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 10.1 Distribution of patients, by unit affiliation, 2009
Figure 10.2 Percent change in the number of dialysis units & patients, 2004 to 2009, by ESRD network
Figure 10.3 Dialysis unit & patient counts, by unit affiliation, 2009
Figure 10.4 Dialysis unit distribution, by affiliation & time managed (time under chain management), 2009
Figure 10.5 Distribution of prevalent EPO-treated dialysis patients, by hemoglobin level & unit affiliation, 2009
Figure 10.6 i IV iron use in dialysis patients, by type of iron & unit affiliation, 2009
Figure 10.7 Months with IV iron in the first six months of dialysis, by unit affiliation, 2009
Figure 10.8 Mean total IV iron dose in the first six months of dialysis, by unit affiliation, 2009
Figure 10.9 Dialysis patients with one or more transfusion events, by unit affiliation, 2009
Figure 10.10 Glycosylated hemoglobin (A1c) testing in diabetic dialysis patients, by unit affiliation & number of tests, 20082009
Figure 10.11 Lipid testing in diabetic dialysis patients, by unit affiliation & number of tests, 20082009
Figure 10.12 Diabetic eye examinations in diabetic dialysis patients, by unit affiliation & number of tests, 20082009
Figure 10.13 Influenza vaccinations in dialysis patients, by unit affiliation, 2009
Figure 10.14 Pneumococcal pneumonia vaccinations in dialysis patients, by unit affiliation, 20082009
Figure 10.15 Hepatitis B vaccinations in dialysis patients, by unit affiliation, 2009
Figure 10.16 Per person per year costs for treatment & services in dialysis patients
Figure 10.17 Per person per year costs for treatment & services in dialysis patients, by unit affiliation, 2009
Figure 10.18 All-cause standardized hospitalization & mortality ratios, by unit affiliation, 2009
Figure 10.19 All-cause standardized hospitalization & mortality ratios in large dialysis organizations, 2009
Figure 10.20 All-cause standardized hospitalization & mortality ratios in small dialysis organizations, by U.S. Census Division, 2009
Figure 10.21 All-cause hospitalization & mortality ratios in hospital-based dialysis units, by U.S. Census Division, 2009
Figure 10.22 All-cause standardized hospitalization & mortality ratios, by unit affiliation, 2009: whites
Figure 10.23 All-cause standardized hospitalization & mortality ratios, by unit affiliation, 2009: African Americans
Figure 10.24 All-cause standardized hospitalization & mortality ratios in hospital-based dialysis units, by U.S. Census Division, 2009: whites
Figure 10.25 All-cause standardized hospitalization & mortality ratios in hospital-based dialysis units, by U.S. Census Division, 2009: African Americans

Chapter Ten

Providers

Sections this chapter: 

Introduction

Following consolidation of Gambro dialysis units into DaVita, and of Renal Care Group units into Fresenius, the landscape of dialysis providers appears to have stabilized. 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 20199 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.

Recent clinical trials have reported adverse outcomes with hemoglobin levels above 11 g/dl. In 2011, the Food and Drug Administration (FDA) removed the target hemoglobin range of 1012 g/dl from package inserts of erythropoiesis stimulating agents (ESAs), instructing that ESA treatment for dialysis patients be initiated when the hemoglobin falls below 10 g/dl, and that providers reduce or interrupt the ESA dose if the level approaches or exceeds 11 g/dl. In 2009, nearly one-fifth of dialysis patients treated with erythropoietin (EPO) across providers had a hemoglobin level exceeding 12 g/dl. The FDA's "black box" warning is designed to encourage physicians to individualize ESA treatment in their patients, and should ultimately change ESA dosing patterns among dialysis providers, reducing the likelihood of ESRD patients reaching high hemoglobin levels.

The new prospective bundled dialysis payment system, also introduced in 2011, alters provider incentives for treatment. The effect of this system on patient treatment and outcomes, and of the FDA's changes in the labeling for ESAs, will be examined in future ADRs.

To maintain optimal hemoglobin levels, it is important that patients have adequate iron stores. In 2009, 66 percent of prevalent dialysis were treated with Venofer and 20 percent with Ferrlecit; INFeD is used sparingly, in only 0.2 percent of patients. As noted in earlier chapters, the number of patients receiving a total iron dose of 2,700 mg or more over the first six month of dialysis has increased from 22 percent in 2000 to 40 percent in 2009. Adequate safety studies on the use of these large doses of IV iron have yet to be performed, limiting our ability to assess this major change in clinical practice.

This year we again examine preventive care services delivered by providers, focusing on diabetic care and vaccinations. Glycemic control (A1c) testing in diabetic patients differs by unit affiliation, with 6365 percent of patients in Fresenius, DaVita, SDO, and independent units receiving four or more A1c tests during 20082009, compared to 4247 percent of patients in hospital-based and DCI units. Just 56 percent of diabetic patients on dialysis receive two or more lipid tests, and fewer than one in three are tested four or more times; those treated in an independent or hospital-based unit are more likely to receive four or more tests than their counterparts in chain-owned or SDO units. These practice patterns may change based on results from the SHARP study, demonstrating reduced atherosclerotic events when patients are treated with a combination lipid lowering therapy (Lancet, June 2011). Eye examinations are another important preventive care tool, used to detect diabetic retinopathy. Fewer than one in four prevalent dialysis patients with diabetes received an eye exam in 20082009. Rates of vaccination, both for influenza and for pneumococcal pneumonia, have improved over the years; patients dialyzing in units owned by DaVita are the most likely to receive these vaccinations.

Medicare payments vary considerably across provider groups. Per person per year (PPPY) expenditures for dialysis rose just 1.5 percent in 2009, to $17,851 overall, but ranged from a low of $17,016 in hospital-based units to a high of $18,717 in units owned by SDOs. PPPY costs for ESAs totaled $6,175 overall, and were again lowest in hospital-based facilities.

We conclude with an analysis of mortality and hospitalization ratios. Standardized hospitalization ratios (SHRs) and standardized mortality ratios (SMRs) in 2009 are similar across providers; SHRs, however, are slightly higher in independent facilities, while hospital-based facilities tend to have slightly higher SMRs. Among the large dialysis organizations, DCI continues to have the lowest statistically significant SHRs and SMRs. SDOs in the East North Central, Middle Atlantic, and New England census divisions have statistically significant higher SHRs. In hospital-based units, statistically significant higher SHRs and SMRs exist in the East South Central, South Atlantic, and West South Central divisions. The USRDS will continue to assess provider outcomes over time to determine areas for improvement.

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

Provider Growth | Anemia Treatment Top

Figure 10.2 Percent change in the number of dialysis units & patients, 2004 to 2009, by ESRD network (see page 391 for analytical methods. CMS Annual Facility Survey, 1988-2009.)
Figure 10.3 Dialysis unit & patient counts, by unit affiliation, 2009 (see page 391 for analytical methods. CMS Annual Facility Survey, 1988-2009.)
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.)

Between 2004 and 2009, the number of dialysis units grew 41 percent in Network 9, and 44 percent in Network 14. In Network 2, in contrast, the number of units rose only 2 percent. Growth in the number of patients ranged from 12 percent in Network 2 to 2730 percent in Networks 14, 15, 16, and 18.

In 2009, Fresenius and DaVita were the largest dialysis providers, with approximately 60 percent of all dialysis units and patients; units owned by DCI totaled 213, with just 3.4 percent of the total dialysis population. Small dialysis organizations (SDOs) defined as those with 20199 dialysis units accounted for 1112 percent of units and patients, and independently owned facilities accounted for 15 percent. Hospital-based facilities represented 14 percent of all dialysis units, and accounted for 10 percent of the dialysis population.

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 1819 percent of those receiving treatment in Fresenius or independent units.

Figure 10.6 IV iron use in dialysis patients, by type of iron & unit affiliation, 2009 (see page 391 for analytical methods. Point prevalent dialysis patients, 2009.)
Figure 10.7 Months with IV iron in the first six months of dialysis, by unit affiliation, 2009 (see page 391 for analytical methods. Incident dialysis patients treated with EPO, 2009.)
Figure 10.8 Mean total IV iron dose in the first six months of dialysis, by unit affiliation, 2009 (see page 391 for analytical methods. Incident dialysis patients treated with EPO, 2009.)
Figure 10.9 Dialysis patients with one or more transfusion events, by unit affiliation, 2009 (see page 391 for analytical methods. Point prevalent dialysis patients, 2009.)

In 2009, 20 percent of prevalent dialysis patients were treated with Ferrlecit, and 66 percent with Venofer; INFeD is now used sparingly, in only 0.2 percent of patients.

Choice of IV iron type varies considerably by provider. In units owned by DaVita and DCI, for example, 8687 percent of patients receive Venofer, compared to 4850 percent of patients treated in independently owned or hospital-based units. In these latter units, Ferrlecit is used by 37 and 28 percent of patients.

In the first six months of dialysis, the number of months in which patients receive IV iron is 4.6 overall, and slightly higher in for-profit units. The mean total IV iron dose is 2,348 mg overall, and highest in units owned by Fresenius, at 2,491.

In 2009, 15.1 percent of prevalent dialysis patients had one or more transfusion events. By unit affiliation, the percentage ranges from 12.7 in units owned by DCI to 17 in independently owned and hospital-based units.

Preventive Care | Costs for Intervention Top

Figure 10.10 Glycosylated hemoglobin (A1c) testing in diabetic dialysis patients, by unit affiliation & number of tests, 20082009 (see page 391 for analytical methods. Point prevalent dialysis patients with diabetes, age 18-75, 2008-2009.)
Figure 10.11 Lipid testing in diabetic dialysis patients, by unit affiliation & number of tests, 20082009 (see page 391 for analytical methods. Point prevalent dialysis patients with diabetes, age 18-75, 2008-2009.)
Figure 10.12 Diabetic eye examinations in diabetic dialysis patients, by unit affiliation & number of tests, 20082009 (see page 391 for analytical methods. Point prevalent dialysis patients with diabetes, age 18-75, 2008-2009.)

Overall, 61 percent of prevalent dialysis patients with diabetes received four or more glycosylated hemoglobin (A1c) tests in 20082009. Patients in units owned by DCI were the least likely to receive four or more tests, at 47 percent. Forty-four percent of diabetic patients receive fewer than two lipid tests annually; this reaches 62 percent in DCI units. And across unit affiliations, 57.3 percent of diabetic patients did not receive a diabetic eye examination during 2008-2009.

Figure 10.13 Influenza vaccinations in dialysis patients, by unit affiliation, 2009 (see page 391 for analytical methods. Point prevalent dialysis patients, 2009.)
Figure 10.14 Pneumococcal pneumonia vaccinations in dialysis patients, by unit affiliation, 2008-2009 (see page 391 for analytical methods. Point prevalent dialysis patients, 2009.)
Figure 10.15 Hepatitis B vaccinations in dialysis patients, by unit affiliation, 2009 (see page 391 for analytical methods. Point prevalent dialysis patients, 2009.)

In the prevalent dialysis population, influenza vaccination rates reached 69 percent overall in 2009, and were highest in units owned by DaVita and DCI, at 80 and 72 percent, respectively. With an overall rate of 30 percent, pneumococcal pneumonia vaccination rates in 2008-2009 ranged from 20 in hospital-based units to 36 in units owned by DaVita. And 28 percent of prevalent dialysis patients received a hepatitis B vaccination in 2009, with a range from 23 in DCI units to 2930 in units owned by Fresenius and DaVita.

Figure 10.16 Per person per year costs for treatment & services in dialysis patients (see page 391 for analytical methods. Period prevalent dialysis patients.)
Figure 10.17 Per person per year costs for treatment & services in dialysis patients, by unit affiliation, 2009 (see page 391 for analytical methods. Period prevalent dialysis patients, 2009.)

Per person per year (PPPY) costs for dialysis rose just 1.5 percent in 2009, to $17,851; growth has slowed from 7.5 percent in 2006. PPPY costs for IV iron rose nearly 10 percent, to $789, while costs for erythropoiesis stimulating agents (ESAs) and for other injectables each rose 7.6 percent, to $6,175 and $224, respectively.

By unit affiliation, PPPY dialysis costs in 2009 ranged from $17,016 in hospital-based units to $18,717 in the small dialysis organizations (SDOs), while ESA costs were lowest in hospital-based units, at $5,296, and highest in units owned by Fresenius, at $6,625. DaVita units had the highest PPPY costs for both IV iron and IV vitamin D hormone, at $876 and $1,671, respectively. Laboratory costs ranged from $1,382 in DCI units to more than $1,900 in independent units and those owned by SDOs.

Standardized Hospitalization & Mortality Ratios Top

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.)
Figure 10.20 All-cause standardized hospitalization & mortality ratios in small dialysis organizations, by U.S. Census Division, 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 10.21 All-cause hospitalization & mortality ratios in hospital-based dialysis units, by U.S. Census Division, 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.

Within the SDOs, three U.S. Census Divisions East North Central, Middle Atlantic, and New England have statistically significant higher SHRs; the Mountain and Pacific divisions have statistically significant lower ones. A mortality ratio less than one and statistically significant occurs only in the Pacific division. Among hospital-based units, the Mountain, Pacific, and West North Central divisions have lower SHRs, while the East South Central, South Atlantic, and West South Central divisions each have higher SHRs and SMRs.

Figure 10.22 All-cause standardized hospitalization & mortality ratios, by unit affiliation, 2009: whites (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 10.23 All-cause standardized hospitalization & mortality ratios, by unit affiliation, 2009: African Americans (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 10.24 All-cause standardized hospitalization & mortality ratios in hospital-based dialysis units, by U.S. Census Division, 2009: whites (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 10.25 All-cause standardized hospitalization & mortality ratios in hospital-based dialysis units, by U.S. Census Division, 2009: African Americans (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.)

In units owned by Fresenius and DaVita, white patients have statistically significant higher SHRs, while African American patients have statistically significant lower SHRs in Fresenius units, and lower SMRs in DaVita units. In hospital-based units, SHRs are lower than one and statistically significant for whites, but higher than one for African Americans.

Among hospital-based dialysis units in the Middle Atlantic and South Atlantic divisions, white patients have a statistically significant higher SHR, as do African Americans in the East North Central, East South Central, Middle Atlantic, New England, South Atlantic, and West South Central divisions. In the Mountain and Pacific divisions, the SHR is lower than one for both whites and African Americans. SMRs greater than one and statistically significant are reported for both white and African American patients in the East South Central, South Atlantic, and West South Central divisions.