingenix i3 patients. In the fourth quarter prior to ESRD initiation, for example, 3034 percent of Medicare patients have a first lipid test; this rises to 6669 percent by the quarter just prior to ESRD. In employed patients with CKD of Stages 12, 42 percent have their first lipid test during the fourth quarter prior to ESRD; this rises to 67 percent by the quarter prior.

Figure 7.12 Cumulative percent of diabetic patients with a first glycosylated hemoglobin (A1c) test prior to ESRD, by dataset & CKD diagnosis code, 20062008

The monitoring of A1c levels in patients with diabetes is important in the control and treatment of the disease. In Medicare patients, 3944 percent have a first A1c test in the fourth quarter prior to ESRD, while 7578 percent receive a first test by the end of the quarter prior. In the Ingenix i3 population, 50 percent of Stage 12 CKD patients receive a first A1c test in the fourth quarter before ESRD; by the end of the quarter prior to ESRD, 75 percent have been tested for the first time.

Figures 7.1012; see page 171 for analytical methods. Incident Medicare ESRD patients age 67 & older, & incident Ingenix i3 ESRD patients (all ages), 20062008. Figure 7.12 limited to patients with diabetes.

Figure 7.13 ACEI/ARB/renin inhibitor use during the transition to ESRD, by dataset & CKD diagnosis code, 2008

Among patients with recognized CKD of Stages 35 at eight quarters prior to ESRD, ACEI/ARB/renin inhibitor use falls from 6268 percent to 42 percent in the quarter following ESRD diagnosis. For patients without a CKD code, in contrast, use remains at approximately 40 percent.

Figure 7.14 Beta blocker use during the transition to ESRD, by dataset & CKD diagnosis code, 2008

In contrast to ACE/ARB/renin inhibitor use beta blocker use in Stage 35 CKD patients increased from 3942 percent to 5966. Beta blocker use is lower in patients without a CKD code at eight quarters prior to ESRD, rising from 2024 percent at this point to approximately 50 percent in the quarter after ESRD diagnosis.

Figure 7.15 Dihydropyridine calcium channel blocker use during the transition to ESRD, by dataset & CKD diagnosis code, 2008

The pattern of use for dihydropyridine calcium channel blockers is similar to that of beta blockers, although overall use is lower.

Prescription drug therapy in the transition to esrd  Top

Figure 7.16 Statin use during the transition to ESRD, by dataset & CKD diagnosis code, 2008

With statin medications, use remains fairly constant over time in patients with a diagnosis of Stage 35 CKD and in those without a CKD code, but is higher for CKD patients.

Figure 7.17 Use of diuretics during the transition to ESRD, by dataset & CKD diagnosis code, 2008

As expected, use of potassium-sparing diuretics is very low in patients with Stage 35 CKD eight quarters before ESRD; use of thiazide diuretics falls from 22 percent to 79 percent by one quarter after diagnosis. Loop diuretic use rises modestly until a precipitous drop at ESRD initiation. While thiazide diuretics are generally ineffective alone at GFRs less than 30 ml/min/1.73 m2, they can augment the action of loop diuretics in patients with more advanced CKD. Among patients with Stage 35 CKD eight quarters prior to ESRD, or without a CKD code at this time, simultaneous use of these agents increases close to ESRD, but only 1015 percent are using dual diuretics at one quarter prior to initiation

Figure 7.18 EPO/DPO use during the transition to ESRD, by dataset & CKD diagnosis code, 2008

For patients with Stage 35 CKD eight quarters before ESRD, the use of erythropoiesis stimulating agents (ESAs) doubles by ESRD initiation; only 1518 percent, however, receive an ESA in the quarter prior to ESRD, a much lower percentage than that seen in the Medicare population.

Figure 7.19 Use of oral active vitamin D during the transition to ESRD, by dataset & CKD diagnosis code, 2008

Use of active oral vitamin D (calcitriol, doxercalciferol, paricalcitol) almost triples between eight quarters and one quarter prior to ESRD, then drops off as patients transition to dialysis and receive intravenous forms of these agents.

Figure 7.20 Phosphate binder use during the transition to ESRD, by dataset & CKD diagnosis code, 2008

And, for patients with Stage 35 CKD at eight quarters before ESRD, use of phosphate binders increases from less than 10 percent to 50 percent in the quarter following initiation.

Figures 7.1320; see page 171 for analytical methods. Incident MarketScan & Ingenix i3 patients age 2064, 2008.

Medication continuity in the transition to esrd  Top

Figure 7.21 Medication use prior to & following ESRD initiation: MarketScan patients, 2008

Figure 7.22 Medication use prior to & following ESRD initiation: Ingenix i3 patients, 2008

Figures 7.2122 illustrate the percentage of patients on various medications three quarters prior to ESRD, one quarter after, in both periods, or in neither period. Both the MarketScan and Ingenix i3 commercial datasets show similar trends that vary by medication class. It is interesting to note that 55 percent of patients do not have a claim for an ACEI/ARB/renin inhibitor three quarters prior to ESRD. Fifty-six percent of patients are on a beta blocker one quarter after ESRD, compared to only 40 percent at three quarters prior. The use of lipid lowering agents increases slightly across the transition to ESRD. And approximately 20 and 40 percent of CKD patients receive a thiazide or loop diuretic, respectively, three quarters prior to ESRD.

Figures 7.2122; see page 171 for analytical methods. Incident MarketScan & Ingenix i3 patients age 2064.

Table 7.a Medication continuity in the transition to ESRD, by dataset, 2008 (see page 171 for analytical methods. Incident MarketScan & Ingenix i3 ESRD patients age 2064) shows the number and percentage of patients with medication claims three quarters prior to ESRD, and those remaining on the medications at one quarter after initiation. We also evaluate overall medication use one quarter following ESRD. Of those using the medications three quarters prior to ESRD, 80 percent remain on a beta blocker, 5254 percent on an ACEI/ARB/renin inhibitor, 6369 percent on a lipid lowering agent, and 3239 percent on oral active vitamin D. Few patients receive EPO/DPO through their commercial prescription drug plan after ESRD initiation. The majority of patients who are on a phosphate binder at three quarters prior to ESRD remain on the medication in the quarter following initiation. And interestingly, only 4346 percent of patients on a loop diuretic before ESRD use the medication after starting ESRD therapy.