Chartbook on Effective Treatment

Measures of Effective Treatment of Chronic Kidney Disease

• Process:
  • Nephrology care before kidney failure.
  • Arteriovenous fistula as primary mode of vascular access.
  • Registration for transplantation.
• Outcome:
  • Hemodialysis death rate.

Nephrology Care

Patients Who Saw a Nephrologist Prior to Renal Replacement Therapy, by Race and Ethnicity

Patients who saw a nephrologist at least 12 months prior to initiation of renal replacement therapy, by race and ethnicity, 2005-2013

Left Chart:

Right Chart:

Key: NHOPI = Native Hawaiian or Other Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: U.S. Renal Data System, 2005-2013. https://www.usrds.org/2015/view/v2_02.aspx.
Note: Hispanic includes all races. These charts use data from the newest version of the ESRD Medical Evidence CMS 2278 form. The cohorts include incident hemodialysis patients. Includes only patients for whom it is known whether they saw a nephrologist prior to initiation.

• Importance: Early referral to a nephrologist is important for patients with progressive chronic kidney disease who are approaching kidney failure. Patients who begin nephrology care more than a year before kidney failure are less likely to begin dialysis with a catheter, experience infections related to vascular access, or die during the months after dialysis initiation (USRDS, 2013a).
• Trends: From 2005 to 2013, the total percentage of chronic kidney disease patients receiving care from a nephrologist at least 12 months before the start of renal replacement therapy increased from 25.7% to 34.3%.
• Groups With Disparities:
  • In all years, the percentage of new end stage renal disease (ESRD) patients who began nephrology care at least 12 months prior to initiation of renal replacement therapy was higher for non-Hispanic Whites than for Hispanics.
  • In 2013, nearly 36% of White and Asian ESRD patients began nephrology care at least 12 months prior to initiation of renal replacement therapy while 30% of Black, American Indian/Alaska Native (AI/AN), and Native Hawaiian or Other Pacific Islander (NHOPI) patients began nephrology care at least 12 months prior to initiation of renal replacement therapy.

Patients Who Saw a Nephrologist Prior to Renal Replacement Therapy, by Sex and Age

Patients who saw a nephrologist at least 12 months prior to initiation of renal replacement therapy, by sex and age, 2005-2013

Left Chart:

Right Chart:

Source: U.S. Renal Data System, 2005-2013. https://www.usrds.org/2015/view/v2_02.aspx.
Note: These charts use data from the newest version of the ESRD Medical Evidence CMS 2278 form. The cohorts include incident hemodialysis patients. Includes only patients for whom it is known whether they saw a nephrologist prior to initiation.

• Importance: Early referral to a nephrologist is important for patients with progressive chronic kidney disease who are approaching kidney failure. Patients who begin nephrology care more than a year before kidney failure are less likely to begin dialysis with a catheter, experience infections related to vascular access, or die during the months after dialysis initiation (USRDS, 2013a).
• Trends: From 2005 to 2013, the percentage of male chronic kidney disease patients receiving care from a nephrologist at least 12 months before the start of renal replacement therapy increased from 26.1% to 34.2%. For female patients, the percentage increased from 25.3% to 34.4%.
• Groups With Disparities
  • In 2013, 34% of both males and females began nephrology care at least 12 months prior to initiation of renal replacement therapy.
  • In all years, the percentage of ESRD patients who began nephrology care at least 12 months prior to initiation of renal replacement therapy was higher for patients under age 18 than for patients ages 18-44, 45-64, and 65 and over.

Use of Fistulas

Hemodialysis Patients Who Use Arteriovenous Fistulas for Vascular Access

Adult hemodialysis patients who use arteriovenous fistulas as the primary mode of vascular access, by race and sex, 2012-2013

Left Chart:

Right Chart:

Key: NHOPI = Native Hawaiian or Other Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: U.S. Renal Data System, 2012-2013. https://www.usrds.org/2015/view/v2_02.aspx.

• Importance: Among hemodialysis patients, a usable arteriovenous fistula was associated with the lowest risk of death, infection, and cardiovascular events, compared with other types of vascular access (USRDS, 2015).
• Overall: In 2013, 62.8% of adult hemodialysis patients used arteriovenous fistulas as the primary mode of vascular access.
• Groups With Disparities:
  • In 2013, 74.2% of AI/AN patients, 67.7% of NHOPI patients, 67.3% of Asian patients, 65.2% of White patients, and 57.8% of Black hemodialysis patients used arteriovenous fistulas as the primary mode of vascular access.
  • In 2013, 68.8% of males and 55.1% of female hemodialysis patients used arteriovenous fistulas as the primary mode of vascular access.

Registration for Transplantation

Dialysis Patients Who Were Registered for Transplantation, by Race and Ethnicity

Dialysis patients under age 70 who were registered for transplantation or received a deceased donor kidney within a year of ESRD initiation, by race and ethnicity, 2000-2013

Left Chart:

Right Chart:

2011 Achievable Benchmark: 20.6%.

Key: NHOPI = Native Hawaiian or Other Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: U.S. Renal Data System, 2000-2013. https://www.usrds.org/2015/view/v2_02.aspx.
Note: Hispanic includes all races. The cohort includes patients from 2000-2013 who were younger than 70 at the initiation of ESRD. Percentages are calculated as the number of patients placed on the deceased donor organ waiting list or receiving a deceased donor transplant within 1 year of initiation, divided by the number of patients without a living donor available (i.e., patients receiving a living donor transplant are excluded), and are estimated using the Kaplan-Meier methodology.

• Importance: Kidney transplantation is a renal replacement therapy that replaces the failing kidney with a healthy donor kidney. 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 nearly five times higher than rates among transplant patients (USRDS, 2013b).
• Trends: From 2000 to 2013, the total percentage of dialysis patients under age 70 who were registered for transplantation within 1 year of progressing to ESRD increased from 15.2% to 18.0%.
• Groups With Disparities:
  • In all years, Blacks and AI/ANs were less likely than Whites to be registered for transplantation within 1 year of progressing to ESRD. Asians were more likely than Whites to be registered.
  • From 2000 to 2013, the percentage of dialysis patients registered for transplantation within 1 year of progressing to ESRD was lower for non-Hispanic Blacks than for non-Hispanic Whites and Hispanics.
• Achievable Benchmark:
  • The 2011 top 5 State achievable benchmark for registration for transplantation within 1 year of progressing to ESRD was 20.6%. The top 5 States that contributed to the achievable benchmark are Colorado, Delaware, Minnesota, South Dakota, and Vermont.
  • Hispanics could achieve the benchmark in 5 years, Whites in 8 years, and Blacks in 15 years. AI/ANs and NHOPIs are making no progress toward the benchmark.
  • Asians have already surpassed the 2011 achievable benchmark.

Dialysis Patients Who Were Registered for Transplantation, by Sex and Age

Dialysis patients under age 70 who were registered for transplantation or received a deceased donor kidney within a year of ESRD initiation, by sex and age, 2000-2013

Left Chart:

Right Chart:

2011 Achievable Benchmark: 20.6%.

Source: U.S. Renal Data System, 2000-2013. https://www.usrds.org/2015/view/v2_02.aspx.
Denominator: Patients younger than 70 at ESRD initiation.
Note: Percentages are calculated as the number of patients placed on the deceased donor organ waiting list or receiving a deceased donor transplant within 1 year of initiation, divided by the number of patients without a living donor available (i.e., patients receiving a living donor transplant are excluded), and are estimated using the Kaplan-Meier methodology.

• Importance: Kidney transplantation is a renal replacement therapy that replaces the failing kidney with a healthy donor kidney. 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 nearly five times higher than rates among transplant patients (USRDS, 2013b).
• Groups With Disparities:
  • In 2013, 18.9% of females and 17.1% of males were registered for transplantation within 1 year of progressing to ESRD.
  • In all years, patients under age 18 years were more likely than patients ages 18-44 years, 45-64 years, and 65-69 years to be registered for transplantation within 1 year of progressing to ESRD.
• Achievable Benchmark:
  • The 2011 top 5 State achievable benchmark for registration for transplantation within 1 year of progressing to ESRD was 20.6%. The top 5 States that contributed to the achievable benchmark are Colorado, Delaware, Minnesota, South Dakota, and Vermont.
  • Patients ages 18 and under and 18-44 have already surpassed the 2011 achievable benchmark. Patients ages 45-64 and 65-69 could not achieve the benchmark for approximately 15 years.
  • Female patients could achieve the benchmark in 6 years and males in 11 years.

Hemodialysis Death Rate

Mortality Ratios on Hemodialysis

Standardized mortality ratios on hemodialysis, by State or territory, 2014

Source: University of Michigan Kidney Epidemiology and Cost Center, Dialysis Facility Reports, 2014.
Note: For this measure, lower ratios are better.

• Importance:
  • Hemodialysis patient mortality varies across dialysis facilities and, correspondingly, across States.
  • The standardized mortality ratio (SMR) is designed to summarize the observed death rate at a facility relative to the death rate that was expected based on national death rates during that year for patients with the same characteristics as those in a given facility.
• Geographic Variation:
  • SMRs vary across U.S. States and territories, from a low in South Dakota to a high in Puerto Rico.
  • South Dakota’s SMR of 0.64 indicates facility death rates that are typically 36% below the national death rate.
  • Puerto Rico’s SMR of 1.45 indicates facility death rates that are 45% above the national death rate.

References

U.S. Renal Data System. USRDS 2013 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013a. https://www.usrds.org/atlas13.aspx. Accessed August 19, 2016.

U.S. Renal Data System. USRDS 2013 annual data report reference tables. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013b. https://www.usrds.org/atlas13.aspx. Accessed August 19, 2016.

U.S. Renal Data System. USRDS 2015 annual data report reference tables. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2015. https://www.usrds.org/2015/download/vol2_04_VascularAccess_15.pdf (3.35 MB) Accessed August 19, 2016.

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