Peer Kidney Care Initiative

Transcription

1 Patient Populations Hospitalizations Mortality Cardiovascular Benchmarks Peer Kidney Care Initiative Peer Report Dialysis Care & Outcomes in the United States, 216

2 Financial support for the Peer Kidney Care Initiative is provided by 12 participating dialysis provider organizations: American Renal Associates, Atlantic Dialysis Management Services, Centers for Dialysis Care, DaVita HealthCare Partners, Dialysis Clinic, Inc. (DCI), Fresenius Medical Care, Independent Dialysis Foundation, Northwest Kidney Centers, Satellite Healthcare, The Rogosin Institute, US Renal Care, and Wake Forest-Emory Universities. In collaboration with the Chief Medical Officers of these orga nizations, the Peer Kidney Care Initiative is operated by the Chronic Disease Research Group, a division of the Minneapolis Medical Research Foundation, in Minneapolis, Minnesota. Allan J. Collins, MD, FACP, is the Executive Director of Peer. Peer investig ative and clinical support was provided by James B. Wetmore, MD, and Charles A. Herzog, MD. Analytic support was provided by David T. Gilbertson, PhD; Suying Li, PhD; Jiannong Liu, PhD; Yi Peng, MS; Julia T. Molony, MS; Haifeng Guo, MS; Tanya Natwick, BS; Tom Matlon, BS; and Xinyue Wang, BS. Peer program administrative support was provided by Kimberly Nieman, MS, and Beth Forrest, BBA. Graphic design work and text editing were provided by Julia T. Molony, MS; Kimberly Nieman, MS; Nan Booth, MSW, MPH, ELS; a nd Anne Shaw, BS. Information system and Peer website support were provided by C. Daniel Sheets and Hilford Ponnie. The Peer report publication was designed, organized, and produced by Julia T. Molony and Kimberly Nieman. The data reported here have been supplied by Centers for Medicare & Medicaid Services and the United States Renal Data System. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government. The Peer Kidney Care Initiative has no affiliation with the US government. Citation: Peer Dialysis Initiative, Peer Report: Dialysis Care and Outcomes in the United States, 216, Chronic Disease Research Group, Minneapolis, MN,

3 Contents Patient Populations 13 Hospitalizations 31 Mortality 81 Cardiovascular 19 Benchmarks 122 Methods 144 PEER REPORT DIALYSIS CARE & OUTCOMES IN THE US, 216

4 EXECUTIVE SUMMARY This is the second full Peer Kidney Care Initiative Report, covering data through 213 from the Centers for Medicare & Medicaid Services (CMS) and the United States Renal Data System (USRDS). Peer was initiated through a collaboration among the Chief Medical Officers (CMOs) of twelve dialysis provider organizations in the United States, including all of the ten largest organizations by number of patients treated. Peer focuses on how provider organizations address the challenges of mortality and morbidity, collaboratively and individually, and on how provider organizations can learn from each other through examination of available data, all with the goal of advancing patient care. Objectivity is an important aim of Peer, focusing on actionable ways to improve care. This year s Peer report presents and expands on information related to trends over time, geographic variation in outcomes and care, and seasonality of adverse events with clinical consequences to patients. This year we also added information on pro gress toward achieving the targets set by Healthy People (HP) 22 initially proposed in 27 and 28 by the Department of Health and Human Services to improve outcomes in the kidney disease population. The Chronic Disease Research Group (CDRG), which pr eviously served as the contractor for the United States Renal Data System (USRDS) Coordinating Center, participates in the CMO meetings, presenting an array of issues related to morbidity and mortality that providers may consider for focused attention. In addition, in its role in Peer, CDRG presents to the CMOs on progress toward HP 22 goals and new topics to consider for HP 23. Although organizations such as the USRDS have long presented data on patient care and outcomes, detailed data on actionable wa ys to improve care are rare. Specifics related to heart disease, heart failure, arrhythmias, and infectious complications are needed to address the overall events based on submitted hospital claims. Hospitals may use coding practices to enhance payments fo r diagnosis-related group (DRG) services. Peer presents details related to how, for example, heart failure as a principle diagnosis code may be interconnected with fluid overload diagnosis codes, which in the past were not included in Quality Improvement P rogram (QIP) incentives for hospitals to reduce readmissions. Another example relates to hospitals use of sepsis syndrome diagnosis coding to enhance DRG payments instead of using infection codes tied to specific organ systems. These types of coding shift s must be defined carefully to differentiate changes over time related to specific degrees of disease burden and those related to payment principles. Overall annual mortality has been reported for 25 years, yet variation in mortality within each year has rarely been reported. In this second report, we continue to show that mortality and morbidity patterns vary sea sonally, with the highest rates occurring in January through March of each year, an intuitive finding in light of the PEER REPORT DIALYSIS CARE & OUTCOMES IN THE US, 216 1

5 seasonal virulence of influenza and other upper respiratory infections in the general population. We also show that counts of incident end -stage renal disease (ESRD) patients are cyclical, as are rates of various cause -specific hospital admissions, including acute coronary syndrome, arrhythmia, heart failure, and chronic pulmonary disease. These patterns raise questions about preventive care and interventions, at the levels of the dialysis facility and provider organization, that might blunt the impact of this seasonal burden. This report uses unadjusted data to give a clear picture, nationally and regionally, of trends in clinical outcomes. On the levels of US census divisions and constituent states, these data reflect stark variation in local absolute trends, with impressive progress in some areas and middling progress in others. The impact of the new CMS QIP for readmissions applied to hospitals in the US had a profound effect on hospitalization events. These are reported in Chapter 2; 212 and 213 hospitalization rates dropped substantially, consistent with changes in the general Medicare population. In the first chapter, we describe the incidence of ESRD. We show how the rate r ose during the late 199s and early 2s, but plateaued in the middle of the 2s, and then rose again in 212 and 213. Data stratified by US census division and age, however, demonstrate that this pattern has not been uniform. Trends in numbers of incident patients have also differed substantially across US census divisions and across constituent states, due in part to the size of the local population. The prevalent ESRD population growth is fairly consistent across the states and regions, which appears to be driven mainly by reduced death rates. We also examine pre -dialysis hemoglobin levels ascertained from the Medical Evidence Report, which show a continued decline in 213. We examine trends in vascular access at dialysis initiation; the data demonstr ate that widespread use of catheters at dialysis initiation in hemodialysis patients fell slightly to 77%, compared with 81% in 28. In Chapter 2, we focus on hospitalization in the incident population during the first year of therapy and in the prevalent po pulation, reviewing trends in rates of admission and lengths of stay, overall and by specific causes. Data illustrate variation in rates across US census divisions and constituent states, with continued declines in 212 and 213. Seasonal changes in hospit alization rates are shown, as are expanded infection rates by various organ systems. Thirty -day readmission rates also declined from 211 to 213. Variations in readmission are shown across US census divisions and various causes of hospitalization. Trends in outpatient emergency department visits and observations stays are added to this year s report. The data show increases of 19% over the past 1 years for all -cause visits among prevalent patients, while hospitalization rates have been declining. Chapter 3 regarding mortality shows a continued decline with a slowing in 212 and 213 compared with prior years. Whether the slowing will continue is unclear, particularly as hospitalization rates have declined and they usually track in parallel with mortality. We once again illustrate seasonal variation in outcomes. Mortality data PEER REPORT DIALYSIS CARE & OUTCOMES IN THE US, 216 2

6 during the first year of dialysis demonstrate that some areas of the country have realized little progress, while others have achieved consistent gains. Mortality rates have declined overall, particularly since 24, and growth in the cumulative number of deaths per year has slowed an important finding. This year we added data on mortality rates in the incident and prevalent peritoneal dialysis populations, including geographic variation. These data show wide variation in outcomes, suggesting that national studies may not be representative of local outcomes. Regardless of the geographic variations, declining mortality rates translate to longer lives, as illustrated by gains in expected remaining lifetimes and deaths averted. Trends in cardiovascular deaths and sudden cardiac deaths among prevalent patients are shown in Chapter 4. Rates of cardiovascular death declined more quickly than rates of sudden cardiac death. Kaplan -Meier survival analysis of cardiovascular death and sudden cardiac death among 211 incident patients were performed by age, race, and dialysis modality. We conclude by examining progress toward the HP 22 objectives initially defined in 27 and 28. The objectives were generally modest, and most were achieved even before 21. Progress toward many has substantially exceeded expectations, suggesting that providers are making important advances. We are committed to change through an understanding of meaningful outcom es data. Our progress has been remarkable, but we believe we can do more. As President John F. Kennedy said, The problems of the world cannot possibly be solved by skeptics or cynics, by blank faces in the crowd, whose horizons are limited by the obvious realities. We need men and women who can dream of things that never were. PEER REPORT DIALYSIS CARE & OUTCOMES IN THE US, 216 3

7 Incident patient counts Rate per 1, U.S. population Patient counts Executive Summary 1, Incidence counts, by month & year Patient Populations: Incident 8, 6, 4, 2, Patient counts: by month Patient counts: monthly average during the year Incidence rates, overall & by US census division US (23%) New England (1%) Middle Atlantic (5%) East North Central (35%) West North Central (17%) South Atlantic (8%) East South Central (23%) West South Central (16%) Mountain (18%) Pacific (24%) 25, Incidence counts, by US census division 2, 15, 1, 5, New England Middle Atlantic East North Central West North Central South Atlantic East South Central West South Central Mountain Pacific PEER REPORT DIALYSIS CARE & OUTCOMES IN THE US, 216 4

8 Prevalent patient counts Rate per 1, U.S. population Patient counts Executive Summary 4, Prevalence counts, by month & year Patient Populations: Prevalent 35, 3, 25, 2, 15, 1, 5, Patient counts: on the first day of the month Patient counts: monthly average during the year 2 Prevalence rates, overall & by US census division US (66%) New England (49%) Middle Atlantic (86%) East North Central (84%) West North Central (59%) South Atlantic (46%) East South Central (53%) West South Central (53%) Mountain (64%) Pacific (87%) , Prevalence counts, by US census division 8, 6, 4, 2, New England Middle Atlantic East North Central West North Central South Atlantic East South Central West South Central Mountain Pacific PEER REPORT DIALYSIS CARE & OUTCOMES IN THE US, 216 5

9 Executive Summary 34 First-year mortality rates in incident dialysis patients, by incident year & month Mortality Deaths per 1 patient-years Mortality among all incident patients in the year Mortality among all incident patients in the month 24 One-year mortality rates in prevalent dialysis patients, by calendar year & month Deaths per 1 patient-years Mortality among all patients prevalent on the first day of the year Mortality among all patients prevalent on the first day of the month 16 Incident dialysis patients, quarter 1, 212 SCD 26.7% OCVD 1.6% INF 8.2% Distribution of causes of death SCD 3.1% OCVD 11.% INF 8.% Prevalent dialysis patients, overall, 213 UNK 26.% OTH 14.1% WD 14.4% UNK 24.4% OTH 12.6% WD 13.9% Sudden cardiac death Other cardiovascular death Infection Withdrawal Other known cause Unknown cause PEER REPORT DIALYSIS CARE & OUTCOMES IN THE US, 216 6

10 Executive Summary Deaths per 1 patient-years One-year cardiovascular & sudden cardiac mortality rates in prevalent dialysis patients Cardiovascular CV mortality among patients prevalent on the first day of the quarter CV mortality among patients prevalent on the first day of the year SC mortality among patients prevalent on the first day of the quarter SC mortality among patients prevalent on the first day of the year % 9% Distribution of causes of cardiovascular death in prevalent dialysis patients Congestive Heart Failure Percent of cardiovascular deaths 8% 7% 6% 5% 4% 3% 2% 1% % Other cardiovascular Atherosclerotic heart disease Cardiomyopathy Cerebrovascular accident including intracranial hemorrhage Acute myocardial infarction Sudden cardiac Deaths per 1 patient-years One-year cardiovascular mortality rates, by primary cause of death Congestive Heart Failure Other cardiovascular Atherosclerotic heart disease Cardiomyopathy Cerebrovascular accident including intracranial hemorrhage Acute myocardial infarction Sudden cardiac PEER REPORT DIALYSIS CARE & OUTCOMES IN THE US, 216 7

11 Executive Summary 3 Hospitalizations: Admissions First-year hospital admission rates among incident dialysis patients, by annual & monthly cohorts Admissions per 1 patient-years Admissions within a year: among all incident patients in the month Admissions within a year: among all incident patients in the year Annual & monthly hospital admission rates among prevalent dialysis patients, by calendar year & month 3 Admissions per 1 patient-years Admissions during the month: among prevalent patients on the first day of the month Admissions during the year: among prevalent patients on the first day of the year 8 75 First-year admission rates (incident)/annual & quarterly admission rates (prevalent) Incident Cardiovascular 8 7 Incident Infection Admissions per 1 patient-years Quartertly cohorts Prevalent 5 Yearly cohorts Within the quarter 45 Within the year Admissions per 1 patient-years 6 5 Prevalent 4 3 Quartertly cohorts 2 Yearly cohorts 1 Within the quarter Within the year PEER REPORT DIALYSIS CARE & OUTCOMES IN THE US, 216 8

12 Executive Summary Hospitalizations: Emergency Department Visits & Observation Stays 25 Rates of ED visits/obs stays among prevalent dialysis patients 25 Any cause first-year/annual & quarterly ED visit/obs stay rates Rate per 1 patient-years ED visit and observation stay 5 Observation stay only ED visit only Rate per 1 patient-years Incident 2 Prevalent 15 1 Quartertly cohorts Yearly cohorts 5 Within the quarter Within the year First-year cardiovascular ED visit/obs stay rates Incident Cardiovascular ED visit/obs stay rates Prevalent Rate per 1 patient-years Quartertly cohorts Yearly cohorts Rates per 1 patient-years Within the quarter Within the year First-year infection ED visit/obs stay rates Incident 35 3 Infection ED visit/obs stay rates Prevalent Rates per 1 patient-years Quartertly cohorts Yearly cohorts Rates per 1 patient-years Within the quarter Within the year PEER REPORT DIALYSIS CARE & OUTCOMES IN THE US, 216 9

13 Executive Summary 41 3-day readmission rates among living discharges on maintenance dialysis Hospitalizations: Readmissions 3-day readmission rate (%) Readmissions: among living discharges in the quarter Readmissions: among living discharges in the year day readmission rate among living discharges on maintenance dialysis, by principal discharge diagnosis, 213 Cardiovascular disease Cardiovascular disease as the primary discharge diagnosis Cardiovascular disease as primary discharge diagnosis Acute coronary syndrome (MI & UA) Arrhythmia Infection as primary discharge diagnosis Heart failure & cardiomyopathy Readmission within 1-1 days Readmission within 11-2 days Readmission within 21-3 days Death Infection Infection as the primary discharge diagnosis Fluid overload & pleural effusion Stroke Other cause Gastrointestinal hemorrhage Bacteremia & septicemia Acute respiratory failure Dialysis access infection, including peritonitis Chronic pulmonary disease Pneumonia & influenza Dialysis access complication, excluding infection Intestinal infection with C. difficile Hyperkalemia PEER REPORT DIALYSIS CARE & OUTCOMES IN THE US, 216 1

14 Executive Summary 12 1 Incident rates, by race Benchmarks Mortality in prevalent dialysis patients, by race Rate per 1, US Population All White African American Asian Other Deaths per 1 patients-years All 8 White African American 4 Asian Other Deaths per 1 patient-years Mortality in the first 3 months of dialysis Quarterly cohorts Yearly cohorts Percentage of patients Vascular access at initiation & during first year of dialysis, by primary cause of ESRD Catheters All Diabetes Hypertension Glonerulonephritis Cystic Kidney Other Unknown Initiation 3 mo 6 mo 9 mo 12 mo Percent of patients Fistulas/grafts Initiation 3 mo 6 mo 9 mo 12 mo PEER REPORT DIALYSIS CARE & OUTCOMES IN THE US,

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