KEEP 2005 Annual Data Report

Transcription

1 KEEP 25 Annual Data Report

2 The National Kidney Foundation gratefully acknowledges the support of our primary sponsor and our associate sponsor Additional thanks to Bayer Diagnostics, Satellite Healthcare, Satellite Laboratory Services, LifeScan, Inc. and Ocean Spray Cranberries, Inc.

3 Executive summary I think this is an excellent program. It will certainly encourage more family and friends to participate in the health screening. Especially since kidney disease is a progressive disease. People don t know they are experiencing problems with their kidneys until it s too late. As a breast cancer survivor, I know that early detection is a key factor in survival. This is why I believe KEEP is so important. KEEP Participant Screening date: s1

4 This third annual data report of the National Kidney Foundation s Kidney Early Evaluation Program (NKF-KEEP) summarizes the activities of this national community-based detection program, assessing individuals who volunteer for a health care assessment and evaluation of their kidney function. The KEEP program is a response to the increasing number of end-stage renal disease (ESRD) patients in the United States currently approaching 4,, with more than 1, new patients starting treatment each year. Diabetes and hypertension are the primary causes of kidney failure, and are major targets of assessment in the at-risk individuals participating in KEEP. KEEP s initial pilot program, conducted from 1997 to 1999 and evaluating almost 9 individuals in 21 cities, showed that evidence of chronic kidney disease (CKD) was more common than anticipated, even in populations that are engaged with the medical system and have high degrees of insurance. This year s report summarizes information on the individuals who met the entry criteria of a known history of diabetes or hypertension, or a family history of diabetes, hypertension, or kidney disease. Within the NKF Affiliates throughout the United States, 37,155 individuals met the KEEP entry criteria and are included in this report. The program s geographic distribution continues to increase across the country, with more individuals participating in the southern, western, and upper Midwestern states. The eastern part of the country, however, continues to contribute the greatest number of participants. When compared to the general population, illustrated through National Health and Nutrition Examination Survey (NHANES) data, the KEEP population tends to be slightly older and more educated (58% report education after high school, compared to 51% in the general population). One objective of the KEEP program is to target the uninsured. In 2 21, only 15% of participants were uninsured; in 24, however, this rose to 2%. Hispanics and those of races other than white or black have the lowest rates of insurance coverage. The number of participants who visited a physician during the last year has remained consistent since 2, at almost 9%. Not unexpectedly, those with no health insurance coverage are only half as likely to see a doctor for medical care. s2 National Kidney Foundation Kidney Early Evaluation Program

5 Since the KEEP program is targeted towards individuals with diabetes and hypertension, 25% of participants report having diabetes, compared to only 6.4% in the general population. Almost 83% African-American participants with diabetes have an elevated blood pressure based on the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) criteria, and only 5% have glucose levels within the target range. In those individuals not known to have diabetes, 7% have elevated blood sugars consistent with a new diagnosis of diabetes. Fifty-two percent of participants report having hypertension, and this group is also likely to have elevated blood sugars. Nearly 16% have a history of cardiovascular disease, with 46% or more of these participants having risk factors for cardiac disease (including diabetes, a body mass index greater than 3 kg/m 2, elevated blood pressures, and a history of smoking). Obesity is a common problem in KEEP participants, to a far greater degree than in the general population. Over threefourths are overweight, and more than one-third are considered obese, compared to 25% in the general population. Two percent of KEEP participants report having kidney disease, and almost 7% a history of kidney stones; less than 1% report both. Almost 6% of KEEP participants return their followup forms after the program, and many report consulting with their physicians for reasons related to elevated blood pressures, abnormalities in the urine test, low estimated creatinine clearances, elevated blood sugars, and anemia. Overall, then, 3% of KEEP participants have evidence of diabetes, either by self-reporting or by an elevated blood sugar. The mean blood sugar is almost 161 mg/dl, with only half of the individuals reaching the target blood sugar level. Those who are insured but have less than a high school education are far more likely to have evidence of diabetes. Of those with diabetes, 56% have evidence of microalbuminuria through urine testing, with a mean microalbumin level of 44 mg. Estimated glomerular filtration (egfr) rates tend to be lower in those with diabetes or hypertension than in those who carry neither condition. Based on the NKF classification system, 63% of participants with self-reported diabetes have evidence of CKD. Chronic kidney disease As noted in this year s Annual Data Report, approximately 5% of KEEP participants would have elevated serum creatinine levels based on traditional definitions of kidney disease (males greater than 1.5 mg/dl, females greater than 1.3 mg/dl). Based on the new classification system, however, almost 53% of the population have evidence of CKD a ten-fold greater yield. Almost 25% of the KEEP population have a family history of kidney disease, with African-Americans, Native Americans, Pacific Islanders, and members of other minority groups more likely to have this history than Caucasians. Among Hispanics, those of Mexican heritage are more likely than the non-hispanic population to have a family history of the disease. The prevalence of diabetes increases with CKD stage, reaching almost 55% in participants with Stage 4 CKD. Low hemoglobin levels, as defined by World Health Organization (WHO) guidelines (less than 13 g/dl in men and less than 12 g/dl in women) are also more common with advancing CKD. In the current cumulative data, almost 3% of participants with Stage 3 CKD who have diabetes, have evidence of lower hemoglobin levels, compared to only 13% of those without diabetes; in Stage 4 CKD, these numbers rise to 65 and 46%, respectively. The frequency of microalbuminuria and an elevated albumin/creatinine ratio also grows with CKD stage. Almost Executive Summary s3

6 half of KEEP participants have a positive microalbuminuria test, and this increases to more than 6% of those with diabetes in Stage 3, 8% in Stage 4, and nearly 1% in Stage 5. Interestingly, if microalbuminuria was used as the sole test for evidence of kidney disease in persons with diabetes, almost 4% of participants would be missed. Individuals with evidence of microalbuminuria have a 5% greater likelihood of WHO- or Kidney Disease Outcomes Quality Initiative (K/DOQI)-defined anemia. The adjusted odds ratio of anemia is greatest in African-Americans with diabetes, followed by African-Americans without diabetes. This is similar to the findings in the NHANES data, based on WHO anemia, with African-American who have diabetes having a ten-times greater likelihood of anemia than Caucasians, and African-Americans without diabetes, an almost six-times higher likelihood. The NKF s KEEP detection program continues to demonstrate that kidney disease is common in individuals who have a history of diabetes or hypertension, or a family history of these diseases or kidney disease. Obesity and cardiovascular disease are clearly important areas to address, as both glucose control and blood pressure control remain poor. Anemia is common, particularly for those with Stage 3 CKD, and is twice as likely in persons with diabetes compared to those without the disease. Expanded activities in the areas of calcium, phosphorus, parathyroid hormone abnormalities, and lipid metabolism in KEEP participants will be undertaken in the latter part of 25. Based on the community interest and the expanding Affiliate KEEP programs, this community-awareness activity for chronic kidney disease appears to meet a public health need in the United States. Abbreviations Adjust B BS BMI BP CKD Crt CVD DBP DM egfr EBS El BP ESRD F FH Hgb HTN JNC-7 KD M KEEP MDRD Nat Am NHANES NKF NKF K/DOQI Non-DM NSR OTC Oth Pac Isl Partic PD PVD SBP SR W WHO adjustment black blood sugar body mass index blood pressure chronic kidney disease creatinine cardiovascular disease diastolic blood pressure diabetic or diabetes estimated glomerular filtration rate elevated blood sugar elevated blood pressure end-stage renal disease female family history hemoglobin hypertension National Joint Committee on Prevention, Detection, Evaluation, & Treatment of High Blood Pressure kidney disease male Kidney Early Evaluation Program Modification of Diet in Renal Disease Native American National Health & Nutrition Examination Study National Kidney Foundation National Kidney Foundation s Kidney Disease Outcomes Quality Initiative non-diabetic non-self-reported over the counter other Pacific Islander participant peritoneal dialysis peripheral vascular disease systolic blood pressure self-reported white World Health Organization s4 National Kidney Foundation Kidney Early Evaluation Program

7 Introduction Thank you for the KEEP program. Each time the program is offered I have gone and I plan to continue to go each year. I cannot afford all the tests so it is great that the program is free. The tests are very important to me because I am diabetic. All the workers are so nice and helpful and very understanding. Please continue the program. Each year I compare the test form one year to the next. KEEP Participant Screening date: American Journal of Kidney Disease Vol 46, No. 5, Suppl 3 (Nov), 25

8 Chronic kidney disease is receiving increased attention in the United States and around the world as the precursor to ESRD, a disease requiring treatment with dialysis or transplantation. The growing number of people entering ESRD therapy has placed increased demands on patients, families, and health care resources worldwide. During the past three decades, with ESRD approved for Medicare coverage under Medicare entitlement, the U.S. has led the world in treated incident and prevalent rates. These rates are now being eclipsed, however, by those of other countries, particularly Japan and Taiwan. Taiwan now has the highest incident rates of ESRD in the world, with the United States second and Japan third. Prevalent rates of treated ESRD also show Japan to be first, followed by Taiwan and the U.S. These high rates of ESRD have placed increasing strain on health care budgets, as ESRD consumes an ever-increasing part of health care expenditures. The KEEP program Ten years ago, the NKF created strategies for targeting populations at high risk of kidney disease. Preliminary studies during for the subsequent KEEP were conducted on almost 9 individuals, and showed that targeted populations age 18 and older, with a history of diabetes or hypertension or with a family history of these two diseases or kidney disease, were highly likely to have evidence of kidney damage, microalbuminuria, and reduced kidney function. In the latter part of 2 the NKF expanded its initial, 21-city pilot program to a national effort through its local affiliates. Now in its fifth year, the nationwide KEEP program has seen over 5, individuals, evaluating their blood pressures, height, weight, body mass index (BMI), evidence of kidney damage (through testing of urine for albumin and blood for elevated serum creatinine levels), evidence of anemia, and family history of diabetes, hypertension, and cardiovascular disease. The program provides educational materials to patients and families, as well as to physicians. Consultation with a physician is also available at the end of the program, allowing participants to review their family history and the results of their evaluation. This large effort has now expanded to 45 of the 49 NKF Affiliates across the U.S., and has received attention worldwide through publication of the National Kidney Foundation s KEEP Annual Data Report. s6 National Kidney Foundation Kidney Early Evaluation Program

9 Administrative structure & oversight KEEP s organizational structure (right) has evolved along with the program itself. The program is governed by an External Advisory Committee, which receives significant input on program operations from the NKF Affiliates; there is also a Scientific Advisory Committee chaired by Wendy Brown, MD, and Michael Klag, MD. The Executive Committee communicates monthly, discussing data coordinating center issues, ancillary studies, funding and sponsorship, affiliate support, new program development, and publications. National Kidney Foundation KEEP Organizational Chart External Advisory Committee National Kidney Foundation NKF KEEP Chair:Wendy Brown MD Vice Chair: Mike Klag MD, MPH Steering Committee Executive Committee NKF Affilliates The KEEP Steering Committee works with the Data Coordinating Center and NKF Affiliates on analyses of the KEEP data and on the Annual Data Report. Committee members (see box on next page) have a broad range of expertise, and include experts in nephrology, hypertension and cardiovascular disease, cardiology, diabetes, and minority populations. Members include representatives from the Indian Health Service and the NKF. Data Coordinating Center Ancillary Studies Funding and Sponsorship Affilliate Support Publications Program Development and Evaluation All KEEP data are submitted for entry to NKF s national office in New York; data are then sent to the KEEP Data Coordinating Center at the Minneapolis Medical Research Foundation in Minnesota, which is responsible for the KEEP Annual Data Report. The data collection form for this reporting period was used through December 31, 24. Content of the Annual Data Report The size of the KEEP program allows the Annual Data Report to provide extensive descriptive characteristics of the population. Participant information is organized by age, gender, race, and, where possible, geographic region; we also present data on participant education, insurance coverage, and access to physician care in Chapter 2. Data Coordinating Center Organizational Chart Data & Database Management Cheryl Arko, BS Frank Daniels, BS Eric Frazier, BS C. Daniel Sheets, BS KEEP Data Coordinating Center Allan Collins, MD, Director Project Manager Shu-Cheng Chen, MS Biostatistics Suying Li, MS Changchun Wang, MS Editorial Office Delaney Berrini, BS Edward Constantini, MA Susan Everson, PhD We have included new information this year on the prevalence of diabetes by blood pressure stage as well as by age, Chapter 1 Introduction s7

10 educational level, and insurance coverage. Data on obesity, a common complication and risk factor for cardiovascular disease and diabetes, are presented in detail in Chapter 3. Chapter 4 provides information on diabetes and glycemic control in the KEEP population, as well as on hypertension and hypertension control. While almost 25% of KEEP participants are known to have diabetes, an additional 5% have evidence of diabetes based on blood sugar. And almost 7% of KEEP participants have evidence of hypertension 5% know they have the disease, and another 2% discover it through an elevated blood pressure measured during participation in the program. Chapter 5 presents a more complete evaluation of findings related to (CKD) in this population. We compare results using the traditional definition of CKD (an elevated serum creatinine level) to those using the new NKF classification, and look as well at blood pressure control by CKD stage, and at obesity, anemia, and multiple cardiovascular risk KEEP Steering Committee Wendy W. Brown, MD, MPH, FACP, FAHA: Chair Meharry Medical College, Vanderbilt University Medical Center Michael J. Klag, MD, MPH: Vice Chair Johns Hopkins University Allan Collins, MD, FACP Hennepin County Medical Center & University of Minnesota KEEP Executive committee George Bakris, MD, FACP, FCP Rush Presbyterian, St. Luke s Medical Center Claudine Jurkovitz, MD, MPH Emory University School of Medicine Peter A. McCullough, MD, MPH William Beaumont Hospital Health Center Janet McGill, MD Washington University School of Medicine Andrew Narva, MD, FACP Indian Health Service Kidney Disease Program Keith C. Norris, MD Charles R. Drew University Pablo Pergola, MD, PhD University of Texas Health Science Center at San Antonio Ajay Singh, MD Brigham & Woman s Hospital Ex-officio members Shu-Cheng Chen, MS Chronic Disease Research Group, Minneapolis Medical Research Fd. Marsha Wolfson, MD Ortho Biotech Clinical Affairs NKF Staff John Davis Chief Executive Officer Gigi Politoski Vice President, Programs Division Monica Ryan Gannon Early Intervention Programs Director factors. The chapter also includes data on the prevalence and degree of microalbuminuria, by CKD stage, in diabetic and hypertensive populations. In Chapter 6 we present data on the prevalence of anemia, using anemia guidelines by both the WHO and the NKF s K/DOQI. Diabetic participants are almost twice as likely to have anemia as non-diabetic participants. It also appears that anemia is much more likely in those with evidence of microalbuminuria than in those without. Analytical methods & reference tables The analytical methods used in each chapter are described in the appendix. The reference tables have been expanded this year, and include data on self-reported diabetes and hypertension, elevated blood sugar and blood pressure, blood pressure control, evidence of chronic kidney disease, body mass indices, microalbuminuria, hemoglobin level, and self-reported kidney disease or stones. These tables provide a more complete description of the number of individuals and their distribution in each of these categories. Acknowledgements The KEEP program could not function without the extensive support of NKF volunteers across the United States who help each NKF Affiliate deliver this community service. The dedicated efforts of affiliate staff and the national office, providing support mechanisms to NKF Affiliates, are also extremely important. Sponsors of the KEEP program are listed at the front of the Annual Data Report; they provide affiliates with the necessary materials to carry out the program, and help support laboratory requirements, administrative support, and data analysis. We hope the information in this Annual Data Report will help demonstrate, in the United States and around the world, how a detection program can be used to identify targeted populations with high prevalence of a disease, and to examine the quality of the care they receive. s8 National Kidney Foundation Kidney Early Evaluation Program

11 Participant demographics 2 demographics insurance coverage education access to medical care I just want to thank you, because I have no insurance and a mother with kidney failure. This was an invaluable service to me. The volunteers and Doctor Walworth were kind and helpful. Thank you very much. This process helped me take charge of my own kidney health. KEEP Participant Screening date: American Journal of Kidney Disease Vol 46, No. 5, Suppl 3 (Nov), 25

12 demographics The total number of eligible KEEP participants and of NKF Affiliates both show a steady increase since 2, and as of December 31, 24, totaled 37,155 and 45 respectively. States with the greatest number of participants are located in the southern and eastern half of the country, with Florida having the highest percentage of participants at 9%. The South census region accounts for 5% of all participants, more than twice as many as any other region. Compared to the NHANES 99 2 population, the KEEP population tends to be older, and has more women and more black participants. education The educational status of KEEP participants has changed little with each cohort year. Slightly more than 25% have a high school diploma, while 2% have completed college. Compared to NHANES 99 2 participants, 7% more KEEP participants report having some level of college or post-graduate education. In each study population, the lowest education levels are found in older participants; there is little difference, however, by gender. KEEP participants who are white or black are more likely to pursue further education after high school than those of other races or ethnicities, and higher education is more commonplace in the West than in other census regions. s1 National Kidney Foundation Kidney Early Evaluation Program

13 insurance coverage The proportion of KEEP participants with insurance has declined gradually over each cohort year, and in 24 was 8.3%. This trend is evident across census regions, with the Midwest and West regions exhibiting the greatest declines since 2 21, at 9.5 and 16.3%, respectively. Insurance coverage is generally better in the NHANES population for all age groups, and in both the KEEP and NHANES populations females are more inclined to be insured than males. The percent of KEEP participants with insurance varies by race/ethnicity and by census region as well. In the Midwest, for example, fewer than half (43%) of Hispanics have insurance coverage, while in the Northeast the percent of whites with insurance is 93%. In the NHANES 99 2 population insurance coverage ranges from 86% in whites to 66% in Hispanics. access to medical care Nearly 88% of KEEP participants report having a physician. Those residing in the Northeast census region are the most likely to have a physician while the least likely live in the West. The proportion of participants with a physician increases with age, and women are more likely to have a physician, as are whites and blacks when compared to people of other races and to Hispanics. Participants with insurance are far more likely to have a physician compared to those who have no insurance. Chapter 2 Participant demographics s11

14 demographics Figure 2.1 cumulative number of KEEP participants & affiliates, by year By 24, the total number of eligible participants in the KEEP study reached 37,155, and the number of affiliates had risen to 45. Cumulative # of partic. (1,s) affiliates # of Cumulative Figure 2.2 percentage of KEEP participants, by affiliate (rank order) Florida has the highest percentage of KEEP participants, at 9%, followed by the Northeastern states and the Carolinas. Figure 2.3 geographic variations in the percent of KEEP participants, by state States located in the eastern and southern regions of the country have the highest proportions of KEEP participants to <3.7.9 to <1.7.6 to <.9 below.6 Florida MA/RI/NH/VT North Carolina South Carolina Oklahoma East MO/Met-Et MO Virginia Louisiana Indiana Georgia Central New York East Tennessee Hawaii Connecticut Arizona Mississippi Illinois New Mexico Western New York Delaware Valley Kentucky Nebraska Maine West Tennessee Middle Tennessee Minnesota Upstate New York South/Central Texas Western Pennsylvania Iowa North Texas New York/New Jersey Utah Ohio Northeast New York Northern California South Dakota Alabama West Texas Southern California Oregon/Washington Michigan Arkansas Kansas/Western MO of participants s12 National Kidney Foundation Kidney Early Evaluation Program

15 Figure 2.4 KEEP participants, by U. S. Census Division In most Census Divisions, the number of KEEP participants has increased since Of the total participants so far in the East North Central states, for instance, 46% were seen during 24. participants of 4 2 SA NE WSC WNC PAC ENC MTN MA ESC U.S. Census Divisions (see table below) Figure 2.5 KEEP participants, by U.S. Census Region Fifty percent of KEEP participants live in the South, compared to only 23, 17, and 1% in the Northeast, Midwest, and West, respectively. 6 participants of Northeast Midwest South West Figure 2.6 KEEP & NHANES participants, by age, gender, & race/ethnicity Compared to the NHANES population, the KEEP population has a higher percentage of older participants, of women, and of blacks. participants of Age KEEP NHANES >75 Gender Male Female Race/ethnicity White Black Other Hispanic U.S. Census Divisions SA: South Atlantic NE: New England WSC: West South Central WNC: West North Central PAC: Pacific ENC: East North Central MTN: Mountain MA: Middle Atlantic ESC: East South Central Figure 2.2 KEEP: N=37,155. Figures KEEP: N=37,131. Excludes participants with missing values for state. Figure 2.6 KEEP: N=37,155 for age and gender; N=36,329 for race, NHANES: N=11,441; race & Hispanic ethnicity are not mutually exclusive. Chapter 2 Participant demographics s13

16 education Figure 2.7 educational status in KEEP participants, by year The educational status of KEEP participants has varied little by cohort year; slightly more than one in four completed their education with a high school diploma, while one in five stopped with a college degree. participants 3 2 GSL SHS HSG SC CG PG of Figure 2.8 percent distribution of KEEP & NHANES participants, by educational status Fifty-eight percent of KEEP participants report some level of college or postgraduate education, compared to 51% of NHANES participants. KEEP NHANES 99-2 HSG: 26.8 SHS: 9. 7 GSL: 5.7 HSG: 26 GSL: 23 SC: 27.3 PG: 11.3 CG: 19.2 SC+: 51 Educational Status GSL: Grade school or less SHS: Some high school HSG: High school graduate SC: Some college CG: College graduate PG: Post graduate Figure 2.7 KEEP: N=36,712. Excludes participants with missing values for educational status. Figures KEEP: N=36,712, NHANES: 11,394. Excludes participants with missing values for educational status. Figure 2.11 KEEP: N=35,959 for race; N=36,688 for census region. Excludes participants with missing values for educational status, race, or census region. Figure 2.12 NHANES: N=11,394. Race & Hispanic ethnicity are not mutually exclusive. Figure 2.9 educational status in KEEP & NHANES participants, by age Older participants in both the KEEP and NHANES populations report lower levels of education. participants of KEEP GSL SC NHANES 99-2 SHS CG HSG PG All >75 GSL HSG SC >75 s14 National Kidney Foundation Kidney Early Evaluation Program

17 Figure 2.1 educational status in KEEP & NHANES participants, by gender Education levels in the KEEP and NHANES populations do not differ significantly by gender. participants KEEP NHANES 99-2 GSL SHS HSG SC CG PG GSL HSG SC of 2 1 Male Female Male Female Figure 2.11 educational status of KEEP participants, by race & U.S. Census Region By race, 59 61% of white and black KEEP participants report further education after high school, compared to 5% of those of other races, and 4% of Hispanics. By region, this ranges from 55% in the Northeast to 64% in the West. participants GSL SHS HSG SC CG PG of 1 White Black Other Hispanic Northeast Midwest South West Figure 2.12 educational status of NHANES 99 2 participants, by race Educational status varies more by race in NHANES participants than in the KEEP population. Among whites, 57% have greater than a high school education, compared to 37 38% among those of other races. participants of Grade school or less High school graduate Some college + White Black Other Hispanic Chapter 2 Participant demographics s15

18 insurance coverage Figure 2.13 insurance coverage in KEEP participants, by year The percent of KEEP participants with insurance coverage has fallen slightly, to 8.3 in 24. insurance with Figure 2.14 insurance coverage in KEEP participants, by U.S. Census Region & year The KEEP program is now reaching more uninsured people. In the West, for example, 29% of participants are uninsured. 1 insurance with Northeast Midwest South West Figure 2.15 insurance coverage in KEEP & NHANES participants, by age & gender By age, insurance coverage is slightly greater in NHANES participants, particularly those age 46 6, and increases steadily by age. Women have slightly higher rates of coverage than men. insurance 1 Age KEEP Gender NHANES with 4 2 All >75 Male Female s16 National Kidney Foundation Kidney Early Evaluation Program

19 Figure 2.16 insurance status of KEEP participants, by race & U.S. Census Region Only 43% of Hispanic KEEP participants living in the Midwest have insurance coverage, compared to 93% of whites in the Northeast. 1 insurance with Northeast Midwest South West All White Black Other Hispanic Figure 2.17 insurance status of KEEP & NHANES participants, by race In the KEEP and NHANES populations the percent of participants insured ranges from 89 and 86, respectively, in whites to 57 and 66 in Hispanics. with insurance KEEP NHANES 99-2 White Black Other Hispanic Figure 2.18 distribution by insurance status of KEEP participants reporting they have insurance Fifty-four percent of insured KEEP participants have non-medicare insurance, while 23% are covered by Medicare alone or with an additional payor. Medicare with other than Medi caid: Medicare: 8.4 Medicare/Medicaid: 3.2 Figure 2.13 KEEP N=35,677. Excludes participants with missing values for insurance status. Figure 2.14 KEEP N=35,653. Excludes participants with missing values for insurance status or census region. Figure 2.15 KEEP: N= 35,677. Excludes participants with missing values for insurance status. NHANES: N=11,26. Figure 2.16 KEEP: N=34,881. Excludes participants with missing values for insurance status, race, or census region. Race & Hispanic ethnicity are not mutually exclusive. Figure 2.17 KEEP: N=35,677, NHANES: N=11,26. Figure 2.18 KEEP: N=37,155. Non-Medicare: 54 Unknown or missing: 22.6 Chapter 2 Participant demographics s17

20 access to medical care Figure 2.19 KEEP participants with a physician, by year On average, 88% of KEEP participants report having a physician. physician a with 4 2 All Figure 2.2 KEEP participants with a physician, by U.S. Census Region Ninety-two percent of KEEP participants in the Northeast report having a physician, compared to 85% in the West. 1 physician a with Northeast Midwest South West Figure 2.21 KEEP participants with a physician, by age, gender, & race/ethnicity The percentage of KEEP participants with a physician rises steadily by age. Women are more likely than men to have a physician, and whites and blacks more likely than Hispanics and people of other races. 1 Age Gender Race/ethnicity physician a 8 6 with 4 2 All >75 Male Female White Black Other Hispanic s18 National Kidney Foundation Kidney Early Evaluation Program

21 Figure 2.22 KEEP participants with a physician, by race & U.S. Census Region KEEP participants in the Northeast are more likely to report having a physician, while those in the western states are least likely. 1 with a physician Northeast Midwest South West All White Black Other Hispanic Figure 2.23 KEEP participants with a physician, by education & insurance status Regardless of education, 94% of KEEP participants with insurance have a physician, compared to 52 58% of those lacking insurance. 1 physician a with <HS&NIns <HS&Ins HS+&NIns HS+&Ins Figure 2.19 KEEP: N=36,25. Excludes participants with missing values for physician. Figure 2.2 KEEP: N=36,1. Excludes participants with missing values for physician or census region. Figure 2.21 KEEP: N=36,25. Excludes participants with missing values for physician. Figure 2.22 KEEP: N=35,218. Excludes participants with missing values for physician or census region. Race & Hispanic ethnicity are not mutually exclusive. Figure 2.23 KEEP: N=34,727. Excludes participants with missing values for education, insurance, or physician. Education & insurance <HS&NIns: Less than a high school education, & no insurance <HS&Ins: Less than a high school education, & insurance HS+&NIns: High school education or greater, & no insurance HS+&Ins: High school education or greater, & insurance Chapter 2 Participant demographics s19

22 chapter summary Figure 2.1 By 24, the total number of eligible participants in the KEEP study reached 37,155, and the number of affiliates had risen to 45. Figure 2.5 Fifty percent of KEEP participants live in the South, compared to only 23, 17, and 1% in the Northeast, Midwest, and West, respectively. Figure 2.6 Compared to the NHANES population, the KEEP population has a higher percentage of older participants, of women, and of blacks. Figure 2.7 The educational status of KEEP participants has varied little by cohort year; slightly more than one in four completed their education with a high school diploma, while one in five stopped with a college degree. Figure 2.13 The percent of KEEP participants with insurance coverage has fallen slightly, to 8.3 in 24. Figure 2.15 By age, insurance coverage is slightly greater in NHANES participants, particularly those age 46 6, and increases steadily by age. Women have slightly higher rates of coverage than men. Figure 2.16 Only 43% of Hispanic KEEP participants living in the Midwest have insurance coverage, compared to 93% of whites in the Northeast. Figure 2.18 Fifty-four percent of insured KEEP participants have non-medicare insurance, while 23% are covered by Medicare alone or with an additional payor. Figure 2.11 By race, 59 61% of white and black KEEP participants report further education after high school, compared to 5% of those of other races, and 4% of Hispanics. By region, this ranges from 55% in the Northeast to 64% in the West. Figure 2.12 Educational status varies more by race in NHANES participants than in the KEEP population. Among whites, 57% have greater than a high school education, compared to % among those of other races. Figure 2.19 On average, 88% of KEEP participants report having a physician. Figure 2.21 The percentage of KEEP participants with a physician rises steadily by age. Women are more likely than men to have a physician, and whites and blacks more likely than Hispanics and people of other races. Figure 2.23 Regardless of education, 94% of KEEP participants with insurance have a physician, compared to 52 58% of those lacking insurance. s2 National Kidney Foundation Kidney Early Evaluation Program

23 Health history 3 history of diabetes history of cardiovascular disease history of smoking family history & comorbidity history of hypertension history of obesity evidence of kidney disease intervention I felt the free screening was especially helpful and talking to a doctor afterwards was good. The best part was getting the results in the mail that explained all the tests and what to look for, etc. Please let me know when you will be having another screening. KEEP Participant Screening date: American Journal of Kidney Disease Vol 46, No. 5, Suppl 3 (Nov), 25

24 history of diabetes Twenty-five percent of KEEP participants report having diabetes; the highest rates occur in older patients, men, and people of races other than white or black. Higher rates of JNC 7 stage 1 or 2 hypertension occur in participants with diabetes compared to those without the disease, and elevated blood pressure occurs in 83 and 75% of black and white KEEP participants with diabetes, respectively; rates of elevated blood pressure reach 6% in blacks who do not have diabetes. A blood glucose greater than the normal limit is evident in 7% of participants with no self-reported diabetes but who list a warning sign for diabetes; this rises to 1% in particpants age 76 and older. history of hypertension More than 5% of KEEP participants report having hypertension, compared to 25% in the NHANES population. An elevated glucose is found more frequently in participants with self-reported hypertension, and among these participants it is most common in men, Hispanics, and people of other races. Compared to the number of KEEP participants with self-reported hypertension, 5 9% more have a measured elevated blood pressure; the difference is smaller in the NHANES population. In both the KEEP and NHANES populations the prevalence of self-reported hypertension is highest in participants who have insurance and less than a high school education. history of cardiovascular disease Overall, 16% of KEEP participants report a history of cardiovascular disease (CVD) and this rate is double in participants age 75 and older. Men have slightly higher rates of the disease compared to women, as do whites compared to blacks, people of other races, and Hispanics. Participants with CKD are more likely to report a history of CVD compared to those without the disease. Elevated blood pressure is by far the most common risk factor in KEEP participants with CKD regardless of whether they have cardiovascular disease. Participants with insurance and less than a high school education have the highest rates of CVD. history of obesity Seventy-seven percent of KEEP participants are classified as overweight or obese, compared to 64% of NHANES participants. In both study cohorts being overweight is more common in men; female KEEP participants, however, are more likely to be obese. More than half of black KEEP participants are obese or extremely obese. Participants in the Midwest are the most likely to have a BMI 3 kg/m 2. Rates of hypertension and diabetes rise in parallel with rising BMI. s22 National Kidney Foundation Kidney Early Evaluation Program

25 history of smoking Smoking is less common in KEEP participants than in the NHANES population, at 13 versus nearly 25%. More KEEP participants report that they have quit smoking from 27% of Hispanics to 34% of whites while in the NHANES population 17% of blacks and 27% of whites report quitting. A history of smoking is less likely in participants who have at least a high school education and who have insurance. Diabetes is more common in participants who used to smoke as opposed to those who never smoked or who currently smoke. Sixty percent of KEEP participants who used to smoke report having hypertension, compared to 45% of current smokers. evidence of kidney disease Kidney stones are reported by 7% of KEEP participants, while 2% report having kidney disease. Kidney stones are more common in males, and self-reported kidney disease is not influenced by gender. Compared to blacks, white participants are more than three times more likely to report having kidney stones; overall, stones are reported by 7% of the KEEP population. The proportions of KEEP participants with Stage 2 CKD are similar across racial and ethnic groups; whites, however, are twice as likely to have Stage 3 CKD compared to other participants. Among participants with a warning sign for CKD, more than half of those age 75 and older have a positive urine albumin, while 26% have an abnormal albumin/creatinine ratio. By race, 56% of black participants have a positive microalbumin and 16 17% of blacks and those of other races have abnormal albumin/creatinine ratios. family history & comorbidity The greatest proportion of KEEP participants with CKD reside in the Northeast. Rates of self-reported diabetes range from 22% in the West to 27% in the Midwest. In the Midwest and South, nearly half of participants have BMIs that classify them as obese. Seventy-nine percent of KEEP participants with self-reported diabetes have a family history of the disease, while 78 82% have a family history of hypertension. Twenty percent of KEEP participants have a family member who has suffered a heart attack and 5% have had such an attack themselves. intervention Hypertension and abnormal urine results are the most common reasons KEEP participants see a physician after going through the program. Thirteen percent fail to follow up with a physician because of lack of time. Thirty-five percent of participants receiving treatment for anemia are placed on over-the-counter medications, while 18% receive prescription medications. For the treatment of diabetes, 33% of participants are advised to monitor their blood sugar, while 35% are placed on drug therapy. For the treatment of hypertension, 42% of participants are prescribed medication. Compared to participants of other races, whites are more likely to follow up with a physician following abnormal urine test results. Chapter 3 Health history s23

26 history of diabetes Figure 3.1 self-reported diabetes in KEEP & NHANES participants, by age, gender, & race/ethnicity One in four KEEP participants report having diabetes, compared to 6% of the NHANES population. Rates are greatest in those age 61 75, in males, and in people of other races. DM self-reported Age Gender Race/ethnicity KEEP NHANES 99-2 with 1 All Male Female White Black Other Hispanic JNC 7 Hypertension Normal systolic <12 mmhg & diastolic <8 mmhg Prehypertension systolic mmhg or diastolic 8-89 mmhg Stage 1 systolic mmhg or diastolic 9-99 mmhg Stage 2 systolic 16 mmhg or diastolic 1 mmhg Elevated blood pressure (JNC 7) DM or CKD: Systolic: 13 mmhg or Diastolic: 8 mmhg No DM or CKD: Systolic: 14 mmhg or Diastolic: 9 mm Hg Figure 3.2 blood pressure stages (JNC 7) in KEEP & NHANES participants, by self-reported diabetic status The highest rates of Stage 1 and 2 hypertension occur in KEEP participants with diabetes, at 32 and 19%, respectively. participants of Diabetic KEEP NHANES 99-2 Normal Pre HTN Stage 1 Stage 2 Non-diabetic Normal Pre HTN Stage 1 Stage 2 Education & insurance <HS&NIns: Less than a high school education, & no insurance <HS&Ins: Less than a high school education, & insurance HS+&NIns: High school education or greater, & no insurance HS+&Ins: High school education or greater, & insurance Glucose greater than the normal limit Fasting: >126 mg/dl Non-fasting: >139 mg/dl Figure 3.3 elevated blood pressure (JNC 7) in KEEP & NHANES participants, by race/ethnicity, gender, & self-reported diabetic status Elevated blood pressure occurs in 83% of black KEEP participants with diabetes, and 75% of whites. Rates are lower in participants with no diabetes, but still reach 6% in black participants. BP elevated with 1 Diabetic White Black Other Hispanic Male Female Non-diabetic KEEP NHANES 99-2 White Black Other Hispanic Male Female s24 National Kidney Foundation Kidney Early Evaluation Program

27 Figure 3.4 self-reported diabetes in KEEP & NHANES participants, by blood pressure stage (JNC 7) Sixteen percent of KEEP participants with a normal measured BP report having diabetes, compared to 33% of those with Stage 2 hypertension. Figure 3.5 percent of KEEP & NHANES participants with self-reported diabetes, by education & insurance status Rates of self-reported diabetes are greatest for KEEP participants who have insurance coverage but have less than a high school education. DM self-reported with > NL glucose with KEEP NHANES 99-2 Normal Prehypertension Stage 1 Stage 2 Figure 3.6 measured glucose > normal limit in KEEP participants, by age, gender, race/ethnicity, & self-reported DM Fifty percent of KEEP participants who report having diabetes have a measured glucose level greater than the normal limit. Age Gender Race/ethnicity Self-reported DM No self-reported DM All M F W B Oth. Hisp >75 Figure 3.7 measured glucose > normal limit in KEEP participants with no self-reported diabetes & who listed one of the warning signs for diabetes, by age, gender, & race/ethnicity Seven percent of KEEP participants with no self-reported diabetes who listed a warning sign for diabetes have an elevated glucose; this rises to 1% in those age 75 and older. with self-reported diabetes KEEP: Age NHANES * <HS&NIns HS+&NIns <HS&Ins HS+&Ins Race/ethnicity White Black Other Hispanic <HS&NIns HS+&NIns <HS&Ins HS+&Ins Figure 3.1 KEEP: N=36,727, NHANES N=11,423. Excludes participants with missing values for diabetic status. Figure 3.2 KEEP N=36,368, NHANES N=1,89. Excludes participants with missing values for diabetic or hypertensive status. Figure 3.3 KEEP: N=36,379, NHANES=1,89. Excludes participants with missing values for diabetic status or blood pressure. Figure 3.4 KEEP: N=36,368, NHANES N=1,89. Excludes participants with missing values for diabetic and hypertensive status. Figure 3.5 KEEP: N=34,956, NHANES N=11,165. Excludes participants with missing values for self-reported diabetic status, education, & insurance. *Sample size less than 3 or coefficient of variation is not less than 3%. Figure 3.6 KEEP: N=35,663. Excludes participants with missing values for self-reported diabetic status or blood glucose. Figure 3.7 KEEP: N=11,641. Excludes participants with missing values for self-reported diabetic status & blood glucose. Race & Hispanic ethnicity are not mutually exclusive. with glucose > NL Age Gender Race/ethnicity 2 All M F W B Oth. Hisp >75 Chapter 3 Health history s25

28 history of hypertension Figure 3.8 self-reported hypertension in KEEP & NHANES participants, by age, gender, & race/ethnicity More than one in two KEEP participants report having hypertension, compared to one-quarter of the NHANES population. This number rises with age and, by race/ethnicity, is greatest in blacks. HTN self-reported Age Gender Race/ethnicity KEEP NHANES 99-2 with 2 All >75 Male Female White Black Other Hispanic Elevated blood pressure (JNC 7) DM or CKD: Systolic: 13 mmhg or Diastolic 8 mmhg No DM or CKD: Systolic: 14 mmhg or Diastolic: 9 mm Hg Glucose greater than the normal limit Fasting: >126 mg/dl Non-fasting: >139 mg/dl Education & insurance <HS&NIns: Less than a high school education, & no insurance <HS&Ins: Less than a high school education, & insurance HS+&NIns: High school education or greater, & no insurance HS+&Ins: High school education or greater, & insurance Figure 3.9 elevated blood glucose in KEEP participants, by self-reported HTN Twenty-three percent of those who report hypertension have an elevated blood glucose. glucose elevated with SR HTN No SR HTN Figure 3.1 elevated blood glucose in KEEP participants, by gender, race/ethnicity, & self-reported hypertension In KEEP participants who report hypertension, rates of elevated glucose are higher in men than in women, and in Hispanics and those of other races than in whites and blacks. glucose elevated Gender Race/ethnicity Self-reported hypertension No self-reported hypertension with 1 Male Female White Black Other Hispanic s26 National Kidney Foundation Kidney Early Evaluation Program

29 Figure 3.11 self-reported hypertension vs. elevated measured blood pressure (JNC 7) in KEEP & NHANES participants, by age & gender In the KEEP population, rates of measured elevated blood pressure are higher than those of self-reported hypertension, particularly among those age 18 45, while for NHANES rates are higher in those over 75. of participants KEEP: Age Gender NHANES 99-2: Age Self-reported HTN Measured elevated BP Gender All M F >75 All M F >75 Figure 3.12 self-reported hypertension vs. elevated measured blood pressure (JNC 7) in KEEP & NHANES participants, by race/ethnicity Among KEEP participants, rates of measured elevated blood pressure are 5 9 percentage points greater than those of self-reported hypertension. The two rates are more similar in the NHANES population. 8 KEEP NHANES 99-2 participants of White Black Other Hispanic Self-reported hypertension Measured elevated blood pressure White Black Other Hispanic Figure 3.8 KEEP: N=36,788, NHANES 11,271. Excludes participants with missing values for self-reported hypertension status. Figures KEEP N=35,726. Excludes participants with missing values for glucose or self-reported hypertension status. Figures KEEP: N=36,53, NHANES N=11,271 for self-reported hypertension & N=9,423 for measured blood pressure. Excludes participants with missing values for self-reported hypertension or measured blood pressure. Figure 3.13 KEEP: N=35,, NHANES N=11,271. Excludes participants with missing values for self-reported hypertension status, education, & insurance. *Sample size less than 3 or coefficient of variation is not less than 3%. Race & Hispanic ethnicity are not mutually exclusive. Figure 3.13 Self-reported hypertension in KEEP & NHANES participants, by education & insurance status In both the KEEP and NHANES populations, and across age and race/ethnicity groups, rates of selfreported hypertension are greatest in participants with insurance and less than a high school education. hypertension KEEP: Age Race/ethnicity White NHANES 99-2: Age Race/ethnicity 46-6 Black 61+ Other Hispanic SR with 4 2 <HS&NIns HS+&NIns <HS&Ins HS+&Ins <HS&NIns HS+&NIns <HS&Ins HS+&Ins <HS&NIns HS+&NIns <HS&Ins HS+&Ins * <HS&NIns HS+&NIns <HS&Ins HS+&In Chapter 3 Health history s27

30 history of CVD Figure 3.14 cardiovascular disease in KEEP participants, by age, gender, & race/ethnicity Sixteen percent of KEEP participants report a history of CVD; the rate reaches 32% in those age 76 and above. The rate is slightly higher in men than women, and in whites compared to other races. % with cardiovascular disease Age All >75 Gender Race/ethnicity Male Female White Black Other Hispanic Figure 3.15 cardiovascular disease in KEEP participants with & without CKD, by age, gender, & race/ethnicity Across most age, gender, and race/ethnicity groups, KEEP participants with CKD are more likely than those without it to report a diagnosis of cardiovascular disease. % with cardiovascular disease Age CKD No CKD All >75 Gender Race/ethnicity Male Female White Black Other Hispanic s28 National Kidney Foundation Kidney Early Evaluation Program