The State of CKD, ESRD and Mortality in the First Year on Dialysis: Are We Doing Enough?

1. The State of CKD, ESRD and Mortality in the First Year on Dialysis: Are We Doing Enough? Allan J. Collins, MD, FACP Professor of Medicine University of Minnesota Director, USRDS Coordinating Center

2. Patient counts, by modality Figure p.3 (Volume 2) Incident & December 31 point prevalent patients.

3. Counts of new & returningdialysis patientsFigure p.2 (Volume 2) Data obtained from CMS’s annual End-Stage Renal Disease Facility Survey.

4. Projected growth of prevalent dialysis & transplants populations to 2020Figure 2.2 (Volume 2) counts projected using a Markov model. Original projections used data through 2000; new projections use data through 2006.

5. Adjusted incident rates & annual percent change Figure 2.3 (Volume 2) Incident ESRD patients; rates adjusted for age, gender, & race.

6. Incident counts & adjustedrates, by age Figure 2.5 (Volume 2) Post WW II “Baby Boomers” Incident ESRD patients; rates adjusted for gender & race.

7. Incident counts & adjusted rates,by race Figure 2.6 (Volume 2) Incident ESRD patients; rates adjusted for age & gender.

8. Incident counts & adjusted rates,by primary diagnosisFigure 2.8 (Volume 2) Incident ESRD patients; rates adjusted for age, gender, & race.

9. Adjusted incident rates of ESRD due to diabetes, by age & race/ethnicity: age 20-39Figure 2.12 (continued) USRDS 2006 ADR Increasing disparities illi illi lla lla Rates are increasing in African and Native Americans ages 30-39!

10. Trends in Incident cases of ESRD • Overall, incidence rates appear to have stabilized, however, the absolute number of new cases ESRD patients is driven by the “Baby Boomer” generation age 45-64 years old which has major budgetary implications. • ESRD rates due to Diabetes have stabilized overall and declined in older Racial groups, However, • There is a marker increase in ESRD due to Diabetes in the younger African and Native Americans which is in marked contrast to the younger White population! • These findings continue into the most recent data to be released in September 2009 which demonstrate a growing health disparity issue for the African and Native American Populations

11. Public Health Programs needed to address ESRD due to DM • The racial disparity issues in the younger African and Native American population needs a broad base effort • In 2009 with all the attention on the Economic and Health care stimulus package, these racial disparities are “Shovel Ready” for efforts from • By government: NIDDK, CDC, DHHS, State Departments of Health, Health Caucuses in Congress • NGOs across all domains including foundations, patient advocacy groups should engage these issues • Media: Including Medical Journals, Editorials and the lay press etc. • World Kidney Day, at least in the US, should have a theme on kidney disease and diabetes focusing on the growing disparity issues for a call to action!

12. Adjusted prevalent rates & annual percent change Figure 2.11 (Volume 2) December 31 point prevalent ESRD patients; rates adjusted for age, gender, & race.

13. Growth of the Prevalent ESRD and dialysis population • The prevalent population continues to grow at 3-4% per year • The growth is now driven by the falling death rates since the incidence rate has slowed • The growth, however, places increased demands on the health care budget such that more cost effective treatment is needed. • The proposed new dialysis “Bundled” payment system is an attempt to contain cost in the same way as in 1982 when the original composite rate payment system was created.

14. Quality indicators: percent of patients meeting clinical & preventive care guidelinesFigure 5.1 (Volume 2) Kt/V & vascular access data: incident & prevalent dialysis patients; from 2005 CPM report—patient data from 2004. URR: prevalent hemodialysis patients, 2005; from Medicare claims. Hemoglobin: prevalent dialysis patients, 2005; from Medicare claims. Anemia management: Diabetic care: point prevalent patients initiating ESRD 90 days prior to January 1, 2004, age 18–75 on December 31, 2005, & alive through December 31, 2005, with diabetes as the primary cause of ESRD or a comorbidity on the Medical Evidence form, or with diabetes diagnosed during the first year; HbA1c & lipid tests are at least 30 days apart. Comprehensive monitoring includes at least four HbA1c tests per year, at least two lipid tests per year, & at least one diabetic eye examination per year. Influenza vaccinations: ESRD patients initiating therapy at least 90 days before September 1, 2005, & alive on December 31, 2005; vaccinations tracked between the two dates. Pneumococcal pneumonia vaccinations: ESRD patients initiating therapy at least 90 days before January 1, 2004, & alive on December 31, 2005; vaccinations tracked during entire period. Hepatitis B vaccinations: ESRD patients initiating therapy at least 90 days before January 1, 2005, & alive on December 31, 2005. Vaccinations tracked during entire period.

15. Arteriovenous fistula use in incident hemodialysis patientsFigure hp.11 (Volume 2) illi illi lla lla Incident patients initiating dialysis between January 1 & August 31 of the year of data collection; 1999–2006 ESRD CPM data. Access represents the current access used as of the latest data collection for that year. Includes only patients for whom an access is known.

16. Arteriovenous fistula placement rates in prevalent hemodialysis patients, by age & race/ethnicityFigure hp.12 (Volume 2) illi illi lla lla Period prevalent hemodialysis patients with or without simple fistulas. Data from physician/supplier claims. Some patients may have more than one access at a given point in time. Some patients may have more than one access at a given point in time. For Hispanic patients we present data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity.

17. Access procedures in prevalent hemodialysis patients, by diabetic status Figure hp.13 (Volume 2) Transition to cuffed catheters illi illi lla lla Period prevalent hemodialysis patients with or without simple fistulas. Data from physician/supplier claims. Some patients may have more than one access at a given point in time.

18. Vascular access utilization • The Fistula First Initiative has led to the largest growth in fistulas in the history of the dialysis program reaching 50% of the new patients within the first year! • Placement rates for fistulas has increased 150% over the last 13 years • Placement rates for catheters initially increased significantly but have fallen since 1999, however, cuffed catheters are being used which may reduce placement rates but still expose patients to risks of infections.

19. Preventive care for infectious complications • Influenza Vaccinations • Pneumococcal pneumonia vaccinations • Variations in delivered care

20. Influenza vaccination rates, by age, race/ethnicity, & modality Figure 5.18 (Volume 2) ESRD patients initiating therapy at least 90 days before September 1 of each year & alive on December 31; vaccinations tracked between September 1 & December 31 of each year.

21. Influenza vaccinations, by unit affiliation Figure 10.24 (Volume 2) dialysis patients initiating therapy at least 90 days before September 1 of each year & alive on December 31; vaccinations tracked between September 1 & December 31 of each year. Patients with Medicare inpatient/outpatient & physician/supplier primary payor coverage during entire period.

22. Pneumococcal pneumonia vaccination rates, by age, race/ethnicity, & modality Figure 5.20 (Volume 2) ESRD patients initiating therapy at least 90 days before the start of the period & alive on the period’s last day; vaccinations tracked during entire period.

23. Pneumococcal pneumonia vaccinations, by unit affiliation Figure 10.25 (Volume 2) dialysis patients initiating therapy at least 90 days before the start of the period/year & alive on the period or year’s last day; vaccinations tracked during entire period/year. Patients with Medicare inpatient/outpatient & physician/supplier primary payor coverage during entire period.

24. Preventive care for infectious complications • The variation is vaccination rates for influenza and pneumococcal pneumonia are considerable and unexplained. • These vaccinations are very inexpensive compared to the cost of a single hospitalization for pneumonia yet universal adoption is lacking. • In fact, there has been no progress in influenza vaccination rates for the last 5 years! • Pneumococcal pneumonia vaccinations have increase to a greater degree in some providers! • Providers need to be held accountable for the lack of performance is this area.

25. Morbidity and Mortality trends: Areas of concern • Prevalent mortality rates have been declining since the mid-1990s • Incident based mortality rates have declined modestly in the 2nd to 5th years under treatment • First year death rates have not changed in 12 years which is a major concern • Hospitalization rates in the first year have increased in most categories with infections generating the largest growth. • Vascular access infectious hospitalization have almost doubled in the last 10 which is a major concern.

26. Adjusted mortality rates, by vintage: All Dialysis Figure 6.9 (Volume 2) Dallas Morbidity and Mortality Conference Period prevalent dialysis patients; adjusted for age, gender, race, & primary diagnosis. Dialysis patients, 2005, used as reference cohort.

27. Mortality rates, by modalityFigure 6.1 (Volume 2) Incident ESRD patients; adjusted for age, gender, race, & primary diagnosis. Incident ESRD patients, 2005, used as reference cohort.

28. All-cause & cause-specific mortality in the first months of ESRDFigure 1.1 (Volume 2) incident dialysis patients, 1993–1998 & 1999–2005 combined, adjusted for age, gender, race, & primary diagnosis. Incident dialysis patients, 2005, used as reference.

29. Change in all-cause & cause-specific hospitalization rates, by modality: prevalentFigure p.22 Period prevalent ESRD patients; adjusted for age, gender, race, & primary diagnosis. ESRD patients, 2005, used as reference cohort. Vascular access hospitalizations are “pure” inpatient vascular access events, as described in Appendix A. New vascular access codes for peritoneal dialysis patients appeared in late 1998; therefore, peritoneal dialysis vascular access values are shown as changing since 1999 rather than 1993.

30. Summary • The ESRD incident counts exceeded 110,000 in 2006 with the prevalent ESRD population exceeding 506,000 • Many aspects of cardiovascular care have improved with increased use of diagnostic tests and interventions • Prevalent deaths continue to fall, however, death rates in the first year have changed little over the last 12 years in hemodialysis • Death rates in the first months of dialysis are high and need to be addressed • Later referral is a persistent problem: This is a primary care and nephrology issue!!!! • High rates of catheter utilization at initiation of hemodialysis lead to complications that are avoidable • Hospitals are not held accountable for a vascular access plan and have a conflict of interest since they are highly paid for vascular access DRGs • Hospitals have the ability to regulate the medical staff under their bylaws and extension of practice privileges

31. Conclusions • ESRD incidence rates have slowed considerably since the early 1990s • ESRD rates due to diabetes is a major concern particularly in the younger African and Native American populations which needs attention on a public health level • Prevalence rates have grown based on lower death rates • The use of fistulas in the prevalent population has increased which is an important achievement • Morbidity and mortality in the first year of dialysis is a major concern particularly related to poor planning of transition to dialysis • The new CKD stage 4 education benefit needs to be implemented and providers monitored for effectiveness • Survival of the ESRD and dialysis population has improved but challenges remain particularly in CKD to ESRD transition and first year death and hospitalization rates.