Ashberyh CHAPTER. John

Transcription

1 A knowledge that people live close by is, I think, enough. And even if only first names are ever exchanged The people who own them seem rock-true and marvelously self-suficient. John Ashberyh The Ongoing Story 72 Introduction 74 Cardiovascular comorbidity {cardiovascular comorbidity in diabetic & hypertensive } Bioqemical qaracteristics {blood urea nitrogen} {serum creatinine} {BUN/creatinine ratio} {albumin} 76 Prescription drug therapy for cardiovascular disease { with congestive heart failure, cardiovascular disease, & hypertension} 7 EPO use D anemia at initiation {pre-esrd EPO use & hemoglobin at initiation} {geographic variations} CHAPTER Patient characterisics 2 Predictors egfr {egfr at initiation} {body mass index} {BMI, BUN/creatinine ratio, & albumin as predictors egfr} {egfr & comorbidity} 4 Characterisics institutionalized {demographics} {diseases} {cognitive & physical impairment} 6 Summary

2 atient selection for ESRD treatment has been changing since the early 19s, as increasing numbers enter therapy with a diagnosis cardiovascular disease. In with both diabetes and hypertension at the start ESRD, for example, percent carry a diagnosis cardiovascular disease in the following year; in non-diabetics with hypertension, the number is 55 percent. and black with both diabetes and hypertension have similar levels cardiovascular disease, but when diabetes is not present levels are lower in blacks; this is particularly true for ischemic heart disease, peripheral vascular disease, and congestive heart failure Across all age groups, and consistent with the problem fluid retention secondary to the progressive loss urine output as approach ESRD, heart failure is the most widespread complicating condition at initiation. The diabetic population with advancing chronic kidney disease is particularly vulnerable to diuretic resistance, as illustrated by their initiation dialysis treatment with higher estimated glomerular filtration rates (egfrs), lower blood urea nitrogen (BUN) levels, and lower serum creatinine levels. We assess here treatment for congestive heart failure (CHF) in a younger prevalent dialysis population, using data from the Medstat MarketScan database on prescription drug use in an employed population. The percent age who receive angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin II receptor blockers (ARBs) grew from 3.2 in to 53. in 2. The use ACE inhibitors/arbs is even greater in dialysis with CHF, with almost percent those age receiving these drugs. But given that ACE inhibitors have been the most significant factor in the recent improvement heart failure survival rates in the general population, the number dialysis who might benefit from these two classes drugs may be greater than the number receiving treatment. The data show that a higher percent younger dialysis (age 44) with CHF are being treated with ACE inhibitors/arbs, but since very few are represented in this group these data must be interpreted with caution. Information on the Medical Evidence form allows us to assess some the care provided to chronic kidney disease prior to their initiation ESRD therapy. Only thirtythree percent new ESRD, for example, receive EPO treatment before beginning ESRD therapy. And while mean hemoglobins at initiation rose overall from 9.2 g/dl in May 1995 to 1.1 g/dl in May 3, these levels are still well below the minimum target set by the National Kidney Foundation s K/DOQI guidelines 11 g/dl; nearly three out four Introducion 72 Patient characteristicsh

3 incident enter treatment with a hemoglobin below this level. Overall, the lowest hemoglobin levels continue to occur in pediatric though more these now receive epoetin before dialysis and in blacks, who are less likely to receive epoetin prior to initiation. Geographic depictions hemoglobin levels across the country show marked improvements nationwide, which may reflect better pre-dialysis care, but could also represent starting ESRD therapy at an earlier point in their course disease. In our exploration biochemical characteristics at initiation, data show that serum creatinine and BUN levels at initiation are declining, while egfrs are increasing also an indication, perhaps, that are beginning ESRD therapy earlier in the course their CKD. Our continued assessment the association between egfr and incident patient comorbidity shows a direct relationship, suggesting that this earlier initiation therapy may be due to increased comorbidity, with conditions such as fluid overload and CHF amplifying the need for renal replacement therapy. This year we have added new data on the BUN/creatinine ratio, a clinical measure pre-renal azotemia, which is itself typical CHF, nephrotic syndrome, and liver disease. High BUN/creatinine ratios occur in elderly, in whites, and in with lower albumin levels, and high ratios are also a risk factor for carrying a diagnosis CHF. Other risk factors include diabetes, older age, ASHD, a high BUN level, a low creatinine level, a low albumin level, and a high BUN/ 1 Other primary diagnosis, with DM secondary Hypertension, with DM secondary Glomerulonephritis, with DM secondary Diabetes: primary N Am Asian Hispanic {3.1} Primary diagnosis diabetic ESRD at initiation, by race incident ESRD with diabetes & a first service date between May 1995 & June 3; data from Medical Evidence form. creatinine ratio. These data are consistent with the increasing degrees CHF as a complicating condition seen in the ESRD population at initiation. A marker nutrition and potential obesity, the body mass index (BMI) has been rising, slowly but steadily, across all segments the population entering ESRD. Indices are lowest in the Asian population, and highest in Native Americans and blacks. These results are consistent with data showing a high prevalence diabetes in these populations. This year we present new information on ESRD who reside in nursing homes, comparing them to the entire population receiving ESRD therapy. As expected, nursing home both incident and prevalent are older, more likely to be female, and more likely to have diabetes. Cognitive impairment in this population is widespread, with 3 percent unable to name the season, and percent having impaired decision-making skills. Up to percent require a mobility assistance device. The annual mortality this population is two to three times higher than that the ESRD population as a whole, and is highest among whites. And the population s comorbidity is extraordinary diabetes occurs in 63 percent, Alzheimer s in percent, depression in 37 percent, CHF in 39 percent, and CVA/TIA in 29 percent; a full 7 percent have evidence cardiovascular disease. Information we present here is only {3.7} The percent the beginning what needs to be a prevalent dialysis thorough study this particularly with CHF who vulnerable population, and an receive ACE inhibitors/ ARBs and/or beta blockers examination the success increased from to 2. rehabilitation programs in meeting and with CHF are receiving Only 13.4 percent age digitalis preparations. {3.1} The mean patient needs. hemoglobin level at initiation increased from 9.2 g/dl in 1995 to 1.1 in May 3. Preemptive transplant have the highest hemoglobins, at approximately 11. g/dl, while levels are lowest in hemodialysis, at 1. g/dl. {3.a} CHF at initiation is highly associated with advancing age, female gender, diabetes, ischemic heart disease, peripheral vascular disease, high BUN, low Chapter highlights creatinine, and a high BUN/creatinine ratio. {3.32} Mean BMI at initiation has increased from 25 kg/m 2 in 1995 to nearly 2 in 3. Asians have the lowest BMI at initiation, and Native Americans and blacks the highest. H4 USRDS Annual Data Report 73

4 {3.2} Cardiovascular comorbidity in incident who survive one year after ESRD initiation: diabetic with hypertension, by race hospitalized cardiovascular disease CHF ISHD PVD Pecent Year initiation {3.3} Cardiovascular comorbidity in incident who survive one year after ESRD initiation: non-diabetic with hypertension, by race hospitalized cardiovascular disease CHF ISHD PVD Year initiation {3.4} Cardiovascular comorbidity in incident who survive one year after ESRD initiation: diabetic with hypertension, by age & race : all cardiovascular disease CHF ISHD PVD hospitalized Year initiation Cardiovascular comorbidity 74 Patient characteristicsh

5 rior to 1995, comorbid conditions were not included on the Medical Evidence form, making it difficult to assess long-term comorbidity. As an alternative, we have used inpatient hospitalization claims to assess comorbidity, looking here at the presence cardiovascular disease since 194. The proportion diabetic with cardiovascular disease has increased 1.4 percent since 194 (Figure 3.2). This increase is reflected in both whites and blacks, though a slightly greater percentage whites carry the disease. Congestive heart failure is the most common cardiac condition in both races, and since 194 has increased by 17.5 percent in whites and 16.5 percent in blacks. Patterns in non-diabetic are similar to those diabetics, though cardiovascular disease is less frequent. The percent with congestive heart failure, for example, is.7, a level 4.2 percent lower than that found in diabetic (Figure 3.3). Interestingly, the increase cardiovascular disease since 194 is largest in younger than 65, while the percent with the disease remains greater in those age 65 and older (Figure 3.4). By race, and regardless diabetic status, blacks age 44 show the largest increases (.5 and 15.3 percent) since 194. In 1, the percentage non-diabetics with cardiovascular disease was 7 1 percent less for under age 65 compared to diabetics, but since 194 the percent with cardiovascular disease has increased more in older non-diabetics ( percent) compared to slightly smaller increases (.6 4. percent) in diabetics during the same time period (Figure 3.5). {Figures 3.2 5} incident Medicare surviving one year days after initiation, with Medicare Parts A & B as primary payor. Hospitalization data from REBUS inpatient hospitalization diagnosis codes; data from ESRD inpatient database. {3.5} Cardiovascular comorbidity in incident who survive one year after ESRD initiation: non-diabetic with hypertension, by age & race : all cardiovascular disease CHF ISHD PVD hospitalized Year initiation H4 USRDS Annual Data Report 75

6 ecause the Medicare database contains prescription drug data only on selected parenteral drugs such as erythropoietic agents, intravenous iron, vitamin D products, and antibiotics, previous Annual Data Reports have focused on these drugs. In this report, however, we use the Medstat MarketScan database to obtain information on prescription drug use in chronic kidney disease and dialysis. Medstat data is a compilation patient data from multiple employer group health plans (EGHPs) and as such represents younger, in general, than does the Medicare database. {3.6} Cumulative percent prescription drug use in incident dialysis, overall, by age, gender, & diabetic status ACE-I/ARBs: Age Gender Diabetic status -44 Male Female Diabetic Non-diabetic receiving drug Lipid-lowering agents 1 2 Diuretics Months {3.7} Cumulative percent prescription drug use in incident dialysis with CHF, by age, gender, & diabetic status 1 75 ACE-I/ARBs: Age Gender Diabetic status -44 Male Female Diabetic Non-diabetic receiving drug Beta blockers Digitalis preparations Diuretics Months Prescription drug therapy for cardiovascular disease 76 Patient characteristicsh

7 {3.} Cumulative percent prescription drug use in incident dialysis with CVD, by age, gender, & diabetic status ACE-I/ARBs: Age Gender Diabetic status -44 Male Female Diabetic Non-diabetic receiving drug Beta blockers Lipid-lowering agents Months {3.9} Cumulative percent prescription drug use in incident dialysis with hypertension, by age, gender, & diabetic status ACE-I/ARBs : Age Gender Diabetic status -44 Male Female Diabetic Non-diabetic receiving drug Beta blockers Calcium channel blockers Months Figures show the cumulative percent incident dialysis who received selected drugs in the years 2. Figure 3.6 shows the use ACE inhibitors/arbs, lipid lowering agents (including statins), and diuretics. It is noteworthy that the use ACE inhibitors/arbs and lipid-lowering agents is increasing overall. Interestingly, 26 percent dialysis, overall, receive some type diuretic therapy. Figures show selected drug use in dialysis with CHF, cardiovascular disease, and hypertension. The use ACE inhibitors/arbs and beta blockers has increased in dialysis overall, as well as in with various cardiovascular disorders. {Figures 3.6 9} incident EGHP dialysis, age 64. Two-year study period includes a one-year selection period, used to define comorbidity, & a oneyear observation period, used to count prescription drug therapy. Months shown are months in the observation period. H4 USRDS Annual Data Report 77

8 {3.1} Mean hemoglobin at initiation, by first modality Hemoglobin (g/dl) Transplant 11 Peritoneal dialysis 1 Hemodialysis ean hemoglobin levels at the initiation ESRD treatment increased from 9.2 g/dl in May 1995 to 1.1 g/dl in May 2 (Figure 3.1). Levels are consistently highest in transplant, and lowest in those on hemodialysis. Patients treated with EPO prior to ESRD have higher hemoglobin levels up to.55 g/dl higher than those not receiving treatment (Figure 3.11). The use EPO in the period leading up to a diagnosis ESRD has grown; nearly one-third now receive this treatment, compared to 22 percent in early Between May 1995 and June 3, the percent with initial hemoglobins 11 g/dl or higher the target set by the National Kidney Foundation s Kidney Disease Outcomes Quality Initiative (K/DOQI) rose from 15.9 percent to 29 percent (Figure 3.). The percent with hemoglobins above g/dl has {3.11} Mean hemoglobin at initiation, by EPO treatment {3.} Patient distribution, by mean monthly hemoglobin (g/dl) at initiation Hemoglobin (g/dl) Hgb: with EPO % receiving EPO Hgb: without EPO Hgb: Overall receiving EPO < 1-<11 9-<1 < {3.13} Hemoglobin & EPO at initiation, by age & gender {3.14} Hemoglobin & EPO at initiation, by race/ethnicity & gender 1.4 Mean hemoglobin: Male Female 1.4 Mean hemoglobin: Male Female Hemoglobin (g/dl) Hemoglobin (g/dl) EPO use.4 EPO use receiving EPO 3 receiving EPO Asian N Am Hispanic Asian N Am Hispanic EPO use D anemia at initiation 7 Patient characteristicsh

9 more than doubled, from 6.9 to 14.2 percent. Across age groups and genders, the increase in hemoglobin levels since has been relatively consistent, at.5 g/dl (Figure 3.13). This same consistency is not seen, however, in EPO use prior to ESRD. The youngest those age 19 remain the most likely to receive EPO, but their rate use has increased very little, particularly in girls, with 37.4 percent receiving pre-esrd EPO in, and 37.2 percent in 2. EPO use for men age and for women ages 75 and older has, in contrast, grown nearly 11 percentage points since. By race, mean hemoglobin levels at initiation continue to be highest in white, and are now lowest in blacks both genders and in Native American females (Figure 3.14). Since, the greatest increase.6.7 g/dl has occurred in Asian both genders, while in Native American women the increase has been only.3 g/dl. The greatest increase in pre-esrd EPO use has occurred in black and Native American males, while Asian and white females have seen the smallest increase. Mean hemoglobins at the initiation dialysis increased in most areas the country during the 2 period, but remain below the K/DOQI target levels (Figures 3.15). Hemoglobins tend to be lower in the southern and Gulf Coast portions the country and, when comparing levels by race, are slightly higher in whites than in blacks. Nationwide, more are now receiving EPO prior to the initiation dialysis than in earlier years; this in all likelihood accounts for the overall rise in mean hemoglobins at the start therapy (Figure 3.16). There are small differences in the percentages whites and blacks receiving EPO when comparing the upper quintiles, and race-specific assessments show noticeable regional differences in the black population. s residing in the Upper Midwest are more likely to receive EPO prior to initiation compared to blacks in the southern regions the country. {3.15} Geographic variations in mean hemoglobin (g/dl) at initiation, by race {3.16} Variations in the % receiving EPO before initiation, by race 1996 : 1 2: 1.+ (1.1) 9.5 to < to < to <9.74 below 9.59 (9.32) 1996 : s 1996 : s 1 2: s (41.4) 2.2 to < to <2.2. to <24.3 below. (17.4) 1 2: s (.) 29.2 to < to < to <25.5 below 22.2 (1.3) 1996 : s 9.3+ (1.2) 9.6 to < to < to <9.54 below 9.33 (9.9) 1 2: (39.6) 2.2 to < to <2.2. to <24.3 below. (16.) 1.7+ (1.3) 9.94 to < to < to <9.3 below 9.71 (9.54) 1.7+ (1.2) 9.94 to < to < to <9.3 below 9.71 (9.4) 9.3+ (1.1) 9.6 to < to < to <9.54 below 9.33 (9.) 1996 : 1.+ (1.2) 9.5 to < to < to <9.74 below 9.59 (9.44) 1 2: s 1996 : s {Figures } incident ESRD with a first service date between May 1995 & June 3; data from Medical Evidence form. {Figures } incident ESRD, by HSA, unadjusted; data from the Medical Evidence form (41.3) 29.2 to < to < to <25.5 below 22.2 (19.3) 1 2: 33.+ (.7) 29.9 to < to < to <25. below 21.7 (16.3) 33.+ (39.7) 29.9 to < to < to <25. below 21.7 (17.6) H4 USRDS Annual Data Report 79

10 Blood urea nitrogen (BUN) at initiation {3.17} by age {3.1} by race/ethnicity etween 1995 and 3 the mean blood urea nitrogen (BUN) level in starting ESRD therapy fell.6 mg/dl (Figure 3.17). By age, the smallest change occurred in the youngest, and the greatest in the oldest 4.5 and 1. mg/dl, respectively. Asian consistently have the highest pre-esrd BUN levels, while blacks and Native Americans tend to have the lowest (Figure 3.1). Levels have decreased most in Asians and Native American, and least in Hispanics. Serum creatinine levels at initiation show a more distinct pattern by age, with levels highest in age 44, and lowest in those age 75 and older (Figure 3.). Since 1995, levels have decreased. mg/dl in the youngest, and 1.5 mg/dl in the eldest. By race and ethnicity, they are highest in blacks, and lowest in whites (Figure 3.21). Levels have fallen 1. mg/dl in blacks and Asians, and 1.1 mg/dl in Native Americans. It is ten assumed that with low serum creatinine levels have high levels residual renal function. But this is not always the case, as poor nutrition and low muscle mass can also be marked by low creatinine levels. Caution should therefore be used in interpreting the data to reflect earlier initiation ESRD treatment. The BUN/creatinine ratio can be used to assess hydration and metabolic processes. At the start therapy, ratios are consistently highest in age 75 and older, and lowest in those age 44 (Figure 3.23). Since 1995, the ratios for these age groups have increased 2.1 and.5, respectively. Ratios are highest in whites and lowest in blacks; the greatest increase 1. has occurred in whites (Figure 3.24). Ratios are also highest in older with albumins below the test s lower limit, possibly indicating catabolic tendencies due to poor nutrition (Figure 3.26). {Figures } incident ESRD with a first service date between May 1995 & June 3; data from Medical Evidence form. In Figure 3.19 data for Native Americans age 19 are omitted because the small patient population. {Table 3.a} incident ESRD with a first service date between May 1995 & July 3. BUN (mg/dl) {3.19} by age & race/ethnicity BUN (mg/dl) Serum creatinine (mg/dl) Serum creatinine (mg/dl) BUN (mg/dl) Serum creatinine (mg/dl) Native American Asian Hispanic Serum creatinine at initiation {3.} by age {3.21} by race/ethnicity {3.22} by age & race/ethnicity N Am Native American Asian Hispanic N Am Asian Hispanic Asian Hispanic Bioqemical characeristics Patient characteristicsh

11 BUN/serum creatinine ratio at initiation {3.23} by age {3.24} by race/ethnicity BUN/serum creatinine ratio & albumin {3.26} by age BUN/creatinine ratio BUN/creatinine ratio N Am Asian Hispanic BUN/creatinine ratio 15 Albumin < test s lower limit Albumin > test s lower limit {3.25} by age & race/ethnicity {3.27} by race/ethnicity BUN/creatinine ratio Native American Asian Hispanic BUN/creatinine ratio 15 Albumin < test s lower limit 1 N Am Albumin > test s lower limit Asian Hispanic {3.a} Odds ratio (OR) having CHF at initiation, by race/ethnicity Native American Asian Hispanic OR CI p-value OR CI p-value OR CI p-value OR CI p-value OR CI p-value Age <35.35 ( ) <.1.4 ( ) <.1.44 ( )..51 ( )..32 ( ) <.1 35-<5.65 ( ) <.1.71 ( ) <.1.74 (.56-.9).4.93 ( ) ( ) <.1 5-<65 1. reference < 1.25 ( ) < ( ) ( ) ( ) ( ) ( ) < ( ) < ( ) ( ) < ( ).4 Gender Male 1. reference Female 1.14 ( ) < ( ) < ( ).1 1. (.9-1.2) ( ). Primary DM 1. reference diagnosis HTN.4 (.1-.7) <.1.92 (.7-.97)..69 (.4-1.).5.79 ( ).1.73 (.66-.1) <.1 GN.61 ( ) <.1.6 ( ) <.1.64 (.42-.9).4.61 ( ) <.1.62 ( ) <.1 PKD.29 ( ) <.1.41 ( ) <.1.41 ( ).1.51 ( ).6.17 (.1-.29) <.1 Other.7 (.72-.3) <.1.74 (.64-.4) <.1.92 ( ).7.6 (.46-1.).5.59 ( ) <.1 Comorbidity ASHD 2.94 ( ) < ( ) < ( ) <.1 4. ( ) < ( ) <.1 Cancer.75 ( ) <.1.77 (.69-.6) <.1.69 (.-1.19) ( ) ( ).1 Cardiac/oth ( ) < ( ) < ( ) ( ) < ( ) <.1 COPD 1.3 ( ) < ( ) < ( ) ( ) < ( ) <.1 CVA/TIA 1.11 ( ) < ( ) (.-1.71) ( ) (.1-1.5).23 PVD 1.65 ( ) < ( ) < ( ) ( ) < ( ) <.1 Albumin < normal 1.34 ( ) < ( ) < ( ) < ( ) < ( ) <.1 Normal 1. reference BUN <5.9 (.4-.96).. (.73-.9) <.1.9 ( ) ( ) ( ).9 5-<7.95 (.9-.99).2.9 (.3-.96)..96 ( ) ( ).2.97 (.7-1.).57 7-<9 1. reference < (1.2-1.). 1.4 ( ).3 1. (.4-1.5) ( ) ( ) ( ) < ( ) ( ) (.6-1.3) (.4-1.1).57 Creatinine < ( ) < ( ) < (.6-1.1) (.6-1.1) ( ).1 4-< ( ) < ( ) <.1.93 ( ) (.3-1.2) ( ). 6-< 1. reference <1.7 (.3-.91) <.1.2 (.77-.) <.1.77 ( ) ( ).17.9 (.-1.1) ( ) <.1.7 ( ) <.1. (.-1.3) ( ).9.9 (.7-1.4).14 BUN/creat. <11.6 ( ) <.1.67 (.-.74) <.1.74 ( ) (.45-.5)..71 (.-.3) <.1 ratio 11-<16. (.77-.4) <.1.4 ( ) <.1.5 (.-1.19).34.1 ( )..2 ( ). 16-<21 1. reference < ( ) < ( ) ( ) ( ) ( ) ( ) < ( ) ( ) ( ) (1.-1.7). Entry year reference (.5-.91) <.1.94 (.9-.99) (.9-1.).35. ( )..93 (.6-1.1) (.77-.2) <.1.5 (.-.9) < ( ).59. ( ).1.6 (.7-.94). H4 USRDS Annual Data Report 1

12 he hypothesis that are beginning ESRD therapy at an earlier point in their CKD may be supported by recent increases in estimated glomerular filtration rates (egfr) at initiation. Since 1995 this rate has increased 2.2 ml/min/1.73 m 2, to 9. (Figure 3.2). For most this period it has been highest in children, though rates have leveled f. Rates are consistently lowest in age 44, and the difference in egfrs between these and those age has grown slightly since The greatest increase in egfrs at initiation has occurred in age 75 and older from.2 ml/ min/1.73 m 2 in 1995 to 1.9 in 3. Estimated GFRs in new ESRD show mostly consistent differences by race and ethnicity, with rates lowest in Native American and Asian and highest in whites (Figure 3.29). The greatest increase, from 7. to 1.1 ml/min/1.73 m 2, has occurred in whites, while the lowest has occurred in Native Americans, from 7.1 to.5 ml/min/1.73 m 2. Concerns about the methods used to estimate GFR in with advanced renal failure particularly diabetics, in whom the formulas have not been validated should be acknowledged when considering the data. The overall body mass index (BMI) in starting treatment for ESRD increased 2.4 kg/m 2 between 1995 and 3, to 27.6 (Figures ). Pediatric have the lowest BMIs, and their indices have changed the least over time; the highest indices, and an increase 2.7 kg/m 2, have occurred in age By race, the highest BMIs at initiation are seen in blacks and Native Americans, at kg/m 2, and the lowest, 24. kg/m 2, in Asian descent. Increasing BMIs in ESRD continue to be a source concern. Because these being healthy enough to have survived to ESRD constitute a biased sample, it is not clear how these trends should be interpreted, particularly when high indices in the general population are associated with an increased mortality risk, while the reverse is true in with ESRD. Estimated GFRs are highest in with 4 6 comorbid conditions at initiation, suggesting that these are starting Estimated glomerular filtration rate (egfr) at initiation {3.2} by age {3.29} by race/ethnicity egfr (ml/min/1.73 m 2 ) egfr (ml/min/1.73 m 2 ) BMI (kg/m 2 ) BMI (kg/m 2 ) {3.3} by age & race/ethnicity BMI (kg/m 2 ) egfr (ml/min/1.73 m 2 ) 11 1 N Am Asian 9 Hispanic Native American Asian Hispanic Body mass index (BMI) at initiation {3.31} by age {3.32} by race/ethnicity {3.33} by age & race/ethnicity N Am Asian Hispanic Native American Asian Hispanic 2 Predicors egfr 2 Patient characteristicsh

13 ESRD treatment at an earlier stage CKD (Figure 3.37). Differences by the number conditions are especially striking among non-diabetic ; the rate in with 4 6 conditions, for instance, is 2.2 ml/min/1.73 m 2 higher than in with only one comorbidity at the beginning ESRD. {Figures } incident ESRD with a first service date between May 1995 & June 3. The lower limit albumins measured by bromcresol purple is 3.2 g/dl, & by bromcresol green is 3.5 g/dl. Figure 3.37 includes all comorbidities listed on the ME form. {Table 3.b} incident ESRD with a first service date between May 1995 & July 3. x {Figures & Table 3.b} egfr calculation for ages 1 from Schwartz et al., & for ages 19 & above from Levey et al. {3.34} BMI & albumin as predictors egfr {3.35} BUN/creatinine ratio & albumin as predictors egfr egfr (ml/min/1.73 m 2 ) Albumin < test s lower limit Albumin > test s lower limit BMI <21.9 BMI <25.3 BMI <29.9 BMI egfr (ml/min/1.73 m 2 ) 15 1 Albumin < test s lower limit BUN/creatinine ratio <.. - < < Albumin > test s lower limit {3.36} Estimated GFR, by diabetic status & cardiac comorbidity {3.37} egfr, by diabetic status & number comorbidities egfr (ml/min/1.73 m 2 ) Diabetic Non-diabetic Diabetic Non-diabetic CV disease CHF ISHD PVD Zero One Two 7 Three egfr (ml/min/1.73 m 2 ) {3.b} Odds ratio having an egfr greater than the gender-specific mean for the entire ESRD population Native American Asian Hispanic OR CI p-value OR CI p-value OR CI p-value OR CI p-value OR CI p-value Age < ( ) <.1.9 (.3-.9) ( ) ( )..9 (.5-1.) <5.6 (.2-.9) <.1.74 (.7-.79) <.1.7 ( ) ( ).2. (.72-.9) <.1 5-< < 1.35 ( ) < ( ) < ( ) ( ) < ( ) < ( ) < ( ) < ( ). 2.1 ( ) < ( ) <.1 Gender Male Female. (.7-.2) <.1.69 ( ) <.1.73 (.59-.9)..73 (.64-.4) <.1.9 (.4-.96). Primary DM diagnosis HTN.62 (.-.64) <.1.56 ( ) <.1.75 (.52-1.)..59 (.5-.71) <.1.56 ( ) <.1 GN.45 (.43-.4) <.1.5 ( ) <.1. ( ) <.1.42 ( ) <.1.49 ( ) <.1 PKD.44 (.-.4) <.1.7 (.57-.6)..4 ( ) (.-.7).1.43 (.32-.5) <.1 Other.61 ( ) <.1.52 ( ) < ( ) (.2-.65) <.1.55 (.45-.6) <.1 Comorbidity ASHD 1.41 ( ) < ( ) < ( ) ( ) < ( ) <.1 Cancer.73 ( ) <.1.77 (.69-.5) < ( ).29.4 ( ).41.1 (.66-.9).3 Cardiac/oth ( ) < ( ) < (.7-2.9) ( ) ( ). CHF 1.75 ( ) < ( ) < ( ). 1.5 ( ) < ( ) <.1 COPD 1.22 ( ) < ( ) < ( ) ( ) ( ).2 CVA/TIA 1.3 (.9-1.7) ( ) <.1.9 ( ).53.1 ( ). 1. ( ).25 PVD 1.13 ( ) < ( ) < ( ).4.4 ( ) ( ).1 Albumin < normal.93 (.9-.95) < ( ).1.1 ( ).7.9 ( ).1.9 (.3-.96). Normal BUN < ( ) < ( ) < ( ) < ( ) < ( ) <.1 5-<7 2.5 ( ) < ( ) < ( ) < ( ) < ( ) <.1 7-< <11.7 (.6-.73) <.1.64 ( ) <.1. (.45-.)..56 (.46-.6) <.1.69 ( ) < (.5-.54) <.1.46 ( ) <.1.44 ( ) <.1.43 ( ) <.1.42 (.3-.47) <.1 Entry year ( ) < ( ) < ( ) ( ) ( ) < ( ) < ( ) < ( ) < ( ) < ( ) <.1 H4 USRDS Annual Data Report 3

14 s the U.S. ESRD population ages, the number ESRD residing in nursing homes is growing rapidly. Almost all nursing homes in the U.S. are required by the 197 Omnibus Budget Reconciliation Act to assess each resident s functional, medical, psychosocial, and cognitive status using a standard instrument known as the CMS Minimum Data Set (MDS). This information is gathered on admission and then quarterly thereafter, and includes documentation acute changes in condition. Table 3.c describes the incident and point prevalent cohorts U.S. nursing home residents with ESRD in We define an incident ESRD cohort within the nursing home as those who develop ESRD while in the nursing home, and point prevalent nursing home ESRD as those who are nursing home residents and also ESRD on December 31, See Appendix A for details explaining these definitions. In 1999 there were 16, point prevalent ESRD residing in nursing homes 4. percent the country s ESRD. After exclusions (see Appendix A), the population included,3 true point prevalent, and 2,1 diagnosed with ESRD during the year. The mean age point prevalent nursing home was 7.4, compared to. in the population as a whole; almost 23 percent were age or older, while 26. percent were younger than 65. Figures compare demographic and clinical characteristics in nursing home and general ESRD. There was a higher percentage females in the incident nursing home cohort (57 versus 47 percent); results were similar when comparing prevalent cohorts. Racial distributions were similar, but, for point prevalent, the distribution by primary diagnosis differed more nursing home had diabetes as a primary diagnosis (51.6 versus 34.2 percent), while fewer had glomerulonephritis (5.5 versus 16.3 percent). Of the incident nursing home ESRD in 1999, 57.7 percent were assessed as having moderately to severely impaired decision-making ability, 29 percent were unable to recall the season, and 14. percent were unable to recall that they were in a nursing home (Figure 3.). Using the six Katz activities daily living (ADLs) shown, there was a mean 1.23 impaired ADLs per resident. More than 44 percent were unable to walk independently, almost 25 percent were unable to transfer from bed to chair, and.3 percent were unable to move themselves in bed. Almost two-thirds had no advanced directive indicated on the MDS, while 26.3 percent were designated do not resuscitate, and 1.2 percent do not hospitalize (Figure 3.41). There was a high prevalence mental illness in nursing home ESRD, with depression diagnosed in 36.5 percent, bipolar disease or schizophrenia in 4.3 per- 1 1 Age Nursing home ESRD Age Nursing home ESRD {3.c } Summary statistics on nursing home ESRD Patient Incident cohort Dec. 31 point prevalent cohort characteristics Count Count Age , , , , , , Mean age Median age , , , Native American Asian/Pacific Islander Other/unknown Male , Female 1, , Primary diagnosis Diabetes 1, , Hypertension , Glomerulonephritis Cystic kidney disease Urologic disease Other known cause Unknown cause Missing cause ,1 1.,3 1. {3.3} Characteristics incident ESRD : nursing home & all ESRD Gender Race/ethnicity Primary diagnosis M F W B NA A Other DM HTN GN CK Other {3.39} Characteristics point prevalent ESRD : nursing home & all ESRD Gender Race/ethnicity Primary diagnois M F W B NA A Other DM HTN GN CK Other Characerisics insitutionalized 4 Patient characteristicsh

15 {3.} Cognitive & physical impairment in nursing home with ESRD {3.d} Diseases in nursing home ESRD Cannot recall current season Cannot recall in nursing home Cannot recall staff names & faces Impaired decision making skills Uses cane/walker/crutch Bedfast most the time Impaired ADL Walk in room Transfer Toilet use Bed mobility Dressing Incident 199- Point prevalent 1999 Disease Count * Alzheimer s/dementia 2, Bipolar/schizophrenia COPD 1, Cancer 1, 9. Depression 4, Diabetes 7, HIV infection Mental retardation/ developmental disabilities ASHD 2, CHF 4,7 3. PVD 3, Cardiac dysrhythmias 1, Other CVD 4, CVA/TIA 3, Cardiovascular disease group** 9, * based on total number point prevalent nursing home ESRD in 1999:,3. Eating with condition {3.43} Physical functioning in nursing home pts {3.41} Advanced directives in nursing home with ESRD 15 1 Nursing home 1999 Nursing home 199- ESRD 1999 Do not resuscitate 5 Do not hospitalize No advanced directive Incident 199- Point prevalent 1999 Inability to ambulate Inability to transfer years 1, patient Rate per Age with condition {3.42} Unadjusted annual mortality rates in period prevalent ESRD : nursing home & all ESRD Nursing home ESRD cent, and dementia in 19.9 percent (Table 3.d). The reported dementia prevalence is likely an underestimate, since dementia is significantly under-reported in Medicare claims data. The prevalence dementia in most U.S. nursing homes without ESRD Gender Race Male Female N Am Asian residents is greater than 5 percent. Not unexpectedly, 77.5 percent carried cardiovascular diagnoses. The rate diabetes, however, was markedly high, at 62.9 percent. Only.32 percent were receiving hospice care (not shown). The mean death rate for nursing home residents with ESRD was 3.5 times that the ESRD population as a whole, at 629 per 1, patient years (Figure 3.42). The greater death rate among these residents was true across all age groups and races, but was most pronounced among whites and those younger than age 65. These death rates compare 1999 period prevalent nursing home to the combined 199 period prevalent cohort for all ESRD, as reported in Table H. the 2 ADR. {Table 3.c} incident & prevalent ESRD institutionalized in a nursing home, {Figure 3.3} incident ESRD, {Figure 3.39} prevalent ESRD, {Table 3.d} December 31 point prevalent ESRD institutionalized in a nursing home, **Cardiovascular disease group includes ASHD, CHF, PVD, cardiac dysrhythmia, other CVD, & CVA/TIA. {Figures 3. 41} incident ESRD institutionalized in a nursing home, 199 combined, & prevalent ESRD institutionalized in a nursing home, {Figure 3.42} period prevalent ESRD institutionalized in a nursing home in 1999, & all ESRD, 199 combined. {Figure 3.43} incident ESRD institutionalized in a nursing home in 1999 & in 199 combined, & all ESRD, H4 USRDS Annual Data Report 5

16 summary ChapterJo Introduction Cardiovascular comorbidity Prescription drug therapy for cardiovascular disease {Figure 3.1 Forty-four percent new cases ESRD are attributed to diabetes, and diabetes as a secondary diagnosis occurs in approximately percent whites and 22 percent blacks.} {Figures In surviving one year after the initiation ESRD therapy, there has been approximately a 15 1 percent increase in overall cardiovascular disease over the last 17 years. s carry a greater degree cardiovascular comorbidity than blacks. Rates congestive heart failure are times those ischemic and peripheral vascular disease.} {Figure 3.6 The percent prevalent dialysis receiving ACE inhibitor/arb therapy increased substantially from to 2. Over percent receive diuretic therapy.} {Figure 3.7 The percent prevalent dialysis with CHF who receive ACE inhibitors/arbs and/or beta blockers increased from to 2. Only 13.4 percent age and with CHF are receiving digitalis preparations.} {Figures 3. 9 ACE inhibitor/arb use has risen greatly in all subgroups prevalent dialysis with CHF. The use beta-blockers has grown, particularly in females. Similarly, the percent receiving ACE inhibitors/arbs has greatly increased in dialysis with hypertension. Beta blocker use has increased, particularly in females and with diabetes.} EPO use & anemia at initiation {Figure 3.1 The mean hemoglobin at initiation increased from 9.2 g/dl in 1995 to 1.1 in May, 3. Preemptive transplant have the highest levels 11. g/dl while levels are lowest in hemodialysis, at 1. g/dl.} {Figure 3. At the start ESRD therapy, almost three in four have hemoglobin levels less than the K/DOQI target 11 g/dl.} {Figures Female ESRD age 44 continue to have the lowest hemoglobin levels at initiation.} {Figure 3.15 In the 1996 cohorts, mean hemoglobin levels at initiation varied by approximately. g/dl between the lowest and highest quintiles the U.S. This difference still occurred in the 1 2 cohort, but mean levels were 1. g/dl in the majority HSAs.} {Figure 3.16 The highest levels EPO use across the country approach percent in both whites and blacks, while the average lowest use is 1 percent.} Biochemical characteristics {Figure 3.1 The mean BUN at initiation has fallen almost 9 g/dl since Asians have the highest BUNs at initiation, and blacks the lowest.} {Figure 3.21 Serum creatinine at initiation has fallen almost.5 mg/dl, with blacks having the highest levels and whites the lowest.} {Figure 3.23 The BUN/creatinine ratio at initiation, a traditional marker pre-renal azotemia, has risen over the last nine years.} {Table 3.a CHF at initiation is highly associated with advancing age, female gender, diabetes, ischemic heart disease, peripheral vascular disease, high BUN, low creatinine, and a high BUN/creatinine ratio.} Predictors egfr {Figure 3.2 As creatinine levels at initiation have fallen, egfr levels have increased from 7.5 ml/min/1.73 m 2 in 1995 to 9. in 3.} {Figure 3.32 Mean BMI at initiation has increased from 25 kg/m 2 in 1995 to nearly 2 in 3. Asians have the lowest BMI at initiation, and Native Americans and blacks the highest.} {Table 3.b Predictors an egfr greater than the gender-specific mean at initiation include age younger than 35 or older than 65, have and cardiovascular disease. A BUN at initiation less than 5 mg/dl is associated with a 4.5-times greater likelihood a high egfr at initiation. Females and diabetics are less likely to have egfr values above the gender-specific mean.} Characteristics institutionalized {Table 3.c Almost half both incident and point prevalent nursing home are diabetic, and nearly one in three have hypertension. Their mean age is in the low 7s.} {Figures Compared to the entire ESRD population, nursing home ESRD are 5 percent more likely to be age 65 or older.} {Figure 3. Cognitive and physical impairment are significant in nursing home with ESRD, and cardiovascular disease is present in almost 7 percent.} Maps: National means & patient populations Figure number /all 1-2/all 96-7/wh 1-2/wh 96-7/bl 1/2/bl 96-7/all 1-2/all 96-7/wh 1-2/wh 96-7/bl 1/2/bl Overall value for all pts Total 157, ,46 97,6 2,935 45,614 54,3 143,5 177,323 97,6 2,935 45,614 54,3 Overall value for pts mapped Missing HSA/state: pts dropped 2,64 3, , ,64 3, , Chapter summary 6 Patient characteristicsh