2011 USRDS Annual Data Report
View
Download
Chapter (PDF)*
Chapter (all slides)*
*corresponding data in Excel included
Search This Page
Search All
Translate

Figure List
Figure P1 Distribution of general (fee-for-service) Medicare patients & costs for CKD, CHF, diabetes, & ESRD, 1999 & 2009
Figure P2 Counts of new & returning dialysis patients
Figure P3 Patient counts, by modality
Figure 1.3 Adjusted incident rates of ESRD & annual percent change (page 186)
Figure 1.6 Incident counts & adjusted rates of ESRD, by race (page 186)
Figure 1.9 Adjusted incident rates of ESRD & annual percent change (page 186)
Figure 1.12 Prevalent counts & adjusted rates of ESRD, by race (page 188)
Figure 1.15 Incident patient distribution, by first modality & payor (page 190)
Figure 1.16 Prevalent patient distribution, by modality & payor (page 191)
Figure 1.19 Access use at first outpatient hemodialysis, by pre-ESRD nephrology care, 2009 (page 192)
Figure 1.20 Mean hemoglobin at initiation, by pre-ESRD ESA treatment (page 193)
Figure 2.2 Patient distribution, by mean monthly hemoglobin (g/dl; page 198)
Figure 2.4 Mean monthly hemoglobin after initiation, by year (page 198)
Figure 2.15 Cumulative number of Part D medications in ESRD patients, by race/ethnicity & low income subsidy (LIS) status, 2008 (page 202)
Figure 3.1 Change in adjusted all-cause & cause-specific hospitalization rates, by modality (page 207)
Figure 3.4 Cause-specific rehospitalization rates 30 days post live hospital discharge, by age (page 210)
Figure 3.7 Adj. 1st-year hosp adm rates & days (from day 90) in matched HD & PD dialysis pts
Figure 5.1 Adjusted all-cause mortality rates, by modality & year of treatment (page 227)
Figure 5.6 Adjusted all-cause mortality rates in the ESRD & general populations, by age & gender, 2009 (page 231)
Figure 6.1 Sources of prescription drug coverage in Medicare enrollees, 2008 (page 235)
Figure 6.15 Per person per year Medicare & out-of-pocket costs for Part D enrollees, 2008 (page 240)
Figure 6.20 Part D non-LIS enrollees who reach each coverage phase, 2008 (page 242)
Figure 7.1 Trends in transplantation: unadjusted rates, wait list, & total transplants, patients age 20 & older (page 249)
Figure 7.4 Outcomes for wait-listed adult patients within three years of listing, by blood type (page 250)
Figure 7.12 Deceased donor transplants, by age, gender, race, & primary diagnosis (page 252)
Figure 7.14 Living donor transplants, by age, gender, race, & primary diagnosis (page 252)
Figure 7.22 Primary diagnoses of cardiac & infectious hospitalizations in the first & second years post-transplant (page 254)
Figure 7.32 Follow-up care & screening in the first 12 months post-transplant, by age (page 255)
Figure 8.1 Incident & prevalent counts & adjusted rates in the pediatric ESRD population, by primary diagnosis (page 259)
Figure 8.3 Hospital admissions for pneumonia, by modality, age, & race, 2006–2009 (page 262)
Figure 8.10 Adjusted all-cause mortality in the first months of ESRD, by age & modality, 2001–2008 (page 265)
Figure 10.1 Distribution of patients, by unit affiliation, 2009 (page 273)
Figure 10.4 Dialysis unit distribution, by affiliation & time managed (time under chain management), 2009 (page 274)
Figure 10.5 Distribution of prevalent EPO-treated dialysis patients, by hemoglobin level & unit affiliation, 2009 (page 275)
Figure 10.18 All-cause standardized hospitalization & mortality ratios, by unit affiliation, 2009 (page 278)
Figure 10.19 All-cause standardized hospitalization & mortality ratios in large dialysis organizations, 2009 (page 278)
Figure 11.6 Total Medicare ESRD expenditures, by modality (page 284)
Figure 11.7 Total Medicare ESRD expenditures per person per year, by modality (page 284)
Figure 11.9 Total Medicare spending for injectables (page 284)
Figure 11.19 Total PPPY outpatient expenditures, by dialysis modality & race, 2009 (page 287
Figure 11.21 PPPY expenditures for ESAs, by dialysis modality & race, 2009 (page 287)
Figure 11.22 PPPY expenditures for IV vitamin D, by dialysis modality & race, 2009 (page 287)
Figure 11.23 PPPY expenditures for IV iron, by dialysis modality & race, 2009 (page 287)
Table P.A1 Summary statistics on reported ESRD therapy in the United States, by age, race, ethnicity, gender, & primary diagnosis, 2009
Table P.A2 Wait-list for kidney & kidney/pancreas transplants
Table P.A3 Medicare & non-Medicare spending*
Table 2.C Access events & complications in prevalent dialysis patients (ESRD CPM data; rate per patient year; page 201)
Table 4.B Cardiovascular disease & pharmacological interventions (row percent), by diagnosis and modality, 2008 (page 221)
Table 6.C Top 25 drugs used by Part D-enrolled dialysis patients, by frequency & net cost, 2008 (page 244)
Table 6.D Top 25 drugs used by Part D-enrolled transplant patients, by frequency & net cost, 2008 (page 245)
Table 11.A Top 25 Part D prescription drugs used in the ESRD population, by frequency & net cost, 2008 (page 288)

Prιcis

An Introduction to End-Stage Renal Disease in the United States

Sections this chapter: 

Introduction

Peritoneal dialysis now accounts for 6–7 percent of the incident and prevalent dialysis populations, a level far lower than the 12–18 percent in the 1980s and 1990s; there are signs, however, that use of this therapy is growing. The number of kidney transplants reached 17,736 in 2009, while the prevalent transplant population increased 4.2 percent, to 172,553, despite continued growth in the number of patients on the transplant wait list. The median time on the kidney-only and kidney-pancreas wait lists was 1.7 years.

In the rest of this Prιcis we highlight data from Volume Two. We show, for instance, that rates of new ESRD cases remain quite stable, at 355 per million population in 2009. While ESRD due to diabetes has also been stable over the last decade, at a rate of 154, ESRD caused by hypertension has grown 10 percent. The prevalence of ESRD continues to grow at a rate of 2 percent per year, reaching 1,738 in 2009.

Patients who see a nephrologist for more than 12 months before starting dialysis are the most likely to use a fistula or internal graft at the first outpatient dialysis treatment. Since nephrologists are central to discussions with patients and families about ESRD treatment options, greater pre-ESRD referral would help ensure increased use of fistulas, which are associated with the lowest rates of adverse events.

The treatment of anemia has changed during the last four years, after changes in product labeling from the FDA and in payment structures from CMS. Hemoglobin levels at the initiation of dialysis have fallen below 10 g/dl, a level not seen since December, 2000, while the percentage of patients using an erythropoiesis stimulating agent (ESA) prior to initiation has also fallen — to 22 percent, a level not seen since April, 1996. Hemoglobin levels at six months following the start of ESRD therapy are now lower than in 2001, yet the ESA dose is substantially higher. Hemoglobin levels in the prevalent dialysis population have decreased as well.

Hospitalizations continue to be an area of concern, with admissions for infection in hemodialysis patients 43 percent higher than in 1993. New data on rehospitalizations show that rates are twice as high for ESRD patients as in the general Medicare population. Mortality rates continue to improve, though more slowly for the first year of treatment than for the years following. Rates for ESRD patients, however, are 2.0–2.5 times greater than for general Medicare patients with cancer, diabetes, congestive heart failure, or CVA/TIA.

This year we present new data on the Medicare Part D prescription drug benefit, which started in 2006. ESRD and non-ESRD CKD patients have higher Part D coverage with the low income subsidy than do general Medicare patients and, not surprisingly, out-of-pocket expenditures are greatest for ESRD patients, at nearly $6,000 per year compared to $1,985 in the general Medicare population and $3,550 for those with a diagnosis of CKD.

The kidney transplant wait list continues to grow, reaching 80,848 in 2009; 17,736 transplants were performed that year. Living donor donation rates appear to be rebounding, while donations from deceased donors have been stable. Risk factor monitoring among transplant patients has improved, yet rates of influenza vaccinations are still relatively low.

Highlighted data on pediatric ESRD patients show that the number with cystic kidney disease has increased, while there are fewer patients with glomerular disease. Rates of hospitalization for pneumonia are greatest overall in patients younger than 10, and, in the hemodialysis population, mortality is greatest in the first months of therapy.

Dialysis providers continue to consolidate, with Fresenius Medical Care announcing the purchase of additional units in July, 2011; the company thus maintains its position as the largest provider of dialysis care in the United States. Dialysis Clinic, Inc. continues to have the lowest standardized hospitalization and mortality ratios among the large providers, while, among the smaller providers, hospital-based units have the highest standardized mortality ratios.

We conclude the Prιcis with data on the costs of ESRD patient care, which rose very little in 2009. Costs per person per year remain highest for hemodialysis patients, at $82,285, compared to $61,588 and $29,983 for peritoneal dialysis and transplant patients.

Figure p1 Distribution of general (fee-for-service) Medicare patients & costs for CKD, CHF, diabetes, & ESRD, 1999 & 2009 (see page 378 for analytical methods. Period prevalent general (fee-for-service) Medicare patients. Diabetes, CKD, & congestive heart failure determined from claims, 1998–-1999 & 2008-–2009; costs are for calendar years 1999 & 2009.)

Trends in Patient Counts & Spending Top

Table pa 1 Summary statistics on reported ESRD therapy in the United States, by age, race, ethnicity, gender, & primary diagnosis, 2009 (see page 378 for analytical methods. Dialisys & transplant patients, 2009)
Table pa 2 Wait-list for kidney & kidney/pancreas transplants (see page 378 for analytical methods. Dialisys & transplant patients, 2009)
Table pa 3 Medicare & non-Medicare spending* (see page 378 for analytical methods. Dialisys & transplant patients, 2009)

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; 57 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.

In 2009, 116,395 new dialysis and transplant patients initiated ESRD therapy, for an adjusted rate per million population of 355. More than 571,000 patients were receiving treatment on December 31, 2009, for an adjusted rate of 1,738 per million population. Nearly 399,000 of these patients were being treated with dialysis, while 172,553 had a functioning graft; 90,118 ESRD patients died during the year. A total of 17,736 transplants were performed during 2009, including 6,388 from living donors. More than 34,000 patients were added to the transplant wait list, 85,539 were on the kidney-alone and kidney/pancreas wait lists at the end of 2009, and the median time on the list (for pediatric and adult patients combined) was 1.7 years.

With Medicare spending for ESRD at $29 billion, and non-Medicare spending at $13.5 billion, total ESRD costs in 2009 reached $42.5 billion. Medicare costs per person per year were more than $70,000 overall, ranging from $29,983 for transplant patients to $82,285 for those receiving hemodialysis therapy.

Figure p2 Counts of new & returning dialysis patients (see page 378 for analytical methods. CMS Annual Facility Survey.)

The number of new dialysis patients rose 3.5 percent in 2009 — up from a 1.2 percent growth in 2008 — to 112,782. Just over 5,600 patients with graft failure returned to dialysis from transplant, a one-year increase of 2.7 percent. The number of patients restarting dialysis increased 6.6 percent, to 3,492. Overall, the CMS Annual Facility Survey showed 121,880 patients starting or restarting dialysis in 2009, up 3.6 percent from 2008.

Figure p3 Patient counts, by modality (Incident & December 31 point prevalent ESRD patients.)

The size of the prevalent dialysis population increased 4 percent in 2009, reaching 398,861, and is now 40 percent larger than in 2000. The size of the transplant population rose 4.2 percent, to reach 172,553 patients, while the number of incident patients rose 3.3 percent, to 116,395. These data suggest longer lifespans for prevalent patients, ultimately influencing the steady growth of this population and the annual expenditures these patients incur.

Incidence, Prevalence, Modality, pre-ESRD Care Top

Figure 1.3 Adjusted incident rates of ESRD & annual percent change (see page 379 for analytical methods. Incident ESRD patients. Adj: age/gender/race;ref:2005 ESRD patients.)

After a 0.9 percent decline in 2008, the adjusted incident rate of end-stage renal disease rose 1.1 percent in 2009, to 355 per million population. Prior to the slight decline in 2007 and 2008, the rate of new ESRD cases had increased or remained stable each year since 1996.

Figure 1.9 Adjusted prevalent rates of ESRD & annual percent change (see page 379 for analytical methods. December 31 point prevalent ESRD patients. Adj: age/gender/race; ref: 2005 ESRD patients.)

The adjusted rate of prevalent cases of ESRD rose 2.1 percent in 2009 — up slightly from the 1.9 percent growth in 2008 — to 1,738 per million population. This rate is nearly 23 percent higher than that seen in 2000. The annual rate of increase has remained between 1.9 and 2.4 percent since 2003.

Figure 1.6 Incident counts & adjusted rates of ESRD, by race (see page 379 for analytical methods. Incident ESRD patients. Adj: age/gender/race;ref:2005 ESRD patients.)
Figure 1.12 Prevalent counts & adjusted rates of ESRD, by race (see page 379 for analytical methods. December 31 point prevalent ESRD patients. Adj: age/gender/race; ref: 2005 ESRD patients.)

By race, rates for African Americans and Native Americans in 2009 were 976 and 523 per million population, respectively — 3.5 and 1.9 times greater than the rate of 277 found among whites. Since 2000, the rate of new ESRD cases has grown 7.2 percent among whites and 6.4 percent among Asians, while remaining stable in the African American population.

By race, rates of prevalent ESRD remain greatest in the African American and Native American populations, at 5,284 and 2,735 per million population in 2009, compared to 1,279 and 2,101 among whites and Asians. The rate among Hispanics reached 2,538 in 2009, 1.5 times greater than that in the non-Hispanic population.

Figure 1.15 Incident patient distribution, by first modality & payor (see page 379 for analytical methods. Incident ESRD patients.)

Forty-five percent of new hemodialysis patients are covered solely by Medicare, 13.5 percent have dual Medicare/Medicaid coverage, and 15.3 percent are covered by a Medicare HMO provider. Medicare covers 41 and 22 percent of new peritoneal dialysis and transplant patients, while 9.8 and 4.2 percent are dually-enrolled, and 9.8 and 3.5 percent have HMO coverage.

Figure 1.16 Prevalent patient distribution, by modality & payor (see page 379 for analytical methods. December 31 point prevalent ESRD patients.)

Nine in ten prevalent hemodialysis patients had some type of Medicare coverage in 2009, with 40 percent covered solely by Medicare, and 32 percent under Medicare/Medicaid. In the transplant population, in contrast, just 32 percent are covered solely by Medicare. Transplant patients younger than 65 and not disabled lose their entitlement after three years with a functioning graft.

Figure 1.19 Access use at first outpatient hemodialysis, by pre-ESRD nephrology care, 2009 (see page 379 for analytical methods. Incident hemodialysis patients, 2009.)

Among hemodialysis patients who have seen a nephrologist for more than a year prior to starting ESRD therapy, less than half initiate treatment using a catheter; these patients have the greatest likelihood at initiation of having an arteriovenous fistula (AV) or maturing fistula, at 30 and 19.2 percent, respectively. Patients with no pre-ESRD nephrology care most frequently start treatment with a catheter, at 82 percent.

Figure 1.20 Mean hemoglobin at initiation, by pre-ESRD ESA treatment (see page 379 for analytical methods. Incident ESRD patients.)

In the incident ESRD population, the mean hemoglobin at initiation has continued to fall from its peak in 2006, reaching 9.85 g/dl overall, 9.94 for patients receiving pre-ESRD treatment with an erythropoiesis stimulating agent (ESA), and 9.81 for patients without ESA treatment; 22 percent of new patients at the end of 2009 had received a pre-ESRD ESA.

Patient Care | Hospitalization Top

Figure 2.2 Patient distribution, by mean monthly hemoglobin (g/dl; page 198) (see page 381 for analytical methods. Period prevalent dialysis patients.)

During 2009, 40 percent of prevalent dialysis patients had a mean monthly hemoglobin within the previous KDOQI target of 11–12 g/dl. The mean EPO dose per week averaged 18,206 units, down from a peak of nearly 20,000 during 2004–-2007, when a greater proportion of patients had hemoglobins nearing 12 g/dl.

Figure 2.4 Mean monthly hemoglobin after initiation, by year (see page 381 for analytical methods. Incident dialysis patients.)

When compared to 2005 incident patients, those starting dialysis in 2009 did so with slightly lower hemoglobins one month post-initiation, at 10.6 and 10.3 g/dl, respectively. At six months, the mean monthly hemoglobin in 2009 patients was within the KDOQI target of 11–12 g/dl, at 11.5.

Figure 2.15 Cumulative number of Part D medications in ESRD patients, by race/ethnicity & low income subsidy (LIS) status, 2008 (see page 381 for analytical methods. Point prevalent Medicare enrollees alive on January 1, with Part D enrollment, October 1 - –December 31, 2007 & 2008.)

Dialysis and transplant patients received an average of 13.6 and 12.4 distinct medications, respectively, through their Part D plan in 2008. White dialysis patients received the greatest number, at 14.1, and LIS patients received more than did their non-LIS counterparts.

Table 2c Access events & complications in prevalent dialysis patients (ESRD CPM data; rate per patient year; page 201) (see page 381 for analytical methods. Catheter, fistula, graft: prevalent hemodialysis patients age 20 & older, ESRD CPM & claims data. Peritoneal dialysis device: prevalent peritoneal dialysis patients age 20 & older.)

Among prevalent hemodialysis patients in 2007 (the most recent year of available CPM data), the most common access-related event was replacement with a catheter, at 0.86 events per year for patients already using a catheter, and 0.12 and 0.24, respectively, for those with an arteriovenous (AV) fistula or graft. Sepsis is more common than infection, regardless of access type. In 2007, for example, the rate of sepsis among catheter patients was 1.6 times higher than rates of infection; among AV fistula patients, the rate was three times higher.

In peritoneal dialysis patients, the rate of access replacement with another peritoneal access has decreased by a factor of two since 1998, while rates of replacement with an internal hemodialysis access or hemodialysis catheter have each fallen, but to a lesser degree.

Figure 3.1 Change in adjusted all-cause & cause-specific hospitalization rates, by modality (see page 382 for analytical methods. Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2005.)
Figure 3.4 Cause-specific rehospitalization rates 30 days post live hospital discharge, by age (see page 382 for analytical methods. Period prevalent hemodialysis patients age 20 & older, 2009; unadjusted. Includes live hospital discharges from January 1 to December 31, 2009.)
Figure 3.7 Adj. 1st-year hosp adm rates & days (from day 90) in matched HD & PD dialysis pts (see page 382 for analytical methods. Incident hemodialysis & peritoneal dialysis patients age 20 & older. Adj: age/gender/race/primary diagnosis; ref: 2005 incident hemodialysis & peritoneal dialysis patients. Rates show first-year admissions from day 90 to one year after initiation.)

The rate of admissions for infection in the ESRD population is now 43 percent greater than in 1993, while the rate for vascular access procedures has fallen 48 percent. Hospitals have made significant progress in using less costly settings to address vascular access interventions, but equivalent progress in lowering the rate of infectious complications is lacking. In the peritoneal dialysis population there has been little change in the overall rate of hospitalization for infection. Admissions for peritonitis, in contrast, have fallen.

The percent of patients who are rehospitalized and alive following an all-cause index hospitalization was 33 percent overall in 2009, and highest in patients age 20–44, at 41.5 percent. For cardiovascular, infectious, or vascular access hospitalizations, the percentages rehospitalized and discharged alive were again highest in the younger cohort, at 45, 35, and 33 percent, respectively.

In hemodialysis matched to peritoneal dialysis populations, first-year hospitalization rates (from day 90) in 2008 were 26 percent higher for hemodialysis patients than for peritoneal patients, at 1.9 and 1.5, respectively, per patient year. Hospital days per patient year followed suit, and were 30 percent higher in the matched hemodialysis population, at 12.4 compared to 9.5 days in peritoneal dialysis patients.

Cardiovascular Disease in Patients with ESRD | Mortality Top

Table 4b Cardiovascular disease & pharmacological interventions (row percent), by diagnosis and modality, 2008 (see page 385 for analytical methods. January 1 point prevalent ESRD patients with a first cardiovascular diagnosis or procedure between January 1 & November 30, 2008.)

Despite two negative statin trials in dialysis patients (4D and AURORA) there has been no apparent dampening in enthusiasm for the use of these agents. In 2008, statins were used in 57 percent of hemodialysis patients with AMI, and 64 and 70 percent of those undergoing PCI and CABG. Recent publication of results from the SHARP trial might be expected to further increase statin use across the spectrum of CKD.

Only 2–4 percent of patients with PAD receive cilostazol, an approved therapy; 17–24 percent receive clopidogrel, and 39–54 percent statin therapy. As noted in a recent KDIGO Controversies Conference Summary, PAD should be a special cardiovascular target for further improvement in all stages of kidney disease.

Figure 5.1 Adjusted all-cause mortality rates, by modality & year of treatment (see page 386 for analytical methods. Incident ESRD patients. Adj: age/gender/race/primary diagnosis; ref: incident ESRD patients, 2005.)

Between 1993 and 2003 there was little improvement in first-year death rates in the ESRD population. Between 2004 and 2008, however, these rates fell more than 10 percent. And over similar intervals, second- to fifth-year death rates decreased 12–14 percent. Month-by-month mortality rates in the first year of hemodialysis have shown similar improvements, overall and for mortality due to cardiovascular disease and infection. Mortality due to other causes, in contrast, has increased since 1998, a finding which requires further investigation. Still striking are the high rates of all-cause mortality in the early months of therapy.

Figure 5.6 Adjusted all-cause mortality rates in the ESRD & general populations, by age & gender, 2009 (see page 386 for analytical methods. January 1 point prevalent ESRD & general Medicare patients age 65 & older. Adj: age/gender/race/comorbidity; ref: 2009 ESRD patients.)

Adjusted rates of mortality in the prevalent ESRD population age 65 and older rise, not surprisingly, by age, are commonly greater in men than in women, and are 1.8–2.6 times greater for dialysis patients than for those with a transplant. In the transplant population, rates among patients age 65–-79 are lower than rates of mortality among patients with cancer in the general Medicare population.

Prescription Drug Coverage Top

Figure 6.1 Sources of prescription drug coverage in Medicare enrollees, 2008 (see page 386 for analytical methods. Point prevalent Medicare enrollees alive on January 1, 2008.)

Fifty-eight to 59 percent of elderly CKD and general Medicare patients were enrolled in Part D in 2008, compared to 72, 61, and 53 percent of hemodialysis, peritoneal dialysis, and kidney transplant patients.

Figure 6.15 Per person per year Medicare & out-of-pocket costs for Part D enrollees, 2008 (see page 387 for analytical methods. All patients enrolled in Part D.)

At $5,536 and $6,183, the per person per year (PPPY) total cost of medications covered by Medicare Part D is 2.3–2.5 times higher, respectively, in dialysis and transplant patients than in the general Medicare population. Proportional to total Part D costs, however, out-of-pocket costs are lower in ESRD patients, representing 8–10 percent of PPPY costs, compared to 19 percent in the general Medicare population.

Figure 6.20 Part D non-LIS enrollees who reach each coverage phase, 2008 (page 242) (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, excluding those in employer-sponsored & national PACE Part D plans.)

In 2008, 42–48 percent of CKD, hemodialysis, peritoneal dialysis, and transplant patients reached the coverage gap, and 8–13 percent reached catastrophic coverage, compared to 23 and 3 percent, respectively, in the general Medicare population.

Table 6.c Top 25 drugs used by Part D-enrolled dialysis patients, by frequency & net cost, 2008 (see page 388 for analytical methods. Part D claims for all dialysis patients, 2008.)

In 2008, cardiovascular and gastrointestinal medications, phosphate binders, insulin, and cinacalcet were the predominant drugs used in the dialysis population. Metoprolol, a beta blocker, continued to be the most frequently used drug, reflecting the extensive use of beta blockers for CHF and atrial fibrillation, and after myocardial infarction, PCI, and CABG. Sevelamer HCl was the predominant phosphate binder, and, at $255 million, topped the list in terms of net Part D costs, with cinacalcet coming in at $213 million. Costs for calcium acetate, insulin therapies, and lanthanum carbonate costs were each close to $50 million.

Sevelamer carbonate represented 5.3 percent of sevelamer use in 2008. Together, costs for sevelamer hydrochloride and carbonate reached $270 million — about 21 percent of the $1.26 billion in Part D costs in the dialysis population.

Table 6d Top 25 drugs used by Part D-enrolled transplant patients, by frequency & net cost, 2008 (page 245) (see page 388 for analytical methods. Part D claims for all transplant patients, 2008.)

Among transplant patients, prednisone (a generic immunosuppressant) was the most frequently used medication in 2008, followed by metoprolol and insulin. Trimethoprim-sulfamethoxazole, used for prophylaxis against pneumocystis carinii pneumonia, was sixth on the list. Except for tacrolimus, no trade name immunosuppressant made the top 25 list in terms of frequency, not surprising given that most are covered under Medicare Part B. Valganciclovir, which is used for prophylaxis against cytomegalovirus and does not have an available generic, topped the list by cost, though not by frequency. The immunosuppressants tacrolimus, mycophenolate mofetil, sirolimus, cyclosporine, and mycophenolate sodium do appear on the list by cost, implying that their costs are relatively higher than the frequency of their use.

Transplantation Top

Figure 7.1 Trends in transplantation: unadjusted rates, wait list, & total transplants, patients age 20 & older (see page 388 for analytical methods. Unadjusted incident & transplant rates: limited to ESRD patients age 20 & older, thus yielding a computed incident rate higher than the overall rate presented elsewhere in the ADR. Wait list counts: patients age 20 & older listed for a kidney or kidney-pancreas transplant on December 31 of each year. Wait time: patients age 20 & older entering wait list in the given year. Transplant counts: patients age 20 & older as known to the USRDS.)

In 2009, the most recent year of available data, 17,736 kidney transplants were performed in the United States — 323 more than in the previous year, ending a two-year decline in the annual number of transplants performed. There were 420 more living donor transplants performed in 2009 compared with 2008, an increase of 7 percent, compared with a 1 percent decline in deceased donor transplants. The number of living-unrelated transplants rose 11 percent, compared with a 3 percent increase in living-related transplants.

Figure 7.4 Outcomes for wait-listed adult patients within three years of listing, by blood type (see page 388 for analytical methods. Pts age 18 & older listed for a first-time kidney or kidney-pancreas transplant.)

The percentage of adult patients receiving a deceased donor transplant within three years of listing has fallen considerably since 1991, and varies by blood type. It continues to be highest for those of blood type AB — at 50 percent for patients listed in 2006 — and lowest for those of type O or B. The percentage receiving a living donor transplant has been rising, and varies little by blood type.

Figure 7.12 Deceased donor transplants, by age, gender, race, & primary diagnosis (see page 388 for analytical methods. Pts age 18 & older. Includes kidney-alone & kidney-pancreas transplants.)

Since 2000, the number of deceased donor transplants among patients age 65 and older has more than doubled, to 1,911, and there has been an increase of 47 percent among patients age 50-–64. Among those age 18–34, in contrast, transplants have fallen 24 percent, to 1,166. Among African Americans and Asians, the number of transplants has grown 45 and 92 percent, respectively.

Figure 7.14 Living donor transplants, by age, gender, race, & primary diagnosis (see page 388 for analytical methods. Patients age 18 & older. Includes kidney-alone & kidney-pancreas transplants.)

Among patients younger than 50, the number of living donor transplants has fallen 3–7 percent since 2000. For those age 50–64, in contrast, the number is now 41 percent higher, and for patients age 65 and older it has more than doubled. While living donor transplants among whites and African Americans have increased just 9-–10 percent in this period, they have tripled among Asians.

Figure 7.22 Primary diagnoses of cardiac & infectious hospitalizations in the first & second years post-transplant (see page 389 for analytical methods. First-time, kidney-only tx recipients, age 18 & older, with Medicare primary payor coverage, transplanted in 2005–-2009.)

In the first and second years after transplant, 22–23 percent of cardiovascular hospitalizations are due to CHF. Hospitalizations for coronary atherosclerosis and CVA/TIA rise from 6.2 and 5.0 percent in year one to 12 and 10 percent in year two. UTI, septicemia, and pneumonia are the most common diagnoses among transplant patients admitted for infection.

Figure 7.32 Follow-up care & screening in the first 12 months post-transplant, by age (see page 389 for analytical methods. Patients age 18 & older receiving a first-time, kidney-only transplant.)

In 2008, 24 percent of recipients age 18-–49 received an influenza vaccination in the 12 months post-transplant, compared to 32 percent of those 60-–64, and 45 percent of those age 65 and older. Lipid screening rates range from 84 percent in the youngest adults to 93 percent in those age 60-–64. Since 2003, nearly all recipients have received a CBC test in the year after transplant.

Pediatric ESRD | ESRD Providers Top

Figure 8.1 Incident & prevalent counts & adjusted rates in the pediatric ESRD population, by primary diagnosis (see page 390 for analytical methods. ESRD patients age 0–-19. Adj: age/gender/race; ref: 2005 ESRD patients.)

The overall incidence of ESRD in the pediatric population rose slowly between 1984 and 1990, a period when expertise in pediatric dialysis and transplantation was growing. Consistent with findings in the adult population, incidence due to glomerular disease has been declining gradually since 1990, and the number of patients has remained remarkably consistent. Both the incidence of ESRD due to cystic kidney disease and the number of children with this diagnosis, however, have been rising, a finding that merits investigation to determine whether the disease is truly increasing or if earlier recognition and treatment have led to more children coming to ESRD.

Figure 8.3 Hospital admissions for pneumonia, by modality, age, & race, 2006-–2009 (page 262) (see page 390 for analytical methods. Period prevalent ESRD patients age 0–-19, 2006–-2009; unadjusted.)

Overall rates of admission for pneumonia are greatest in patients age 0–4, at 91 per 1,000 patient years at risk. By modality, pneumonia admissions for transplant patients age 0–4 reach 96, compared to 29 for those of the same age on hemodialysis, and 84 for those treated with peritoneal dialysis.

Figure 8.10 Adjusted all-cause mortality in the first months of ESRD, by age & modality, 2001–-2008 (see page 390 for analytical methods. Incident pts age 0–-19, 2001–2008 (8.10–12) & 2000–2004 (8.13). Adj: age/gender/race/primary diagnosis. Ref: incident ESRD pts age 0-–19, 2004-–2005.)

In the first month of therapy, mortality in patients age 0–4 reaches 153 deaths per 1,000 patient years at risk, compared to 24 for ages 5–9, and 5.3 for ages 10–14. Overall, all-cause mortality in pediatric patients reaches 48 in the first month after initiation, peaks at 57 in the next two months, then falls to 28 in months 9–<12.

Figure 10.1 Distribution of patients, by unit affiliation, 2009 (see page 391 for analytical methods. CMS Annual Facility Survey, 2009.)

At the end of 2009, 122,216 prevalent patients were being treated by Fresenius in 1,742 units, 110,299 were receiving care in one of DaVita's 1,556 units, and 13,023 patients were being treated by Dialysis Clinic Inc. (DCI), with 213 units. These three major providers manage the majority of the 5,760 dialysis units across the United States. Small dialysis organizations (SDOs), comprising 20–199 units, treated 44,793 patients in 605 units, while independent and hospital-based providers treated 58,090 and 38,596 patients in 848 and 796 units, respectively.

Figure 10.4 Dialysis unit distribution, by affiliation & time managed (time under chain management), 2009 (see page 391 for analytical methods. CMS Annual Facility Survey, 1988–-2009.)

The percentage of units remaining under consistent ownership for five or more years was nearly 60 in 2009. Major unit purchases by DaVita and Fresenius in 2005 and 2006 reduced the proportions of their units with five or more years of ownership to 51 and 60 percent, down from approximately 70 percent in 2004 (2010 Annual Data Report). The most consistent ownership remains that of Dialysis Clinic, Inc., with nearly 90 percent of units in 2009 owned for five years or longer.

Figure 10.5 Distribution of prevalent EPO-treated dialysis patients, by hemoglobin level & unit affiliation, 2009 (see page 391 for analytical methods. Period prevalent dialysis patients, 2009.)

In 2009, the proportion of EPO-treated prevalent dialysis patients with a hemoglobin of 10–<12 g/dl varied little by provider, ranging from 72 to 79 percent, and reaching 78 percent overall. Twenty-five percent of DCI patients had a hemoglobin greater than 12 g/dl, compared to 18–-19 percent of those receiving treatment in Fresenius or independent units.

Figure 10.18 All-cause standardized hospitalization & mortality ratios, by unit affiliation, 2009 (see page 391 for analytical methods. January 1 point prevalent hemodialysis patients, 2009, with Medicare as primary payor (SHRs); January 1 point prevalent hemodialysis patients, 2009 (SMRS). SHRS & SMRS are calculated based on national hospitalization & death rates. Adj: age/ gender/race/dialysis vintage.)

Figure 10.19 All-cause standardized hospitalization & mortality ratios in large dialysis organizations, 2009 (see page 391 for analytical methods. January 1 point prevalent hemodialysis patients, 2009, with Medicare as primary payor (SHRs); January 1 point prevalent hemodialysis patients, 2009 (SMRS). SHRS & SMRS are calculated based on national hospitalization & death rates. Adj: age/ gender/race/dialysis vintage.)

For 2009, standardized hospitalization ratios (SHRs) are almost equal in small and large dialysis organizations (SDOs and LDOs), as are standardized mortality ratios (SMRs). Independent facilities have the highest SHR, and hospital-based facilities the highest SMR. By unit affiliation among the LDOs, DCI continues to have the lowest ratios for both hospitalization and mortality.

Costs of ESRD Top

Figure 11.6 Total Medicare ESRD expenditures, by modality (page 284) (see page 392 for analytical methods. Period prevalent ESRD patients; patients with Medicare as secondary payor are excluded.)

Figure 11.7 Total Medicare ESRD expenditures per person per year, by modality (page 284) (see page 392 for analytical methods. Period prevalent ESRD patients; patients with Medicare as secondary payor are excluded.)

After rising 11 percent between 2007 and 2008, total Medicare expenditures for hemodialysis and transplant rose only 0.2 and 0.4 percent in 2009, to $20.8 and $2.4 billion, while costs for peritoneal dialysis fell 3.3 percent, to $1.1 billion. Per person per year costs fell less than 1 percent across modalities, to $82,285 for hemodialysis, $61,588 for peritoneal dialysis, and $29,983 for transplant.

Figure 11.9 Total Medicare spending for injectables (page 284)

Of the $2.78 billion spent in 2009 on injectables for dialysis patients, ESAs accounted for 68 percent, or $1.89 billion. The proportions of total costs for IV vitamin D, IV iron, and other injectables were 18.3, 10.3 and 3.6 percent, or $509 million, $286 million, and $99 million, respectively. Period prevalent dialysis patients.

Figure 11.19 Total PPPY outpatient expenditures, by dialysis modality & race, 2009 (see page 392 for analytical methods. Period prevalent dialysis patients, 2009.)

In 2009, per person per year (PPPY) outpatient dialysis expenditures were 5.5 percent higher in African Americans than in whites, at $32,030 and 30,365, respectively. When comparing costs by modality in unmatched dialysis populations, those for hemodialysis were 26 percent higher than those for peritoneal dialysis. This difference was sustained among hemodialysis patients matched to peritoneal patients, at 25 percent for whites and 29 percent for African Americans.

Figure 11.21 PPPY expenditures for ESAs, by dialysis modality & race, 2009 (see page 392 for analytical methods. Period prevalent dialysis patients, 2009.)

Figure 11.22 PPPY expenditures for IV vitamin D, by dialysis modality & race, 2009 (see page 392 for analytical methods. Period prevalent dialysis patients, 2009.)

Figure 11.23 PPPY expenditures for IV iron, by dialysis modality & race, 2009 (see page 392 for analytical methods. Period prevalent dialysis patients, 2009.)

Per person per year (PPPY)costs for erythropoiesis stimulating agents (ESAs) are higher for hemodialysis patients than for those on peritoneal dialysis, and greater in African Americans than in whites. In unmatched populations, costs for hemodialysis compared to peritoneal dialysis are 75 and 44 percent greater in whites and African Americans, respectively; costs for the matched hemodialysis patients are 74 and 50 percent higher.

PPPY expenditures for IV vitamin D are 74 percent greater for African Americans than for whites.

IV iron costs in matched hemodialysis patients are 5.0–5.6 times higher than those for peritoneal dialysis patients. Costs for IV antibiotics in 2009 were highest in patients on peritoneal dialysis, at $14.48 and $18.16 among whites and African Americans, respectively.

Table 11.a Top 25 Part D prescription drugs used in the ESRD population, by frequency & net cost, 2008 (see page 392 for analytical methods. Period prevalent ESRD patients enrolled in Part D, 2008.)

This table displays the top 25 Part D prescriptions used in ESRD patients by frequency, as measured in total days supply, and by net cost, a reflection of both frequency of use and cost. In 2008, cardiovascular and gastrointestinal medications, phosphate binders, insulin products, levothyroxine, cinacalcet, prednisone, and pain medications were the predominant drugs used in the ESRD population. Metoprolol, a beta blocker, continues to be the most frequently used drug, reflecting the extensive use of beta blockers for congestive heart failure and atrial fibrillation, and after myocardial infarction, percutaneous coronary intervention, and coronary artery bypass graft. Sevelamer HCl is the predominant phosphate binder, and, at $260 million, topped the list in terms of net Part D costs, with cinacalcet coming in at $228 million. Costs for calcium acetate, and lanthanum carbonate each near $50 million.