2011 USRDS Annual Data Report
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Healthy People 2020

The Healthy People program, now in its third decade, was established to improve the health of all Americans through the development and evaluation of national health objectives. HP2020, launched on December 2, 2010, is the next step in the continuum of care, with its foundation based on the success of the four previous HP initiatives. One of the major goals of the HP2020 program is to "reduce new cases of chronic kidney disease (CKD) and its complications, disability, death, and economic costs." The development and progression of CKD, which results in reduced quality of life, is a major health concern. The HP2020 CKD objectives are designed to further reduce the long-term burden of kidney disease, improve the quality of life among those with the condition, and eliminate disparities racial or otherwise within the healthcare system. To accomplish these goals, the HP2020 program developed 14 objectives related to CKD, along with targets designed to evaluate the program's success. We provide data for ten of these objectives, plus information on microalbumin testing in non-CKD patients diagnosed with diabetes. Because we use the Medicare 5 percent data to evaluate objectives related to CKD patients not on dialysis, results are limited to those age 65 and older.

In 2009, 11.5 percent of hospital patients with acute kidney injury had a follow-up renal evaluation six months post-discharge, a slight increase from the 10.5 percent seen in 2008, but below the objective's modest goal of 12.4 percent.

Patients with diabetes are at increased risk of CKD. HP2020 has set a goal that 37 percent of persons with diagnosed diabetes obtain an annual urinary microalbumin measurement. The percentage of elderly patients with diabetes receiving this measurement rose from 12.3 in 2000 to 37.3 in 2009, just over the suggested HP2020 target, but less than would be expected from clinical guidelines.

Serum creatinine and microalbumin are important laboratory markers for monitoring the presence and progression of CKD, and lipid tests are important for assessing cardiovascular risk in this population. In 2009, 28.2 percent of patients received these recommended medical evaluations, an increase from 26.7 percent in 2008, and just below the minimal recommended HP2020 target of 28.4 percent.

Patients with either Type 1 or Type 2 diabetes and CKD require more comprehensive laboratory monitoring. The hemoglobin A1c test is used to assess blood glucose control over prolonged periods of time in patients with diabetes, while diabetic retinopathy can be detected through regular eye examinations. One in four elderly diabetic patients receives A1c and eye testing along with serum creatinine, lipid, and microalbumin tests, almost meeting the HP2020 target of 25.4 percent, but a level certainly in need of further improvement.

Use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) is a recommended medical treatment to slow the progression of CKD in patients with diabetes and CKD. In 2008, 73.2 percent of fee-for-service beneficiaries age 65 and older and enrolled in Medicare Part D received these medications, well above the now outdated HP2020 target of 60 percent.

A major HP2020 health objective is targeted at reducing new cases of ESRD, a disease which greatly affects an individual's quality of life, and is an enormous burden on the healthcare system, accounting for approximately 6 percent ($29 billion) of total Medicare costs. In 2009, the rate of new ESRD cases stood at 355 per million population, 11. 5 percent above the new HP2020 target of 318.5, but showing relatively little improvement over the past ten years.

Patients with diabetes are at increased risk of ESRD. The rate of kidney failure due to diabetes fell from 2006 to 2008, but remained similar in 2009, at 154 per million population 10.6 percent above the HP2020 target of 139.2.

In past ADRs the USRDS raised concerns that late referral to a nephrologist prior to ESRD, or the lack of such referral, may contribute to higher morbidity and mortality in the first year of treatment. HP2020 has set a target referral rate of 29.8 percent a conservative goal that should be updated. Rates have increased since 2005, from 25.6 percent to 28.4 percent in 2009.

We have reported on the high use of catheters at the first outpatient hemodialysis session, and on the associated risks. Among patients who have seen a nephrologist for more than a year, fewer than half use a catheter; they also have the greatest likelihood at initiation of having an arteriovenous (AV) fistula or maturing internal access. In an effort to improve vascular access for hemodialysis patients, HP2020 has developed objectives designed to increase the use of AV fistulas. In 2007, 49.6 percent of prevalent hemodialysis patients had an AV fistula as their primary vascular access, just under the 50.6 percent HP2020 target. The proportion of prevalent patients using a catheter as the only mode of vascular access stood at 27.7 percent in 2007, slightly above the target of 26.1 percent. And in 2009, 32 percent of incident hemodialysis patients used an AV fistula or had a maturing fistula for their primary mode of vascular access, still below the HP2020 target of 34.5 percent.

ESRD patients who receive a kidney transplant have lower mortality and hospitalization rates than those on dialysis. First-year all-cause mortality rates in hemodialysis patients, for example, are four times higher than rates among transplant patients. HP2020 has set a goal of 18.8 percent of dialysis patients younger than 70 being wait-listed and/or receiving a deceased donor kidney transplant within one year of ESRD initiation. In 2008, 19.7 percent of patients met this criterion. Additional goals call for 19.7 percent of patients with treated chronic kidney failure to receive a transplant with three years of registration on the waiting list (the number was 16.7 for 2006 patients), and for increasing the number who receive a transplant at the start of ESRD; of 2009 incident patients younger than 70, only 3.2 percent received a preemptive transplant.

Expanded HP2020 objectives call for reductions in total death rates for persons on dialysis, reduced death rates in the first three months of renal replacement therapy, and a reduced cardiovascular death rate in dialysis and transplant patients. The most impressive gain toward achieving an HP2020 objective is the continued decline in cardiovascular mortality rates in prevalent dialysis patients, from 121.5 per 1,000 patient years at risk in 1999 to 82.6 in 2009, just slightly above the HP2020 goal of 81.3. There have also been positive developments in reducing the death rate in dialysis patients in the first three months after initiation of therapy, from 382.6 in 2001 to 353.7 in 2009; this remains far, however, from the target of 319.9.

Additional information on the HP2020 program objectives can be found at www.healthypeople.gov (Many HP2010 targets were set 23 years before release of the goals, & may need to be updated.).

Recommended care among patients with AKI, diabetes, & CKD

HP2020 CKD-3 - Increase the proportion of hospital patients who incurred acute kidney injury who have follow-up renal evaluation in six months post discharge

TARGET: 12.4%

In 2000, just 2.1 percent of patients age 65 and older who were hospitalized for acute kidney injury had a follow-up renal evaluation during the following six months. By 2009 this had increased to 11.5 percent, close to the Healthy People 2020 goal of 12.4 percent.

The lowest rate of follow-up evaluation occurs in the oldest patients, with just 6.2 percent of those age 85 and older receiving such care, compared to 16 percent of those age 6574. By race and ethnicity, rates range from 9.5 percent among American Indians/Alaskan Natives to 17.5 percent in the Asian population.

Table 3 (see page 378 for nalytical methods. Medicare patients age 65 & older (5 percent Medicare sample) with a hospitalized AKI event in given year.)

HP2020 D-12 - Increase the proportion of persons with diagnosed diabetes who obtain an annual urinary microalbumin measurement

TARGET: 37.0%

In the diabetic population age 65 and older, the percentage of patients receiving an annual urinary microalbumin measurement has increased from 12.3 in 2000 to 37.3 in 2009, just over the HP2020 target of 37 percent.

Rates fall with age, from 42 percent among those age 6574 to 24 percent among those 85 and older. By race and ethnicity, rates range from 24 percent among American Indians/Alaskan Natives to nearly 40 percent in the Asian population. Testing may, however, be under-reported in Native Americans, as the Indian Health Service does not report claims through the Medicare system.

Rates vary little by gender, at 38 percent for men and 37 percent for women in 2009.

Table D12 (see page 378 for analytical methods. Medicare patients with diabetes, age 65 & older.)

HP2020 CKD-4 - Increase the proportion of persons with diabetes and chronic kidney disease who receive recommended medical evaluations

In the Medicare CKD population age 65 and older, 28.2 percent received serum creatinine, lipid, and microalbumin testing in 2009 a considerable increase from the level of 6 percent in 2000, and nearly reaching the Healthy People 2020 goal of 28.4 percent. Testing rates by race range from 19 percent among American Indians/Alaskan Natives to 38 percent among Asians. Rates vary little by gender, and by age are lowest among the oldest patients, at 14 percent.

In the diabetic CKD population age 65 and older, 25.2 percent of patients in 2009 received serum creatinine, microalbumin, glycosylated hemoglobin (A1c), and lipid testing, as well as an eye examination; this also nearly reaches the HP2020 goal, set at 28.4 percent. The reported percentage of patients receiving comprehensive diabetic testing is lowest among American Indians/Alaskan Natives, at just 11 percent (care provided by the Indian Health Service, however, is not reported to Medicare), and highest among Asians, at 27 percent. Rates again vary little by gender, and decrease by age.

HP2020 CKD-4.1 - Increase the proportion of persons with chronic kidney disease who receive medical evaluation with serum creatinine, lipids, and microalbumin

TARGET: 28.4%

Table 4 1 (see page 378 for analytical methods. Medicare patients age 65 & older with CKD (4.12) & diabetes (4.2).)

HP2020 CKD-4.2 - Increase the proportion of persons with type 1 or type 2 diabetes and chronic kidney disease who receive medical evaluation with serum creatinine, microalbumin, HbA1c, lipids, and eye examinations

TARGET: 25.4%

Table 4 2 (see page 378 for analytical methods. Medicare patients age 65 & older with CKD (4.12) & diabetes (4.2).)

HP2020 CKD-5 - Increase the proportion of persons with diabetes and chronic kidney disease who receive recommended medical treatment with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers

TARGET: 60.0%

In 2008, 73 percent of patients age 65 and older with diabetes and CKD received recommended medical treatment with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), considerably higher than the Healthy People 2020 target of 60 percent.

Whites are more likely to receive this treatment than blacks/African Americans, at 75 and 65 percent, while 77, 72, and 71 percent, respectively, of American Indians/Alaska Natives, Asians, and Hispanics/Latinos received these medications. Use varies little by gender, at 7980 percent. And by age, 74, 72, and 77 percent, respectively, of patients age 6574, 7584, and 85 and older received ACEIs/ARBs in 2008.

Table 5 (see page 378 for analytical methods. Fee-for-service beneficiaries enrolled in Medicare Part D, age 65 & older.)

HP2020 CKD-8 - Reduce the rate of new cases of end-stage renal disease (ESRD)

TARGET: 318.5 new cases per million population

At 355 per million population, the rate of new cases of ESRD is now 4.1 percent greater than in 2000, and considerably higher than the HP2020 goal of 318.5.

There is substantial variation by race in the rate of new ESRD cases. Among whites and Asians, for example, the rates are 288 and 344, respectively. But the rate among blacks/African Americans is 1,015, and for Native Hawaiians/Pacific Islanders it reaches 2,188. By ethnicity, the rate ranges from 355 among those who are not Hispanic or Latino to 516 among those who are. And the rate of 452 cases per million population among men is 60 percent greater than the rate of 282 among women.

Table 8 (see page 378 for analytical methods. Incident ESRD patients. Adj: overall, age/gender/race; rates by age adjusted for gender/race; rates by gender adjusted for age/race; rates by race/ethnicity adjusted for age/gender. Ref: 2005 patients.)

HP2020 CKD-9 - Reduce kidney failure due to diabetes

The rate of kidney failure due to diabetes has varied little in the last decade, with a range of 153160 cases per million population; the rate of 154 seen in 2009 was the same as that occurring in 2000. The HP2020 goal of 139.2 is met only by whites, by women, and by patients younger than 44.

The highest rate of diabetic ESRD occurs among Native Hawaiians/Pacific Islanders, at 1,363; the rate among blacks/African Americans reaches 435. In 2009, the adjusted rate of kidney failure due to diabetes among diabetic patients was 2,423 per million population, 8.5 percent lower than in 2007 but still above the HP2020 target of 2,374.

HP2020 CKD-9.1 - Reduce kidney failure due to diabetes

TARGET: 139.2 per million population

Table 9 1 (see page 378 for analytical methods. Incident ESRD patients. Adj: age/gender/race; ref: 2005. NHIS 2006-2010 used to estimate diabetes prevalence; SUDDAN used for national estimates (9.2). *Values for cells with ten or fewer patients are suppressed.)

HP2020 CKD-9.2 - Reduce kidney failure due to diabetes among persons with diabetes

TARGET: 2,374.1 per million population

Table 9 2 (see page 378 for analytical methods. Incident ESRD patients. Adj: age/gender/race; ref: 2005. NHIS 2006-2010 used to estimate diabetes prevalence; SUDDAN used for national estimates (9.2). *Values for cells with ten or fewer patients are suppressed.)

HP2020 CKD-10 - Increase the proportion of chronic kidney disease patients receiving care from a nephrologist at least 12 months before the start of renal replacement therapy

TARGET: 29.8%

In 2009, 28.4 percent of patients beginning ESRD therapy on hemodialysis had seen a nephrologist for at least 12 months prior to initiation; this is close to the 29.8 percent goal set by Healthy People 2020, and up slightly from the level of 25.6 percent seen in 2005.

By race, rates of pre-ESRD nephrologist care range from 23.8 percent among Native Hawaiians/Pacific Islanders to nearly 30 percent among whites; rates by ethnicity are lowest among Hispanics/Latinos, at 21.8 percent. There is little difference in pre-ESRD care by gender; by age, however, rates range from 23.3 percent among those age 2044 to 37.6 percent in the pediatric population. Incident hemodialysis patients with a valid Medical Evidence form; nephrologist care determined from Medical Evidence form.

Table 10 (see page 378 for analytical methods. Incident hemodialysis patients with a valid Medical Evidence form; nephrologist care determined from Medical Evidence form.)

HP2020 CKD-11 - Improve vascular access for hemodialysis patients

Identified through the ESRD CPM dataset, use of an arteriovenous (AV) fistula as the primary mode of vascular access in prevalent hemodialysis patients has increased from 27 percent in 1998 to 50 percent in 2007 (the most recent year of available CPM data). By race, use is highest among Asian patients, at 57 percent, and lowest among African Americans, at 42. The most dramatic variations occur by gender, with fistula use at just 40 percent among women, compared to 57 percent among men. Patients age 65 and older have the lowest use by age of fistulas as their primary access, at 47 percent, compared to 55 percent among those age 1844.

Among prevalent hemodialysis patients, use of a catheter as the only mode of vascular access has remained relatively stable since the late 1990s. At 28 percent overall in 2007, use ranges by race from 19 percent among Asian patients to 29 percent among whites. Use remains highest among women, at 32 percent compared to 24 percent for men, and is similar among age groups, with a range of 2730 percent.

Overall, just 32 percent of patients starting hemodialysis therapy in 2009 29 percent of women, and 35 percent of men had a maturing AV fistula or were using one as their primary vascular access. This varies by race from 31 percent among blacks/African Americans to 41 percent among American Indians/Alaskan Natives.

Programs such as HP2020 and the Fistula First Initiative continue to work to increase the use of fistulas and promote early placement prior to initiation of ESRD therapy. Prevalent hemodialysis patients; ESRD CPM data. Vascular access determined from "current access" within CPM data.

HP2020 CKD-11.1 - Increase the proportion of adult hemodialysis patients who use an arteriovenous fistula as the primary mode of vascular access

TARGET: 50.6%

Table 11 1 (see page 379 for analytical methods. Prevalent year represents year of data collection. DNC: data not collected (11.12).)

HP2020 CKD-11.2 - Decrease the proportion of adult hemodialysis patients who use catheters as the only mode of vascular access

TARGET: 26.1%

Table 11 2 (see page 378 for analytical methods. Prevalent year represents year of data collection. DNC: data not collected (11.12).)

HP2020 CKD-11.3 - Increase the proportion of adult hemodialysis patients who use arteriovenous fistulas or have a maturing fistula as the primary mode of vascular access at the start of renal replacement therapy

TARGET: 34.5%

Table 11 3 (see page 379 for analytical methods. Incident hemodialysis patients age 18 & older)

HP2020 CKD-12 - Increase the proportion of dialysis patients wait-listed and/or receiving a deceased donor kidney transplant within one year of end-stage renal disease start (among patients under 70 years of age)

TARGET: 18.8% of dialysis patients

In 2008, the proportion of dialysis patients wait-listed and/or receiving a deceased donor kidney transplant within one year of end-stage renal disease start was 16.9 percent slightly below the HP2020 target of 18.8 percent.

The target is currently met only among Asians, individuals of two or more races, and those age 0-19 and 2044. Those furthest from the target include American Indian/Alaskan Natives and individuals age 65 to less than 70.

Table 12 (see page 379 for analytical methods. Incident ESRD patients younger than 70)

HP2020 CKD-13 - Increase the proportion of patients with treated chronic kidney failure who receive a transplant (among patients under 70 years of age)

The goal of Objective 13.1 is to have 19.7 percent of incident ESRD patients younger than 70 transplanted within three years of initiation; as of 2006, just 16.7 percent of patients meet this goal. Rates are lowest among blacks/African Americans, American Indians/Alaskan Natives, and Native Hawaiians/other Pacific Islanders, at 9.110.9 percent.

After remaining at 6870 percent through the 1990s and mid-2000s, the percentage of pediatric ESRD patients transplanted fell to 64 in 2006. The proportion of patients receiving a preemptive transplant was 3.2 percent in 2006.

HP2020 CKD-13.1 - Increase the proportion of patients receiving a kidney transplant within three years of end-stage renal disease

TARGET: 19.7%

Table 13 1 (see page 379 for analytical methods. Incident ESRD patients younger than 70)

HP2020 CKD-13.2 - Increase the proportion of patients who receive a preemptive transplant at the start of ESRD

Table 13 2 (see page 379 for analytical methods. Incident ESRD patients younger than 70)

HP2020 CKD-14 - Reduce deaths in persons with end-stage renal disease

Since 1998, the overall death rate among prevalent patients on dialysis has fallen 14 percent, from 232 deaths per 1,000 patient years to just under 200 in 2009 approaching the HP2020 target of 190.8. By race, the rate ranges from 146 among Asians to 235 among whites; by ethnicity, it is 149 among Hispanics and Latinos and 209 among those not in either group. The mortality rate has fallen for all groups since 1998; for Hispanics and Latinos, and for those age 044, the rate has declined more than 20 percent.

The rate of mortality in the first three months of ESRD has fallen from its peak of 388 in 2003, but, at 354 in 2009, remains a distance from the HP2020 target of 319.9 deaths per 1,000 patient years at risk. The highest rate by race occurs among whites, at 412 compared to 158 among American Indians/Alaskan Natives, and 207212 among Asians and Native Hawaiians/Pacific Islanders.

At 82.6 deaths per 1,000 patient years in 2009, the rate of cardiovascular mortality among dialysis patients is close to the HP2020 goal of 81.3. The rate has fallen 31 percent overall since 1998, and 35 percent for whites and for patients age 65 and older. By race, the rate is highest, once again, among whites, at 95 compared to 6770 among blacks/African Americans, American Indians/Alaskan Natives, and Asians.

For patients with a functioning transplant, the overall rate of mortality in 2009 rose slightly from the previous year, to 32.6 deaths per 1,000 patient years a bit above the HP2020 goal of 29.4. By race, mortality ranges from 17.9 among Asians to 59.4 among American Indians/Alaskan Natives.

The rate of cardiovascular mortality among transplant patients has fallen 37 percent since 1998, but, at 5.4 deaths per 1,000 patient years, still remains above the HP2020 target of 4.5. The rate is just 1.7 among Asian patients, but 9.4 among American Indians/Alaskan Natives.

HP2020 CKD-14.1 - Reduce the total death rate for persons on dialysis

TARGET: 190.8 deaths per 1,000 patient years

Table 14 1 (see page 379 for analytical methods. Period prevalent dialysis patients; unadjusted)

HP2020 CKD-14.2 - Reduce the death rate in dialysis patients within the first three months of initiation of renal replacement therapy

TARGET: 319.9 deaths per 1,000 patient years at risk

Table 14 2 (see page 379 for analytical methods. Incident dialysis patients; unadjusted)

HP2020 CKD-14.3 - Reduce the cardiovascular death rate for persons on dialysis

TARGET: 81.3 deaths per 1,000 patient years at risk

Table 14 3 (see page 379 for analytical methods. Period prevalent dialysis patients; unadjusted)

HP2020 CKD-14.4 - Reduce the total death rate for persons with a functioning kidney transplant

TARGET: 29.4 deaths per 1,000 patient years at risk

Table 14 4 (see page 379 for analytical methods. Period prevalent transplant patients; unadjusted)

HP2020 CKD-14.5 - Reduce the cardiovascular death rate in persons with a functioning transplant

TARGET: 4.5 cardiovascular deaths per 1,000 patient years at risk

Table 14 5 (see page 379 for analytical methods. Period prevalent transplant patients; unadjusted)