2010 USRDS Annual Data Report
This Chapter
Download
Download PDF
Download all slides
*corresponding data in Excel included
Search This Page
Search All
Translate

Figure List
Figure P.1Distribution of general (fee-for-service) Medicare patients &costs for CKD, CHF, diabetes, &ESRD, 1998 &2008
Figure P.aSummary statistics on reported ESRD therapy in the United States
Figure P.2Counts of new &returning dialysis patients
Figure P.3Patient counts,by modality
Figure P.4Incident patient counts &adjusted rates, by modality
Figure P.5Prevalent patient counts &adjusted rates, by modality
Figure P.6Transplant (kidney only) wait list &wait times
Figure P.7Geographic variations in adjusted incident rates (per million population), by HSA
Figure P.8Geographic variations in adjusted prevalent rates (per million population), by HSA
Figure P.9Care &counseling prior to ESRD
Figure P.10Vascular access at first outpatient dialysis
Figure P.11Vascular access use at first outpatient hemodialysis, by pre-ESRD nephrology care, 2008
Figure P.12Vascular access use at initiation, by race, 2008
Figure P.13Hemodialysis patients receiving transfusions
Figure P.14Distribution of diabetic patients, by glycosylated hemoglobin (A1c) level at initiation
Figure P.15Mean cholesterol levels at initiation
Figure P.16Change in adjusted all-cause &cause-specific hospitalization rates, by modality
Figure P.17Adjusted mortality rates in period prevalent patients, by vintage &modality
Figure P.18Adjusted mortality rates in incident patients, by modality &year of treatment
Figure P.19Unadjusted survival in dialysis patients, using matched hemodialysis &peritoneal dialysis populations, by race &diabetic status, 2008
Figure P.20Total PPPM costs during the transition to ESRD, 2007
Figure P.21PPPM inpatient costs during the transition to ESRD, 2007
Figure P.22Costs of the Medicare &ESRD programs
Figure P.23Total Medicare spending on injectables
Figure P.24Total ESRD expenditures, by modality
Figure P.25Total per person per year outpatient expenditures, by race
Figure P.26Total per person per year inpatient expenditures, by race
Figure P.27Total per person per year outpatient expenditures, by modality &race, 2008
Figure P.28Total per person per year inpatient expenditures, by modality &race, 2008

Prιcis

Sections this chapter: 

This year's ADR is framed with celestial images drawn from many times and cultures, illustrating how the same sky can be interpreted in innumerable ways, which in turn often help structure and define a culture itself. So, too, can the same disease affect different populations in different ways. In this 2010 edition of the USRDS ADR we focus on disparities in disease burden and patient care across races and ethnicities, and view the expanse of kidney disease as it relates to other chronic diseases affecting populations worldwide.

The universal impact of chronic diseases was codified in 2005, when the World Health Organization reported on these diseases in low, middle, and high income countries. The presentation focused on premature loss of life and on the economic impact of deaths during individuals' most productive years. With the effect of chronic diseases in the U.S. long an area of concern, we summarize one perspective in the Venn diagrams on the next page, looking at Medicare patients with diabetes, congestive heart failure (CHF), chronic kidney disease (CKD), and end-stage renal disease (ESRD).

Diabetic patients accounted for 17.2 percent of the 1998 Medicare population, and 32 percent of costs; by 2008 these numbers had grown to 25.6 and 41.2 percent, respectively. Patients with CHF are now 12.7 percent of the population, but account for 36.3 percent of expenditures. And as shown by the intersecting circles, these conditions clearly overlap with kidney disease.

While CKD has been characterized from population-level estimates in the NHANES data, much of the disease is silent and unrecognized, complicating any full assessment of its impact. Here we define recognized CKD patients through diagnosis codes reported on claims — an approach which clearly underestimates CKD in the Medicare population, but has been shown to have high specificity, indicating individuals likely to have the disease. As identified from these codes, CKD has grown from just 3.3 percent in 1998 to 9.5 percent in 2008. It is probable that this represents increased recognition of the disorder, since the disease burden identified through NHANES data has grown little over the same period. Costs for CKD patients are now 23 percent of Medicare expenditures in the fee-for-service sector; when added to costs for ESRD patients, it appears that 31 percent of all Medicare expenditures are incurred by patients with a diagnosis of kidney disease.

Despite this high disease burden, the rate of progression to ESRD has been relatively stable over the last several years, suggesting either that CKD patients are dying at a higher rate before they reach ESRD or that their rate of progression to ESRD has slowed. The continuing decline in rates of death from cardiovascular disease (the major cause of mortality in the CKD population), along with improved treatment and control of hypertension and increased use of ACEs/ARBs/renin inhibitors, suggest that progression of CKD to ESRD may indeed have slowed.

The size of the ESRD population reached a new high in 2008, with 547,982 patients under treatment. The number of patients returning from a failed transplant rose to 5,459, while the number restarting dialysis increased to 3,277. Peritoneal dialysis now accounts for 6–7 percent of the incident and prevalent dialysis populations, continuing to fall from peaks of 12–18 percent in the 1980s and 1990s. The number of kidney transplants reached 17,413 in 2008, while the prevalent transplant population rose 4.3 percent, to 165,639, despite continued growth in the number of patients on the transplant wait list. The median time on the kidney-only wait list was 732 days.

We also look here at vascular access use at initiation, its relation to pre-ESRD nephrologist care (which suggests that the transition from CKD to ESRD is often poorly managed), hospitalization and mortality, and ESRD expenditures — including new data on costs in matched dialysis populations. Greater growth in general Medicare costs compared to those for ESRD (in 2008, 16.9 versus 4.9 percent), along with the recent inclusion of Part D drug benefits in total Medicare costs, have led to a decline in the percentage of the Medicare budget spent on ESRD, now at 5.9. In the 2011 ADR we will fully reconcile Part D costs for ESRD patients so as to more completely understand their impact on total Medicare expenditures for these patients.

Figure P.1 Distribution of general (fee-for-service) Medicare patients &costs for CKD, CHF, diabetes, &ESRD, 1998 &2008 (see page 468 for analytical methods. Period prevalent general (fee-for-service) Medicare patients. Diabetes, CKD, &CHF determined from claims, 1997–1998 &2007–2008; costs are for calendar years 1998 &2008)

Trends in patient counts &spending  Top

Figure P.a Summary statistics on reported ESRD therapy in the United States, by age, race, ethnicity, gender, &primary diagnosis, 2008 (see page 469 for analytical methods. Dialysis &transplant patients, 2008)

In 2008, 112,476 new dialysis and transplant patients initiated ESRD therapy, for an adjusted rate per million population of 351. Nearly 548,000 patients were receiving treatment on December 31, 2008, for an adjusted rate of 1,699 per million population. More than 382,000 of these patients were being treated with dialysis, while 165,639 had a functioning graft; 88,620 ESRD patients died during the year. A total of 17,413 transplants were performed during 2008, including 5,968 from living donors. More than 33,000 patients were added to the transplant wait list, 77,695 were on the kidney-alone and kidney/pancreas wait lists at the end of 2008, and the median time on the list was 1.6 years.

With Medicare spending for ESRD at $26.8 billion, and non-Medicare spending at $12.7 billion, total ESRD costs in 2008 reached nearly $39.5 billion. Medicare costs per person per year were nearly $66,000 overall, ranging from $26,668 for transplant patients to $77,506 for those receiving hemodialysis therapy.

A Incident counts: include all known ESRD patients, regardless of any incomplete data on patient characteristics and of U.S. residency status.

B Includes only residents of the 50 states and Washington D.C. Rates are adjusted for age, race, and/or gender using the estimated July 1, 2005 U.S. resident population as the standard population. All rates are per million population. Rates by age are adjusted for race and gender. Rates by gender are adjusted for race and age. Rates by race are adjusted for age and gender. Rates by disease group and total adjusted rates are adjusted for age, gender, and race. Adjusted rates do not include patients with other or unknown race.

C Patients are classified as receiving dialysis or having a functioning transplant. Those whose treatment modality on December 31 is unknown are assumed to be receiving dialysis. Includes all Medicare and non-Medicare ESRD patients, and patients in the U.S. Territories and foreign countries.

D Deaths are not counted for patients whose age is unknown.

E Age is computed at the start of therapy for incidence, on December 31 for point prevalence, at the time of transplant for transplants, and on the date of death for death.

F Includes patients whose modality is unknown.

G Unadjusted total rates include all ESRD patients in the 50 states and Washington D.C.

H Total transplants as known to the USRDS; 63 transplants with unknown donor type excluded from counts.

I Adjustments using the Bureau of Labor Statistics inflationary adjustment and the CMS inflation adjustment for the medical component.

* Values for cells with ten or fewer patients are suppressed. "." Zero patients in this cell.

Figure P.2 Counts of new &returning dialysis patients

The number of new dialysis patients rose 1.2 percent in 2008 — up slightly from growth of 0.85 percent in 2007 — to 108,926. Just over 5,400 patients with graft failure returned to dialysis from transplant, a one-year increase of 1.1 percent. The number of patients restarting dialysis increased 8.1 percent, to 3,277. Overall, the CMS Annual Facility Survey showed 117,662 patients starting or restarting dialysis in 2008, up 1.4 percent from 2007.

Figure P.2. CMS Annual Facility Survey.

Trends in modalities  Top

Figure P.3 Patient counts,by modality

The prevalent dialysis population increased 3.6 percent in 2008, reaching 382,343, and has grown 34.7 percent since 2000. The size of the transplant population rose 4.4 percent in 2008 to reach 165,639 patients, while growth in the incident population changed slightly, with the number of patients rising only 1.2 percent in 2008, to 112,476. These data suggest longer lifespans for prevalent patients, ultimately influencing the steady growth of this population and the annual expenditures these patients incur.

Figure P.3. Incident &December 31 point prevalent ESRD patients.

Figure P.4 Incident patient counts &adjusted rates, by modality

At 102,876, the hemodialysis population accounted for nearly 92 percent of new patients in 2008, with an adjusted rate of 321.5 per million. The number of peritoneal dialysis patients showed a slight increase of 1.0 percent, yet the actual rate fell 0.7 percent, and is nearly 23 percent less than in 2000. Transplant patients comprise 2.4 percent of the incident population, at a rate of 7.9 per million.

Figure P.4. Incident ESRD patients; excludes those with unknown modality. Adj: age/gender/race; ref: 2005 ESRD patients.

Figure P.5 Prevalent patient counts &adjusted rates, by modality

In 2008, patients on hemodialysis accounted for nearly 65 percent of prevalent ESRD patients, with an adjusted rate of 1,096.5 per million population — 17 percent higher than in 2000. Three of every ten prevalent patients now have a transplant, with the rate increasing by 2.7 percent in 2008 to 516 per million; this rate has grown nearly 33 percent since 2000.

Figure P.5. December 31 point prevalent ESRD patients; excludes those with unknown modality. Adj: age/gender/race; ref: 2005 ESRD patients.

Figure P.6 Transplant (kidney only) wait list &wait times (see page 469 for analytical methods. Patients listed for kidney-only transplants on December 31 of each year)

On December 31, 2008, 75,553 patients were listed for a kidney-only transplant — 6 percent more than in the previous year, and 3.2 times more than in 1995. The median wait time for patients receiving a transplant during 2008 was 732 days, 8 percent longer than the median for patients transplanted in the prior year.

Figure P.7 Geographic variations in adjusted incident rates (per million population), by HSA

In 2008, the adjusted incident rate of ESRD was 351 per million population (see Table p.a), and geographically averaged 441 in the upper quintile. The highest adjusted rates occur in the Ohio Valley, California, Texas, and the southwestern states.

Figure P.8 Geographic variations in adjusted prevalent rates (per million population), by HSA

The rate of prevalent ESRD in 2008 was 1,699 per million population (see Table p.a), and averaged 2,235 in the upper quintile. With the addition of high rates in the Upper Midwest, geographic patterns generally follow those found in the incident population, with rates in the upper quintile occurring through much of the southern and southwestern portions of the country.

Figures P.7–8. Incident &December 31 point prevalent ESRD patients. Adj: age/gender/race; ref: 2005 ESRD patients.

Trends in quality of care  Top

Figure P.9 Care &counseling prior to ESRD (see page 469 for analytical methods. Incident ESRD patients)

In 2008, 57 percent of new ESRD patients had received some pre-ESRD nephrology care; just 25 percent received care for more than twelve months. Slightly more than 26 percent were on therapy with an erythropoiesis stimulating agent (ESA) prior to ESRD; just 7.9 percent received it for more than 12 months. And fewer than one in ten patients received any pre-ESRD dietary care.

Figure P.10 Vascular access at first outpatient dialysis (see page 469 for analytical methods. Incident hemodialysis patients.P.10 Vascular access at first outpatient dialysis)

Catheters remain the most common access at the first outpatient dialysis, reaching 64.8 percent in 2008; in 15.3 percent of patients, a catheter is accompanied by a maturing fistula. Use of arteriovenous fistulas increased from 11.8 percent in 2005 to 13.6 in 2008. And arteriovenous graft use has decreased slightly, from 4.9 percent in 2005 to 3.3 percent in 2008.

Figure P.11 Vascular access use at first outpatient hemodialysis, by pre-ESRD nephrology care, 2008 (see page 469 for analytical methods. Incident hemodialysis patients, 2008)

Among 2008 incident hemodialysis patients with no pre-ESRD nephrology care, 83 percent used a catheter on their first outpatient dialysis treatment, compared to 2.8 percent who used an AV fistula. Of those with more than 12 months of care, 44 percent used a catheter and nearly 30 percent initiated with an AV fistula.

Figure P.12 Vascular access use at initiation, by race, 2008 (see page 469 for analytical methods. Incident hemodialysis patients, 2008)

In 2008, arteriovenous (AV) fistula use at the initiation of dialysis was 14.1 and 12.1 percent in white and African American hemodialysis patients, respectively. Catheters are used more widely, at 65.5 and 64.2 percent, while AV graft use is slightly higher in African Americans compared to whites, at 4.5 and 2.7 percent.

Figure P.13 Hemodialysis patients receiving transfusions (see page 469 for analytical methods. Hemodialysis patients receiving at least one billed transfusion)

After peaking in the early 1980s, the use of transfusions has undergone a dramatic reduction. From a high of 19 percent, followed by a significant drop after the introduction of EPO in 1989, the proportion of hemodialysis patients transfused in an outpatient dialysis center was just 0.37 percent in 2008, and 7 percent overall.

Figure P.14 Distribution of diabetic patients, by glycosylated hemoglobin (A1c) level at initiation (see page 469 for analytical methods. Incident ESRD patients with diabetes as their primary diagnosis or as a comorbidity)

Glycosylated hemoglobin (A1c) levels of 7.0 percent or above are an indication of poorly controlled diabetes. In 2005, 39.4 percent of new ESRD patients entered treatment with A1c levels greater than or equal to 7.0 percent. This fell slightly by 2008, to 36.9 percent, perhaps indicating increased efforts by clinicians to lower blood glucose levels in patients with kidney disease.

Figure P.15 Mean cholesterol levels at initiation see page 469 for analytical methods. Incident ESRD patients

Total cholesterol levels at the start of ESRD therapy have changed little since 2005, and in 2008 averaged 156.3 mg/dl, well below the action level for treatment of 200 mg/dl or greater. The yearly trend of lower pre-treatment total cholesterol levels coincides with an average reduction in LDL cholesterol of 8.0 mg/dl since 2005.

Trends in hospitalization & mortality  Top

Figure P.16 Change in adjusted all-cause &cause-specific hospitalization rates, by modality (see page 469 for analytical methods. Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: 2005 ESRD patients)

After reaching their highest point in 2005, infectious hospitalization rates in hemodialysis patients showed a decline in the following two years. In 2008, however, they increased again, to a point 45.8 percent above their 1993 level. Vascular access admissions continue to fall, and are 45.1 percent below levels noted in 1993 — perhaps an indication of more outpatient vascular access procedures and interventions. Other encouraging results indicate a 22.9 percent fall in dialysis access admissions since 1999 for peritoneal dialysis patients, and declines of 14.5, 32.2, and 10.7 percent, respectively, in all-cause, cardiovascular, and infectious admissions for transplant patients.

Figure P.17 Adjusted mortality rates in period prevalent patients, by vintage &modality (see page 469 for analytical methods. Period prevalent dialysis patients. Adj: age/gender/race/primary diagnosis; ref: 2005 prevalent dialysis patients)

While adjusted mortality rates in the prevalent dialysis population continue to fall, they remain higher for those with longer time on dialysis (vintage) than rates found in newer patients. In 2008, for example, rates of mortality in patients with five or more years of therapy were 19–20 percent higher than those found in patients with less than five years of treatment.

Figure P.18 Adjusted mortality rates in incident patients, by modality &year of treatment (see page 469 for analytical methods. Incident ESRD patients. Adj: age/gender/race/primary diagnosis; ref: 2005 incident ESRD patients)

Since 2000, first-year mortality rates for ESRD patients have fallen 11.2 percent overall, to 226.5 per 1,000 patient years at risk in 2007. Rates in hemodialysis, peritoneal dialysis, and transplant patients have decreased 9.7, 35.3, and 40.9 percent, respectively, to 240, 141, and 58 per 1,000 patient years at risk.

After declining 3.4 percent in 2006, first-year mortality rates in hemodialysis patients fell 1.8 percent in 2007, while one-year declines of 8 and 13 percent, respectively, were evident for peritoneal dialysis and transplant patients.

Figure P.19 Unadjusted survival in dialysis patients, using matched hemodialysis &peritoneal dialysis populations, by race &diabetic status, 2008 s(see page 469 for analytical methods. Incident dialysis patients, 2007; unadjusted)

Among diabetic patients, unadjusted one-year survival in matched (hemodialysis to peritoneal dialysis) patients is slightly higher in those on hemodialysis, at 0.86 and 0.84, respectively. Survival in patients with no diabetes, in contrast, is similar, at 0.88 and 0.89. By race, white hemodialysis patients with diabetes have a slight survival advantage over their counterparts on peritoneal dialysis, while the opposite is true for African Americans.

Trends in expenditures  Top

Figure P.20 Total PPPM costs during the transition to ESRD, 2007 (see page 469 for analytical methods. Incident Medicare (age 67 &older) &MarketScan (younger than 65) ESRD patients, 2007)

Total per person per month payments during the transition to ESRD rise sharply after the initiation of therapy. For Medicare patients starting therapy in 2007, costs rose from $6,811 in the month before initiation to nearly $15,000 in the month following. In the younger MarketScan population the increase was five-fold, from $6,288 to $31,904.

Figure P.21 PPPM inpatient costs during the transition to ESRD, 2007 (see page 469 for analytical methods. Incident Medicare (age 67 &older) &MarketScan (younger than 65) ESRD patients, 2007)

For Medicare patients beginning ESRD therapy in 2007, PPPM inpatient costs in the month following ESRD initiation were double those in the month prior, while costs for their younger MarketScan counterparts were 6.2 times greater, reaching nearly $23,000. In the following months, however, costs were nearly equal in the two populations.

Figure P.22 Costs of the Medicare &ESRD programs (see page 469 for analytical methods. Total ESRD expenditures are from paid claims (Table K.2) as well as estimated costs for HMO &organ acquisition)

Total Medicare costs rose nearly 11 percent in 2008 — up from a 7 percent rise the previous year — to $454 billion. ESRD costs rose 13.2 percent, to $26.8 billion, and accounted for 5.9 percent of the Medicare budget. (*Starting in 2006, total Medicare costs include Part D; ESRD data here, however, do not include Part D, making ESRD's portion of Medicare costs appear lower than in prior years. Available Part D data is examined at the end of Chapter Eleven.)

Figure P.23 Total Medicare spending on injectables (see page 469 for analytical methods. Period prevalent dialysis patients)

Total Medicare spending for erythropoiesis stimulating agents (ESAS) fell 2.3 percent in 2008, to $1.8 billion. Costs for IV vitamin D hormone, in contrast, increased 12 percent, to $491 million. And spending on IV iron rose 4.8 percent, to $267 million.

Figure P.24 Total ESRD expenditures, by modality (see page 469 for analytical methods. Period prevalent ESRD patients)

Total expenditures for hemodialysis rose 9.3 percent in 2008 — up from a 3.8 percent increase in the prior year — to reach $19.4 billion. After a slight decrease in 2007, costs for peritoneal dialysis rose 8.3 percent in 2008, to $1.04 billion, while those for transplant rose 10.2 percent, to $2.08 billion — 9.2 percent of total ESRD expenditures.

Figure P.25 Total per person per year outpatient expenditures, by race

Total per person per year (PPPY) outpatient expenditures in the prevalent dialysis population show modest variations by race. In 2008, for example, costs were $29,063 for white patients, $30,821 for African Americans, and $28,132 for those of other races.

Figure P.26 Total per person per year inpatient expenditures, by race

Total PPPY costs for inpatient hospitalizations also differed little between white and African American patients, at $27,446 and $27,282, respectively. Costs among patients of other races, however, were 15–16 percent lower, at $23,083 (Figure p.26).

Figure P.27 Total per person per year outpatient expenditures, by modality &race, 2008

When comparing unadjusted 2008 outpatient costs by dialysis modality in unmatched dialysis populations, those for hemodialysis are 26 percent higher than those for peritoneal dialysis. This difference is sustained among hemodialysis patients matched to peritoneal dialysis patients, at 25 percent for whites and 28 percent for African Americans (Figure p.27).

Figure P.28 Total per person per year inpatient expenditures, by modality &race, 2008

Inpatient costs for unmatched hemodialysis populations are also greater than for peritoneal dialysis — 24 percent higher for whites, and 8 percent for African Americans. In matched hemodialysis populations, however, costs are 3 percent greater than those for peritoneal dialysis in whites, but 7 percent lower in African Americans.

Figures P.25–28; see page 469 for analytical methods. Period prevalent dialysis patients (p.25–26); period prevalent dialysis patients, 2008 (p.27–28).