Morbidity & Mortality

6

morbidity & mortality Who will remember you when I have gone, My darling ones, or who remember me? Only in our wild hearts the dead live on. Yet these frail engines bound to mystery Break the harsh turn of all creation’s wheel, For we remember China, Greece, and Rome, Our mothers and our fathers, and we steal From death itself its rich store, and bring it home.

may sarton “death and the turtle”

American Journal of Kidney Diseases, Vol 47, No , Suppl  (January, 2006): pp s2–s44. 06 morbidity morte 05.indd 121

11/17/2005 1:26:55 PM

6 s122

MORBIDITY & MORTALITY

Introduction

B

Because of the scope of issues related to morbidity and mortality in ESRD patients, we have significantly expanded this chapter. This year, we use interval analyses to present new data on patterns of hospitalization and mortality—overall and cause-specific—in incident patients, and update analyses of survival in the prevalent population. Infectious hospitalizations continue to be a concern, particularly those for pulmonary infections and infections related to vascular access. We also present Bayesian mortality and hospitalization ratios by provider. We look again this year at cancer and pregnancy in women with ESRD, further developing the definitions of these events. New figures compare data on morbidity in dialysis, transplant, CKD, and non-CKD patients, examining events such as myocardial infarction and pneumonia. And the final three spreads address withdrawal and hospice care in ESRD patients, incident and prevalent stroke, and dementia. As illustrated in Figure 6., overall hospital admission rates have altered little since 993. Cause-specific rates, however, have changed dramatically. Infectious and cardiovascular hospitalizations are up 23 and 0 percent, respectively, while those related to vascular access have fallen 25 percent. By primary diagnosis (shown on the following page), admissions are greatest in patients with diabetes—declining during followup time for patients on hemodialysis or with a transplant, but rising for those treated with peritoneal dialysis.

s124 · overall admission rates · survival hospitalization & probabilities · mortality by vintage · mortality expected remaining lifetimes s126 · cause-specific interval analyses · cardiovascular hospitalization procedures · vascular access s128 · cause-specific interval analyses · mortality rates for mortality cardiovascular & other events s130 · hospitalization admissions & days · admissions for & mortality, procedures & diagnoses · five-year by modality survival · cause-specific mortality s132 · Bayesian provider-level ratios overall & for hospitalization & CV disease, infection, & VA, by unit mortality ratios affiliation & U.S. Census division

06 morbidity morte 05.indd 122

Five-year survival rates have improved across all ESRD populations—most dramatically in the transplant population. And new this year is evidence that the prevalent mortality rate has declined in patients with less than two years on treatment, and that it continues to fall for those with 2–5 years of therapy, and even for those who have been on therapy five or more years. This is a new development, since the overall prevalent mortality rate had been fairly stable for the 6–7 years prior to 2003. Interval data on cause-specific hospitalizations show that older patients have higher early admission rates, which decline and then slowly increase during the five-year followup period. Asian patients have dramatically lower admission rates, during the entire followup period, for all hospitalizations and for those related to infection and other causes. Rates of admission that include a cardiovascular procedure, particularly stents and angioplasty, tend to increase over time, also true for the small percentage of admissions associated with valvular procedures. And rates of inpatient vascular access insertions fall dramatically during patients’ first five years on therapy. Overall mortality rates are high in the first six months after initiation of ESRD therapy, then tend to fall in the next six months before increasing steadily during the next four years. These patterns show the dramatic effect of increasing time on dialysis, and the associated changing patterns of overall mortality and

s134 · cancer & hospitalization & treatment rates pregnancy in for cancer · pregnancy, birth, & women with ESRD complication rates · outcomes s136 · morbidity in AMI · CHF · stroke · PVD · pneumonia ESRD, CKD, & · bacteremia/septicemia · hip non-CKD patients fracture · cancer · mortality rates s138 · withdrawal geographic variations in withdrawal & hospice rates & hospice use · causes of death s140 · stroke first & recurrent stroke · probability of hospitalization & death · DM & HTN s142 · dementia probability of hospitalization & death · costs s144 · summary

10/13/2005 8:01:44 AM

MORBIDITY & MORTALITY 2005 Annual Data Report

Percent change from 1993

cause-specific mortality over time. Interestingly, patterns seen for infectious and cardiovascular death are very similar to these. In the prevalent dialysis population, hospitalizations for pulmonary infections continue to increase, particularly in patients on hemodialysis. Admissions for vascular access infections grew steadily between 993 and 2002, but showed a modest decrease in 2003, possibly due to lower catheter insertion rates. Prevalent death rates continue to improve, yet rates for patients on peritoneal dialysis five years or longer remain high. This year we assess provider-related outcomes, using Bayesian mortality and hospitalization ratios to compare data from 2002 and 2003. After adjusting for age, gender, race, primary cause of kidney failure, and time on dialy30 Change in hospital admission rates since 1993 (dialysis) Infection (2003: 22.8%) 20 Cardiovascular (2003: 10.4%)

10 0

All-cause (2003: -1.6%)

-10 -20 -30

Vascular access (2003: -25.4%) 95

97

99

01

03

2.5 Admissions/pt yr at risk

25 Hosp. days/pt yr at risk

2.0

20

1.5

15

10 Hemodialysis Peritoneal dialysis 0.5 5 Transplant All dialysis 0 0.0 93 95 97 99 01 03 93 95 97 99 01 03

sis, hospital-based units appear to have higher mortality rates than non-hospital-based units. In 2002, there were few significant differences between the individual large chains; in 2003, however, five of the large chains showed significant differences from each other, with the hospital-based units again having higher mortality rates than the non-chain and chain-based providers. Caution should be used in interpreting these figures, since hospital-based units may treat patients with worse vascular access problems and with additional comorbidities and complicating conditions, a basis for their increased mortality rates. The complexity of the dialysis population is demonstrated by extraordinarily high event rates across all organ systems. Event rates in dialysis patients are much greater than those of nonCKD patients, and their mortality rates advance more dramatically with age than do the rates of transplant, CKD, and non-CKD patients. Overall, hospitalization rates in dialysis patients have leveled off and for infection and cardiovascular disease, have decreased slightly. Improvements in preventive care are most likely associated with decreases in rates of events such as those noted for vascular access and infectious hospitalizations, and with progressively lower mortality rates for both incident and prevalent populations. These findings suggest that increased attention to the clinical practice guidelines may be having an impact on the morbidity and mortality of ESRD patients.

6 s123

1.0

6. · Change in hospital admissions rates, & adjusted admissions & days by modality: prevalent patients top graph: period prevalent dialysis patients; rates adjusted for age, gender, race, & primary diagnosis. ESRD patients, 2003, used as reference cohort. Vascular access hospitalizations are “pure” inpatient vascular access events, as described in Appendix A. Bottom graphs: period prevalent patients; rates adjusted for age, gender, race, & primary diagnosis. ESRD patients, 2003, used as reference cohort.

Chapter highlights

Figure 6.1 Cause-specific hospital admission rates have changed dramatically since 1993. Infectious and cardiovascular hospitalizations are up 23 and 10 percent, respectively, while those related to vascular access have fallen 25 percent. Figure 6.4 Five-year survival prob-

abilities for ESRD patients continue to rise, despite the greater disease burden now carried by the incident population. Figures 6.5 Since peaking in 1988, overall mortality rates in the prevalent dialysis population have fallen 11 percent, from 270 to 240 deaths per 1,000 patient years. Figures 6.90–91 Dementia in ESRD patients is associated with substantial adverse outcomes: over two years, a 1.8 unadjusted risk of hospitalization, and a striking two-fold increased risk of death—70 percent of those with dementia die, versus 41 percent of those without.

06 morbidity morte 05.indd 123

10/13/2005 8:01:47 AM

Overall hospitalization & mortality Adjusted interval hospital admissions after day incident patients 90 of ESRD, by primary diagnosis & modality age 20 & older

Admissions per patient year at risk

6.2

2.6

All

2.6

2.2

Hemodialysis

2.6

Peritoneal dialysis

2.2

2.2

1.5

Diabetes HTN GN Other

1.8

1.8

1.8

1.4

1.4

1.4

1.0

1.0 6 12 18 24 30 36 42 48 54 60 6 12 18 24 30 36 42 48 Months after day 90 of ESRD

Transplant

1.0

0.5

1.0

6 12 18 24 30 36 42 48 54 60

s124

6.a Adjusted interval hospital admissions (per patient year at risk) incident patients after day 90 of ESRD, by age, gender, race, & primary diagnosis age 20 & older

20-44 45-64 65-74 75+ Male Female White Black Other race Diabetes HTN GN Other cause All

I

Months after day 90 of ESRD 0–6 6–12 12–18 2.04 2.16 2.08 1.84 1.90 1.88 2.20 1.98 1.94 2.42 2.12 2.06 2.00 1.89 1.85 2.27 2.16 2.11 2.16 2.04 1.99 2.15 2.02 1.99 1.65 1.59 1.55 2.35 2.29 2.25 1.95 1.83 1.80 1.65 1.59 1.58 2.10 1.82 1.72 2.13 2.01 1.97

18–24 2.00 1.86 1.92 2.06 1.82 2.10 1.96 1.98 1.55 2.23 1.79 1.54 1.68 1.95

24–30 30–36 36–42 1.91 1.85 1.87 1.83 1.84 1.86 1.91 1.90 1.94 2.03 2.04 2.03 1.79 1.79 1.80 2.07 2.05 2.07 1.92 1.92 1.94 1.96 1.97 1.99 1.57 1.51 1.51 2.21 2.18 2.21 1.76 1.75 1.77 1.49 1.54 1.58 1.63 1.65 1.63 1.92 1.91 1.93

nterval analyses of hospital admissions by primary diagnosis show that rates tend to be slightly higher in the first twelve months after day 90 of ESRD, and are highest in diabetic patients throughout the entire study interval (Figure 6.2). The most dramatic change occurs in diabetic patients on peritoneal dialysis, in whom, between months six and 48, rates increase 23 percent. Younger patients are less likely to be hospitalized, and over a five-year period admission rates after day 90 of ESRD are generally 5 percent higher in females than in males (Table 6.a). There is little difference in rates when comparing whites and blacks. By primary diagnosis, however, admission rates for patients with diabetes are 20–25 percent higher than those found in patients carrying a diagnosis of hypertension. Figure 6.3 illustrates hospital admission rates in elderly patients immediately following the start of ESRD therapy. Rates are highest in the first six months after initiation, then fall by almost half in the next six months. Over the next 48 months rates remain quite steady in patients with a primary diagnosis of diabetes, at 2.2–2.3 admissions per patient year at risk; rates for those with hypertension or glomerulonephritis remain between .9–2.0 and .65–.75, respectively. Five-year survival probabilities for ESRD patients continue to rise, despite the greater disease burden now carried by the incident population (see Chapter Three). Compared to those of the previous period, survival probabilities for patients initiating in 994– 998 increased 7 percent overall—7 percent for hemodialysis, 9 percent for transplant, and 4 percent for peritoneal dialysis (Figure 6.4). By primary diagnosis, diabetic populations have seen the greatest improvement, though these patients also have the lowest five-year survival, at 27 and 23 percent for hemodialysis and peritoneal dialysis, respectively. In the most recent cohort, 34 percent of dialysis patients, and 73 percent of those with a transplant, survived at least five years.

06 morbidity morte 05.indd 124

42–48 48–54 54–60 1.85 1.77 1.75 1.83 1.78 1.76 2.01 1.95 1.92 2.04 2.09 2.07 1.82 1.79 1.79 2.09 2.06 2.00 1.93 1.91 1.84 2.04 2.00 2.05 1.57 1.50 1.60 2.19 2.15 2.12 1.80 1.79 1.75 1.62 1.65 1.57 1.67 1.65 1.69 1.94 1.91 1.89

6.3 Admissions per patient year at risk

6

MORBIDITY & MORTALITY

0.0

6

12

18

24

30

Adj. interval admits in older pts incident pts after initiation, by diagnosis age 65+ 5.0 4.5 4.0 3.5

Diabetes Hypertension Glomerulonephritis Other

3.0 2.5 2.0 1.5 1.0

6 12 18 24 30 36 42 48 54 60 Months after initiation

Since peaking in 988, overall mortality rates in the prevalent dialysis population have fallen  percent, from 270 to 240 deaths per ,000 patient years (Figure 6.5). This change varies significantly, however, in terms of patient vintage. Mortality rates for patients on the therapy less than two years fell 24 percent between 985 and 2003, to 220 deaths per ,000 patient years. But for patients on the modality five or more years, rates grew 2 percent in the same period, reaching 27 in 2003. It is significant to note that mortality rates in patients with five or more years on dialysis have been stable and now appear to be dropping, thus allowing the overall mortaliy rate to decrease as well. This phenomenon may be associated with many factors, such as improved dialysis therapy, changes in iron therapy, higher hemoglobins, and changes in overall medical practice. Vitamin D therapy, for example, underwent dramatic changes in 2000 and 200 with the increased use of Zemplar (see Figure .35), which has now been associated with lower rates of mortality. The decrease in the overall rate of mortality and the associated effects of changing medical practice warrant further investigation. Tables of expected remaining lifetimes show the dramatic contrast between ESRD patients and the general population (Table 6.b). Among dialysis patients expected remaining lifetimes are slightly higher in men up to age 54 and are generally the same between the genders thereafter. In transplant patients, in contrast, with the exception of those younger than 5, expected lifetimes are consistently greater for women. {Figure 6.2} incident ESRD patients age 20 & older, 997–200 combined; adjusted for age, gender, & race. Admissions after day 90 of ESRD. Incident ESRD patients, 200, used as reference cohort. Rates for transplant patients are censored three years after the transplant date & are shown only through month 30 after day 90. {Table 6.a} incident ESRD patients age 20 & older, 997–200 combined; adjusted for age, gender, race, & primary diagnosis. Rates presented for one factor are adjusted for the other three. Admissions after day 90 of ESRD. Incident ESRD patients, 200, used as reference cohort. {Figure 6.3} incident ESRD patients age 65 & older, 997–200 combined; adjusted for age, gender, & race. Admissions after initiation

10/13/2005 8:01:51 AM

MORBIDITY & MORTALITY 2005 Annual Data Report

Adjusted five-year survival, by incident dialysis patients & patients receiving modality & primary diagnosis a first-transplant in the calendar year

6.4

1989–1993 1.0

All patients, by modality

HD pts, by primary diagnosis

PD pts, by primary diagnosis

Survival probability

0.8 0.6 Dial. ( 31.1) HD (31.6) PD ( 28.7) Tx (67.5) All (35.7)

0.4 0.2 0

12

24

DM (23.8) HTN (36.1) GN (42.0) Other (35.6) All (31.6)

36

48

60 0

DM (18.5) HTN (35.2) GN (43.1) Other (34.8) All (28.7)

12 24 36 48 Months after initiation

60 0

12

24

36

48

60

1994–1998

6.5

All patients, by modality

HD pts, by primary diagnosis

PD pts, by primary diagnosis

Deaths per 1,000 patient years at risk

1.0

Survival probability

0.8 0.6 Dial. (33.6) HD (33.9) PD (32.7) Tx (73.3) All (38.1)

0.4 0.2 0

of ESRD. Incident ESRD patients, 200, used as reference cohort. {Figure 6.4} incident dialysis patients & patients receiving a first transplant in the calendar year. All probabilities are adjusted for age, gender, & race; overall probabilities are also adjusted for primary diagnosis. All ESRD patients, 996, used as reference cohort. Modality determined on first ESRD service date; excludes patients transplanted or dying during the first 90 days (five-year survival probabilities noted in parentheses). {Figure 6.5} period prevalent dialysis patients; adjusted for age, gender, race, & primary diagnosis. Dialysis patients, 200, used as reference cohort. {Table 6.b} U.S. data: calculated from Tables –9 in the United States life tables (Arias E). Available at www.cdc.gov/nchs/data/nvsr/ nvsr53/nvsr53_06.pdf. ESRD data: prevalent dialysis & transplant patients, 2003. Expected remaining lifetimes by race & gender can be found in Reference Table H.3. *2003 prevalent ESRD population is the weight used to calculate the overall combined age remaining lifetime.

12

24

DM (26.7) HTN (38.0) GN (44.8) Other (36.3) All (33.9)

36

48

60 0

12

24

DM (22.8) HTN (38.6) GN (46.1) Other (39.5) All (32.7)

36

48

60 0

12

24

36

48

60

6 s125

Adjusted mortality period prevalent rates, by vintage dialysis patients 300 5+ years 270 All 240

2-<5 years <2 years

210

86 88 90 92 94 96 98 00 02

Months after initiation

6.b Expected remaining lifetimes (years) of the general U.S. population general U.S. population, 2002, & prevalent & dialysis & transplant patients, by age, gender, & race dialysis & transplant patients, 2003

General U.S. population, 2002 All races Age All M F 0-14 70.9 68.2 73.4 15-19 61.1 58.4 63.6 20-24 56.3 53.8 58.7 25-29 51.6 49.1 53.9 30-34 46.8 44.4 49.0 35-39 42.1 39.8 44.2 40-44 37.5 35.2 39.5 45-49 33.0 30.8 34.9 50-54 28.6 26.6 30.4 55-59 24.4 22.5 26.0 60-64 20.4 18.7 21.9 65-69 16.8 15.2 18.0 70-74 13.4 12.0 14.4 75-79 10.4 9.3 11.1 80-84 7.8 6.9 8.3 85+ 4.3 3.8 4.5 overall* 25.2

06 morbidity morte 05.indd 125

23.4

26.6

White All 71.3 61.4 56.7 51.9 47.1 42.4 37.7 33.2 28.8 24.5 20.5 16.8 13.4 10.3 7.7 4.2

M 68.7 58.9 54.2 49.5 44.8 40.1 35.6 31.1 26.8 22.7 18.8 15.2 12.0 9.2 6.9 3.7

25.3

23.5

F 73.7 63.9 59.0 54.2 49.3 44.5 39.7 35.1 30.5 26.1 21.9 18.0 14.4 11.1 8.2 4.3

Black All 66.4 56.7 52.0 47.4 42.8 38.3 33.9 29.7 25.7 22.0 18.5 15.3 12.4 9.9 7.8 4.6

M 62.9 53.3 48.7 44.3 39.8 35.4 31.1 26.9 23.1 19.6 16.4 13.5 10.8 8.6 6.8 4.2

26.7

23.0

20.8

F 69.7 59.9 55.0 50.2 45.5 40.8 36.3 32.0 27.8 23.9 20.1 16.7 13.5 10.7 8.3 4.8

ESRD patients, 2003 Dialysis Age All M 0-14 18.3 19.2 15-19 16.0 16.9 20-24 13.9 14.8 25-29 12.0 12.7 30-34 10.5 10.8 35-39 9.0 9.2 40-44 7.8 8.0 45-49 6.8 7.0 50-54 5.9 6.0 55-59 5.0 5.0 60-64 4.3 4.3 65-69 3.7 3.6 70-74 3.1 3.1 75-79 2.6 2.6 80-84 2.2 2.2 85+ 1.8 1.7

F 17.3 15.1 12.9 11.3 10.0 8.7 7.6 6.7 5.9 5.0 4.4 3.7 3.1 2.7 2.2 1.8

24.7

overall* 5.5

5.4

5.6

Transplant All M 50.0 50.2 39.7 39.6 36.2 36.1 32.3 32.1 28.5 28.3 25.2 24.8 21.9 21.5 19.0 18.5 16.3 15.7 13.8 13.2 11.5 11.0 9.6 9.1 7.9 7.4 6.7 6.2

F 49.9 39.8 36.4 32.6 28.9 25.8 22.7 19.8 17.2 14.7 12.5 10.6 8.9 7.7

15.1 14.6 15.9

10/13/2005 8:01:55 AM

6

MORBIDITY & MORTALITY

Cause-specific hospitalization Adjusted interval cause-specific hospital admissions after day 90

6.6

by incident dialysis patients age age 20 & older 2.5

All hospitalizations

0.8

Cardiovascular disease

s126

Admissions per patient year at risk

0.7 0.6

2.0 20-44 45-64

0.5 65-74 0.4 75+

1.5

0.3

Infection 0.6

1.3

Other

1.2 0.5

1.1 1.0

0.4

0.9 0.3

6 12 18 24 30 36 42 48 54 60

0.8

6 12 18 24 30 36 42 48 54 60

Months after day 90 of ESRD

6.7

by incident dialysis patients gender age 20 & older

Admissions per patient year at risk

2.5

All hospitalizations

0.7

Cardiovascular disease

0.6 2.0 0.5 1.5

0.4

Infection 0.6

1.2

Male Female

Other

1.1

0.5

1.0 0.4 0.3

0.9

6 12 18 24 30 36 42 48 54 60

0.8

6 12 18 24 30 36 42 48 54 60

Months after day 90 of ESRD

6.8

by race/ incident dialysis patients ethnicity age 20 & older

Admissions per patient year at risk

2.5

All hospitalizations

0.7

White Black

2.0

0.6

Native American Asian

1.5

Hispanic

1.0

0.5 0.4 0.3

Infection 0.6

1.4

Other

1.2

0.5

1.0

0.4

0.8

0.3 0.2

Cardiovascular disease

0.6 6 12 18 24 30 36 42 48 54 60

0.4

6 12 18 24 30 36 42 48 54 60

Months after day 90 of ESRD

06 morbidity morte 05.indd 126

A

t six months after day 90 of ESRD, hospital admissions overall are highest in patients age 75 and older (Figure 6.6). At 2 months rates fall slightly and are comparable to those for patients age 20–44; they remain so through the following four years. Not surprisingly, admissions for cardiovascular complications are highest in older patients. Women tend to have slightly higher admission rates overall and for cardiovascular disease, infection, and other complications (Figure 6.7). It is noteworthy that their cardiovascular admissions are higher—a cause for concern, since in the general population cardiac disease is the greatest cause of mortality in women. Hospitalization rates for all causes are comparable in whites and blacks, and lowest in the Asian population (Figure 6.8). Asians also have lower admission rates for cardiovascular disease, though a clear increase in these rates is evident starting at month 24. Figures 6.9– illustrate rates for admissions with cardiovascular procedures. At month six, rates are highest in patients age 65–74, and a distinct upward trend is evident over the five-year period for patients age 45–64 (Figure 6.9). Patients age 45–74 are the most likely to have an admission for a bypass procedure, and admissions with a stent insertion or angioplasty are highest for this group as well. Overall, women have approximately 0 percent higher rates for admissions with a cardiovascular procedure; rates by gender, however, vary by procedure. Rates for admissions with bypass surgery, for example, are 5–4 percent lower in women, while those with stents or angioplasty are 7–20 percent lower (Figure 6.0). By race, rates for admissions with all cardiovascular procedures are similar in whites and blacks, but cause-specific rates can vary considerably (Figure 6.). At month six, blacks have 47 percent fewer admissions with bypass surgery and 42 fewer admissions with a stent or angioplasty. This disparity is evident throughout the fiveyear period, though the differences do narrow in the later months. Inpatient vascular access insertion rates are highest at month six for all age groups, and fall quite dramatically thereafter (Figure 6.2). Catheter insertion rates are higher than those for fistulas or grafts in all age groups—at month six, for example, rates for catheters are 6–8 times higher than those for fistulas and 3–4 times higher than those for grafts. Overall inpatient vascular access insertion rates are higher in females than in males; this is also true for catheter and graft insertions (Figure 6.3). Women have 9–36 percent higher catheter insertion rates, but have slightly lower fistula creation rates. Rates of graft creation are higher in females, which may indicate that female vasculature is more suited to graft creation than fistula creation. By race, overall inpatient vascular access insertion rates at month six are 40 percent higher in Hispanics than in whites, but while these higher rates are evident throughout the entire five-year interval, the relative difference decreases as time on ESRD grows (Figure 6.4). Insertion rates for catheters are highest in Hispanics through the first two years, but are then surpassed by rates for blacks until year four, at which point there is virtually no difference. The remarkably high rate of inpatient catheter insertions should serve as a reminder that practitioners need to move toward greater compliance with K/DOQI vascular access guidelines, which call for increased use of fistulas as the primary vascular access.

{All figures} incident dialysis patients, 200, used as reference cohort; rates by age are adjusted for gender, race, & primary diagnosis; rates by gender are adjusted for age, race, & primary diagnosis; rates by race/ethnicity are adjusted for age, gen{Figures 6.6–8} incident dialysis patients age 20 der, & primary diagnosis. & older, 997–200 combined; cause-specific categories determined from principal ICD-9-CM diagnosis codes. {Figures 6.9–} incident dialysis patients age 20 & older, 997–200 combined. Values are admission (not event) rates. Rates reflect all admissions with a cardiovascular procedure (excluding vascular access procedures), not just those for the primary purpose of a cardiovascular procedure. A hospitalization that includes more than one type of cardiovascular procedure will be counted under each type. {Figures 6.2–4} incident hemodialysis patients age 20 & older, 997–200 combined. Vascular access insertions in an inpatient setting are obtained from Part B physician/supplier claims.

10/13/2005 8:01:59 AM

MORBIDITY & MORTALITY 2005 Annual Data Report Adjusted interval admissions with cardiovascular procedures after day 90 by incident dialysis patients age age 20 & older 500

6.12

All cardiovascular procedures

20

450

15

400

10

350

20-44 45-64

300

65-74 75+

Stent/angioplasty 50

5 0

8 6

30

4

20

0

All vascular access insertions

500

20-44 45-64

400

600

300

400 300

200

Fistulas 80

150 100

40 50

20 0

6 12 18 24 30 36 42 48 54 60

6 12 18 24 30 36 42 48 54 60

450

15

400

10

350

5

300

0

35

Male Female

6

30 4

25 20

6 12 18 24 30 36 42 48 54 60

2

Male Female

600

Valve procedures 8

Stent/angioplasty 40

500

300

300 200

200 80 Fistulas 60

100

40

0

6 12 18 24 30 36 42 48 54 60

50

6 12 18 24 30 36 42 48 54 60

6.14 20

400

15

350

10

300

5

250 50

10 8

40

Valve procedures White Black

Other Hisp.

6

30

4

20 10

Bypass

0

Stent/angioplasty

2 6 12 18 24 30 36 42 48 54 60

0

6 12 18 24 30 36 42 48 54 60

Months after day 90 of ESRD

06 morbidity morte 05.indd 127

0

6 12 18 24 30 36 42 48 54 60

Months after day 90 of ESRD

Insertions per 1,000 patient years at risk

Admissions per 1,000 patient years at risk

All cardiovascular procedures

150 Grafts

20

by race/ incident dialysis ethnicity patients age 20 & older

450

500 Catheters 400

400

Months after day 90 of ESRD

6.11

6 12 18 24 30 36 42 48 54 60

by incident hemodialysis gender patients age 20 & older

700 All vascular access insertions Insertions per 1,000 patient years at risk

Admissions per 1,000 patient years at risk

6.13 20 Bypass

0

Months after day 90 of ESRD

by incident dialysis gender patients age 20 & older

500 All cardiovascular procedures

Grafts

s127

60

Months after day 90 of ESRD

6.10

65-74 75+

Catheters

500

2 6 12 18 24 30 36 42 48 54 60

by incident hemodialysis age patients age 20 & older

700

Valve procedures 10

40

10

Bypass Insertions per 1,000 patient years at risk

6.9

Admissions per 1,000 patient years at risk

Adjusted interval inpatient Vascular access insertions after day 90

6

by race/ incident hemodialysis ethnicity patients age 20 & older

900 All vascular access insertions White 700 Black Other 500 Hispanic

600 Catheters

300

300

100

200

500 400

90 Fistulas

200 Grafts

70

150

50

100

30

50

10

6 12 18 24 30 36 42 48 54 60

0

6 12 18 24 30 36 42 48 54 60

Months after day 90 of ESRD

10/13/2005 8:02:05 AM

6

MORBIDITY & MORTALITY

Cause-specific mortality Adjusted interval cause-specific mortality

6.15

by incident age dialysis patients

300

All

150

250

120

200

90

150

60

s128

Deaths per 1,000 patient years at risk

100

30

50 0

0 Other 45-64 100 65-74 75+ 80

Infection

40

0-19 20-44

30

60

20

40

10 0

Cardiovascular disease

20 6 12 18 24 30 36 42 48 54 60

0

6 12 18 24 30 36 42 48 54 60

Months after day 90

6.16

by incident gender dialysis patients

160

All

80 60

80

40

Deaths per 1,000 patient years at risk

120

Male Female

40

20

0

0

Infection 25

60

20

50

Other

40

15

30

10

20

5 0

Cardiovascular disease

10 6 12 18 24 30 36 42 48 54 60

0

6 12 18 24 30 36 42 48 54 60

Months after day 90

6.17

by incident race dialysis patients

200

All

100 80

Deaths per 1,000 patient years at risk

150

60

100

40

50

20

0

0

Infection 40 30 20

80

White Black N Am Asian

Other

60 40

10 0

Cardiovascular disease

20

6 12 18 24 30 36 42 48 54 60

0

I

nterval analyses of cause-specific mortality (starting 90 days after initiation of therapy) show that, across categories of age, gender, and race, rates tend to be high at six months, fall—often quite dramatically—over the next six months, and then rise steadily during the following four years (Figures 6.5–7). By age, for example, overall mortality between months six and 2 falls nearly 2 percent for patients age 75 and older, and 25 percent for pediatric patients (Figure 6.5). The decrease is equally dramatic for mortality caused by cardiovascular disease, by infection, and by other causes of death. Between months 2 and 60, rates increase steadily for most age groups; cardiovascular mortality, for example, rises 66 percent for patients age 20–44, and 55 percent for those age 45–64. Rates of infectious mortality in younger adults, in contrast, fall nearly 5 percent in the same period. The pattern of a sharp fall followed by a steady increase is particularly noticeable in rates by gender (Figure 6.6). Overall rates differ little between males and females. Cardiovascular mortality rates are quite similar in the first year; by five years, however, the rate is 0 percent higher in men. Rates of infectious mortality, however, are consistently greater in women. With the exception of infectious mortality, rates by race are highest among white patients, and they increase steadily for this population after one year (Figure 6.7). Some of the most dramatic growth by race is seen in the Asian population; overall rates rise 54 percent in the four years following the first year of therapy, while rates of cardiovascular and infectious mortality increase 76 and 63 percent, respectively. Figures 6.8–26 present interval mortality analyses for major cardiovascular diagnoses, sudden death, malignancy, and infections, including bacteremia/septicemia and pulmonary infection. Many of these also show rates decreasing between months six and 2, then rising steadily over the next four years. In dialysis patients, for example, rates of mortality due to AMI rise 45 percent between months 2 and 60, from 9 to 3 deaths per ,000 patient years (Figure 6.8), while rates of sudden death rise 2 percent in the same period, from 62.5 to 75.4. Rates of mortality due to bacteremia/septicemia in the same population increase 3 percent, from 2 to 6 (Figure 6.24). Because the transplant population is smaller, and generally healthier as well, mortality rates within it are more volatile than those in the dialysis population. Clear across all causes of death, however, is the lower mortality rate for these patients. At five years after initiation, for example, the rate of mortality due to sudden death is 75 per ,000 patient years in dialysis patients, and only 4 for patients with a transplant. {Figure 6.5} incident dialysis patients, 997–200 combined; adjusted for gender, race, & primary diagnosis. Incident patients, 996, used as reference cohort. {Figure 6.6} incident dialysis patients, 997–200 combined; adjusted for age, race, & primary diagnosis. Incident patients, 996, used as reference cohort. {Figure 6.7} incident dialysis patients, 997–200 combined; adjusted for age, gender, & primary diagnosis. Incident patients, 996, used as reference cohort. {Figures 6.8– 26} incident ESRD patients; adjusted for age, gender, race, & primary diagnosis. Incident patients, 996, used as reference cohort. For Figure 6.2, “sudden death” includes cardiac arrhythmia & cardiac arrest.

6 12 18 24 30 36 42 48 54 60

Months after day 90

06 morbidity morte 05.indd 128

10/13/2005 8:02:10 AM

MORBIDITY & MORTALITY 2005 Annual Data Report by time period: AMI ESRD patients Dialysis

8

1992-1996 1997-2001

14 12 10 8

Transplant

4 2

65 60

Transplant 30 20

Adjusted mortality, by time incident period: bacteremia/septicemia ESRD pts

6.25

1992-1996 1997-2001

18

1992-1996 1997-2001

7 6 5

Transplant 3 2

16 14 12 10

Transplant 6 5 4 3 2

0.3 0.2

s129 6 12 18 24 30 36 42 48 54 60 Months after day 90

1992-1996 1997-2001

6 5 4 3 3

Transplant

2 1 0

6 12 18 24 30 36 42 48 54 60 Months after day 90

Adj. mortality, by time incident period: pulmonary infection ESRD pts

4

Transplant

period: malignancy ESRD patients

6 12 18 24 30 36 42 48 54 60 Months after day 90

6.26 Adjusted mortality, by time incident

period: other infection ESRD pts

Dialysis 5 Deaths per 1,000 patient years at risk

Dialysis 20

4 0.4

Dialysis 7

8

0

5

6.23 Adjusted mortality, by time incident

1

6 12 18 24 30 36 42 48 54 60 Months after day 90

1992-1996 1997-2001

6

0.0

6 12 18 24 30 36 42 48 54 60 Months after day 90

9 Deaths per 1,000 patient years at risk

Deaths per 1,000 patient years at risk

70

Dialysis

0.1

Dialysis 10

10

Deaths per 1,000 patient years at risk

2

cerebrovascular disease ESRD pts

1992-1996 1997-2001

75

Dialysis 2 1992-1996 1997-2001

3 2

Transplant 4 3 2

1992-1996 1997-2001 1

0 2

Transplant

1

1

1 6 12 18 24 30 36 42 48 54 60 Months after day 90

06 morbidity morte 05.indd 129

Transplant

6.22 Adj. mortality, by time period: incident

Dialysis 80

0

2

0

6 12 18 24 30 36 42 48 54 60 Months after day 90

period: sudden death ESRD patients

6.24

4

1

6.21 Adjusted mortality, by time incident

0

7

1992-1996 1997-2001

Deaths per 1,000 patient years at risk

0

period: cardiomyopathy ESRD patients

Dialysis

6

3

6.20 Adjusted mortality, by time incident

Deaths per 1,000 patient years at risk

6

time period: ASHD ESRD patients

Deaths per 1,000 patient years at risk

Deaths per 1,000 patient years at risk

16

6.19 Adjusted mortality, by incident

Deaths per 1,000 patient years at risk

6.18 Adjusted mortality, incident

6

0

6 12 18 24 30 36 42 48 54 60 Months after day 90

0

6 12 18 24 30 36 42 48 54 60 Months after day 90

10/13/2005 8:02:15 AM

6

MORBIDITY & MORTALITY

Hospitalization & mortality, by modality

A 6.27 Adjusted hospital admissions incident ESRD

& days, by modality patients age 20 & older

2.5 Admissions per patient year at risk

25 Hospital days per patient year at risk

2.0

20

1.5

15

Hemodialysis Peritoneal dialysis Transplant

1.0

10

0.5

s130

0.0

5

6

0 12 18 24 30 36 42 48 6 12 18 24 30 36 42 48 Months after day 90 of ESRD

6.28 Adjusted cause-specific hospital incident ESRD

admissions & days, by modality patients age 20 & older Peritoneal dialysis

Admissions per patient year at risk

1.1 Admissions: Hemodialysis

Transplant

0.9 0.7 0.5 0.3 0.1

Hospital days per patient year at risk

8 Hospital days

Cardiovascular disease Infection Other

6

4

2

0

6 12 18 24 30 36 42 48

6 12 18 24 30 36 42 48

6

12

Months after day 90 of ESRD

Admissions per 1,000 pt years at risk

6.29

t month six after day 90 of ESRD, adjusted hospital admission rates for peritoneal dialysis patients are 24 percent lower than those for hemodialysis patients (Figure 6.27). As time on dialysis increases, however, these differences lessen, and by year three the rates are the same. Transplant patients are admitted to the hospital far less often than their dialysis counterparts, and their admission rates fall as their time with a functioning graft increases. Transplant patients also spend less time in the hospital. At month six, for example, hospital days for these patients are 50 and 27 percent lower than those of hemodialysis and peritoneal dialysis patients, respectively. In hemodialysis patients, admission rates for cardiovascular disease are 8–33 percent higher than those for infection (Figure 6.28). The opposite holds true in peritoneal patients, in whom, after month six, rates for infection actually outpace rates for cardiovascular disease, and are 8–24 percent higher through year five. Rates of admission for cardiovascular disease and infection are markedly lower in the transplant population, while hospital days for cardiovascular disease and infection over the study interval are similar within each modality. Trend analyses show that hospital admissions for pulmonary infection in hemodialysis patients have grown 24 percent since 993, while a slight fall in vascular access infections occurred in 2003, and may be due to a decreased use of hemodialysis catheters (Figure 6.29). Further study is warranted in this area. Admissions for peritonitis in peritoneal dialysis patients have fallen 38 percent. For cardiovascular procedures, rates have fallen 7 percent for hemodialysis patients, but have increased 2 and 3 percent in the peritoneal dialysis and transplant populations, respectively. And for heart catheterizations, admission rates have grown 4 and 2 percent in hemodialysis and peritoneal dialysis patients, but have fallen 22 percent for those with a transplant. 18 24 30 Between the 989–993 and 994– 998 periods, five-year survival for

Adjusted admissions for principal period prevalent procedures & diagnoses, by modality ESRD patients

140 Pulmonary infection 120

200 Infection (dialysis-related)

Peritoneal dialysis: peritonitis

150 Peritoneal dialysis

80 60

40 Heart catheterizations Hemodialysis

Hemodialysis

Hemodialysis

100

40

400 Cardiovascular procedures

100

300

30

200

Hemodialysis: vascular access infection

Peritoneal dialysis

Peritoneal dialysis 20 Transplant

100

Transplant

10

Transplant 93

95

06 morbidity morte 05.indd 130

97

99

01

03

50

93

95

97

99

01

03

0

93

95

97

99

01

03

0

93

95

97

99

01

03

10/13/2005 8:02:19 AM

MORBIDITY & MORTALITY 2005 Annual Data Report

6.30 Adjusted five-year survival, by incident

modality & primary diagnosis dialysis patients

1.0 Diabetes

Other HD 1989-93 (23.8) PD 1989-93 (18.5) HD 1994-98 (26.7) PD 1994-98 (22.8)

Survival probability

0.8

0.6

0.4 HD 1989-93 (37.3) PD 1989-93 (37.4) HD 1994-98 (39.0) PD 1994-98 (41.1)

0.2

0.0

0

12

24

36

48

60 0

12

24

36

48

60

Months after initiation

Deaths per 1,000 patient years at risk

6.31

Adjusted all-cause period prevalent mortality, by vintage dialysis patients 300 Hemodialysis

450 Peritoneal dialysis

280

400

260

350

240

300 <2 years 2-<5 years 5+ years All (adjusted for vintage)

220

200

85 87 89 91 93 95 97 99 01 03

250

200

85 87 89 91 93 95 97 99 01 03

diabetic patients who begin therapy on peritoneal dialysis grew 23 percent; for patients starting on hemodialysis the change was 2 percent (Figure 6.30). These latter patients, however, continue to have slightly better survival, with 27 percent living five years after initiation compared to 23 percent of those on peritoneal dialysis. Among patients with primary diagnoses other than diabetes, 37–4 percent survive five years; rates here are slightly higher for those on peritoneal dialysis. The overall decrease in mortality rates since 985— 8 percent for hemodialysis patients and 2 percent for those on peritoneal dialysis—continues to mask significant differences by vintage (Figure 6.3). Compared to those on the modality less than two years, for example, hemodialysis patients with a vintage of five or more years had a 9 percent higher mortality rate in 2003. In the peritoneal dialysis population, this difference reaches 94 percent. Rates for patients of the youngest vintage have fallen 2 and 42 percent for hemodialysis and peritoneal dialysis, respectively; for patients of older vintage, however, rates have increased  and 2 percent. Interval analyses of cause-specific mortality rates in incident hemodialysis patients show a dramatic fall between months six and 2, and parallel decreases for mortality due to cardiovascular disease, infection, or other causes (Figure 6.32). Rates for patients on peritoneal dialysis, in contrast, do not exhibit this same initial fall, but rather tend to increase steadily in the five years following initiation.

6 s131

{Figures 6.27–28} incident ESRD patients age 20 & older, 997–200 combined; adjusted for age, gender, race, & primary diagnosis; incident ESRD patients, 200, used as reference cohort. Rates for transplant patient are censored three years after the transplant date & are shown only through month 30. Cause-specific categories in Figure 6.28 determined from principal ICD-9-CM procedure codes. {Figure 6.29} period prevalent ESRD patients; rates adjusted for age, gender, race, & primary diagnosis. ESRD patients, 2003, used as reference cohort. Cardiovascular procedure category excludes vascular access procedures. {Figure 6.30} incident dialysis patients; adjusted for age, gender, & race. ESRD patients, 996, used as reference cohort. Modality determined on first ESRD service date; excludes patients transplanted or dying during the first 90 days (five-year survival probabilities noted in parentheses). {Figure 6.3} period prevalent dialysis patients; rates adjusted for age, gender, race, & primary diagnosis. Dialysis patients, 200, used as reference cohort. {Figure 6.32} incident dialysis patients; rates adjusted for age, gender, race, & primary diagnosis. ESRD patients, 996, used as reference cohort.

6.32 Adjusted cause-specific incident

mortality, by modality dialysis patients

Deaths per 1,000 patient years at risk

200

150

Hemodialysis, 1992-1996

Peritoneal dialysis, 1992-1996

Hemodialysis, 1997-2001

Peritoneal dialysis, 1997-2001

Cardiovascular Infection Other All

100

50

0

06 morbidity morte 05.indd 131

6 12 18 24 30 36 42 48 54 60

6 12 18 24 30 36 42 48 54 60 6 12 18 24 30 36 42 48 54 60 Months after day 90

6 12 18 24 30 36 42 48 54 60

10/13/2005 8:02:23 AM

Bayesian mortality & hospitalization ratios

I

6.33 Comparison of median provider-level prevalent

BMRs for all-cause mortality dialysis patients 2003 2

1

3

5

* *

*

*

3 2002

6

NC

HB *

1

*

2

*

3

*

*

4

*

*

5

*

6

*

NC

*

2

s132

4

*

*

4

*

5 6 NC

*

*

*

*

*

HB

*

*

*

*

*

*

*

1

2

3

4

5

6

NC

2003

1

HB HB

2002 Colored squares indicate the highest median value of the pair, & * indicates that p < 0.05. In a comparison of Chains 2 & 4 in 2002, for example, the blue box shows that Chain 2, in the blue title line at the bottom, has the greatest median value, & the asterisk indicates that the difference is significant.

n the 2004 ADR the USRDS introduced new methods to assess mortality on a provider level. These Bayesian methods help stabilize rates, particularly for smaller units, which have considerably more variability in their death and hospitalization events compared to larger providers. This year we report Bayesian mortality ratios by provider, and compare them to one another for 2002 and 2003, as shown in Figures 6.33–39. Overall mortality ratios show little difference among the chains, with hospital-based and non-chain providers having higher ratios than the others in 2002. The same analyses, however, repeated for 2003, show less significant differences in the non-chain providers and more variability among the chains. Fewer such inconsistencies appear in the cause-specific mortality ratios for cardiovascular disease, but there are greater differences for infectious mortality. These differences in outcomes also appear to relate to geographic location, which may merit increased attention in the future. Hospitalization ratios by provider and geographic location are reported in Figures 6.40–47. These analyses report overall results without direct comparisons of provider groups. Dialysis Clinics, Inc. appears to have lower ratios for all causes and for cardiovascular hospitalizations. Hospital-based units have higher ratios, particularly for infectious hospitalizations. The chain-specific infor-

provider-level mortality ratios

mortality from C.V. disease

Mortality from infection

6.34 BMRs, by unit prevalent affiliation dialysis patients

6.36 BMRs, by unit prevalent affiliation dialysis patients

6.38 BMRs, by unit prevalent

2.7

2003 2.7

1.0

.37

2002 2003

1.0

.37 1

2

3

4

5

6

NC

2

3

4

5

6

NC

2003

1.0

.37 WNC

WSC

ENC

ESC

SA

MA

NE

U.S. Census division (see box at right)

06 morbidity morte 05.indd 132

1.0 .37

1

6.39

2003

1.0

MTN

WNC

WSC

ENC

ESC

SA

MA

3

4

5

6

NC

HB

BMRs, by U.S. prevalent Census division dialysis patients

7.4

2002

PAC

2

Unit affiliation (see box at right)

.37 MTN

2003

2.7

HB

BMRs, by U.S. prevalent Census division dialysis patients 2.7

Mortality ratio (ln scale)

Mortality ratio (ln scale)

6.37

2002

PAC

2002

Unit affiliation (see box at right)

BMRs, by U.S. prevalent Census division dialysis patients 2.7

affiliation dialysis patients

.14 1

HB

Unit affiliation (see box at right)

6.35

7.4

Mortality ratio (ln scale)

2002

Mortality ratio (ln scale)

Mortality ratio (ln scale)

7.4

Mortality ratio (ln scale)

6

MORBIDITY & MORTALITY

NE

U.S. Census division (see box at right)

2002 2003

2.7 1.0 .37 .14

PAC

MTN

WNC

WSC

ENC

ESC

SA

MA

NE

U.S. Census division (see box at right)

10/13/2005 8:02:27 AM

MORBIDITY & MORTALITY 2005 Annual Data Report provider-level hosp. ratios

hospitalization for C.V. disease

6.40 BHRs, by unit prevalent

6.42 BHRs, by unit prevalent

2.7

affiliation dialysis patients

2002

Hospitalization ratio (ln scale)

Hospitalization ratio (ln scale)

affiliation dialysis patients

2003

1.0

.37

2.7

2002 2003

1.0

.37 1

2

3

4

5

6

NC

HB

1

BHRs, by U.S. prevalent Census division dialysis patients

Hospitalization ratio (ln scale)

2.7

6.43

2003

1.0

.37 PAC

MTN

WNC

WSC

ENC

SA

ESC

MA

3

4

5

6

NC

HB

BHRs, by U.S. prevalent Census division dialysis patients 2.7

2002

Hospitalization ratio (ln scale)

6.41

2

Unit affiliation (see box at right)

Unit affiliation (see box at right)

2002 2003

1.0

.37

NE

PAC

MTN

WNC

WSC

ENC

SA

ESC

MA

NE

U.S. Census division (see box at right)

U.S. Census division (see box at right)

hospitalization for infection

hospitalization for Vasc. access

6.44 BHRs, by unit prevalent affiliation dialysis patients

6.46 BHRs, by unit prevalent 2002

2.7

2002

Hospitalization ratio (ln scale)

Hospitalization ratio (ln scale)

2.7

affiliation dialysis patients

2003

1.0

.37

2003

2

3

4

5

6

NC

HB

1

6.47

2002

Hospitalization ratio (ln scale)

Hospitalization ratio (ln scale)

BHRs, by U.S. prevalent Census division dialysis patients 2.7

2

3

4

5

6

NC

HB

Unit affiliation (see box at right)

Unit affiliation (see box at right)

6.45

2003

1.0

{Figures 6.33–47} period prevalent dialysis patients, 2002 & 2003, in all dialysis providers; adjusted for age, gender, race, primary diagnosis, & vintage. Information on the U.S. Census divisions is available at www. census.gov/geo/www/us_regdiv.pdf.

Chain  · Chain 2 · C hain 3 · Chain 4 · Chain 5 ·

Fresenius Gambro DaVita Renal Care Group Dialysis Clinics, Inc. Chain 6 · Nat’l Nephrology Assoc. NC · Non-chain units HB · Hospital-based units

BHRs, by U.S. prevalent Census division dialysis patients 2.7

PAC MTN WNC WSC ENC ESC SA MA NE

· · · · · · · · ·

Pacific Mountain West North Central West South Central East North Central East South Central South Atlantic Middle Atlantic New England

2002 2003

6.48 U.S. Census

divisions New England

1.0 Pacific

Mountain

West North Central East North Central

.37

.37 PAC

MTN

WNC

WSC

ENC

ESC

SA

MA

NE

U.S. Census division (see box at right)

06 morbidity morte 05.indd 133

s133

1.0

.37 1

mation shows divergence, with Gambro having higher infectious and cardiovascular hospitalization ratios compared to other chains. These data will require more complete assessments to determine if these results are consistent or whether they vary as do those reported for mortality. These comparisons highlight the difficulty of using any single year to assess a provider network, and show trends should be addressed over time. Also, while providers are consolidating, assessing them may be difficult since new acquisitions may require more time to address programmatic changes. From this perspective, it may be better to address outcomes in providers that have been in a system for at least one year to account for changing procedures. The USRDS will explore these approaches to provide the clearest picture of how providers are doing in terms of overall outcomes.

6

PAC

MTN

WNC

WSC

ENC

ESC

SA

MA

NE

U.S. Census division (see box at right)

West South Central

East South Central

Middle Atlantic South Atlantic

10/13/2005 8:02:32 AM

{Figures 6.49–5} period prevalent female dialysis patients, age 20 & older. Female dialysis patients, 2003, used as reference cohort; cancer admissions determined from principal ICD-9-CM diagnosis codes. {Figure 6.49} adjusted for age, race, primary diagnosis, & vintage. {Figure 6.50} adjusted for age, race, & vintage. {Figure 6.5} adjusted for age, primary diagnosis, & vintage. {Figure 6.52} prevalent female dialysis patients, age 20 & older, with at least one inpatient cancer claim during the year. Includes only patients alive, with Medicare as a primary payor, & without a transplant for the complete year. {Figures 6.53–60} point prevalent female ESRD patients, age 4–45, 99–2002. Transplant cohorts include only patients within two years of most recent graft on January . {Figure 6.53} average

06 morbidity morte 05.indd 134

6.49 Cancer hospitalization period prevalent female

rates dialysis patients age 20 & older

Admissions per 1,000 pt years at risk

ince 993, hospitalization rates for breast cancer and for cervical, uterine, and ovarian cancer have decreased by 23 and 6 percent, respectively (Figure 6.49). These changes may be a positive indication of a more proactive role by renal practitioners in prescribing cancer monitoring in these patients. When compared to admission rates for cervical, uterine, and ovarian cancer, breast cancer admission rates are considerably higher—6 percent in 2003. While these higher rates may at first be a cause for alarm, they may be explained by the inference that increased monitoring has led to earlier detection of breast cancer, with subsequent hospitalizations for the treatment of this disease. Hospitalization rates for breast cancer in diabetics and nondiabetics have fallen 4 and 32 percent, respectively, since 993, while rates for cervical, uterine, and ovarian cancer are  and 20 percent lower (Figure 6.50). When comparing yearly trend rates between diabetics and non-diabetics for each cancer, no clear patterns emerge. By race, hospitalization rates for breast cancer and for cervical, uterine, and ovarian cancer have fallen for both whites and individuals of other races since 993, and as of 2003 rates by race for each cancer type were virtually the same (Figure 6.5) Treatment rates for cancer reflect changes in clinical practice over the past decade (Figure 6.52). In breast cancer patients, for instance, chemotherapy treatment rates have doubled. In patients with cervical, uterine, or ovarian cancer, the use of radiation therapy has fallen 46 percent, accompanied by a substantial increase (38 percent) in chemotherapy treatment rates over the same period. Data on pregnancy and outcomes in women with ESRD show that the mean age of pregnant patients was 3.5 in 2002 for those on dialysis, and 28.3 for those with a transplant—both higher than in the general population (Figure 6.53). Dialysis patients tend to have considerably more cardiovascular comorbidity, GI disease, liver disease, and dysrhythmia; transplant patients, however, are more likely to have diabetes (Figure 6.54). Since 99 the number of obstetrician visits in the three months before delivery has grown slightly for dialysis patients, while remaining relatively stable for those with a transplant (Figure 6.55). The number varies little by race, and in 2002 reached 6–9 visits. Pregnancy rates and their trends over time vary significantly by modality (Figure 6.56). Since 99 the rate in the dialysis population has increased 20–23 percent overall and in non-white patients, while falling 3.9 percent in whites. In the transplant population, in contrast, the rate has fallen 48.6 percent overall, 66 percent for non-whites, and 38 percent for whites. Complications related to pregnancy follow no clear trends (Figure 6.57). In 2002, 25 percent of dialysis patients, and 2 percent of those with a transplant, suffered a hemorrhage, while 6 and 26 percent, respectively, went into early labor. While the rate of live births is considerably higher in transplant patients than in those on dialysis, it has, like the pregnancy rate, fallen sharply since 99—50 percent for those younger than the mean age, and 54 percent for those older (Figure 6.58). For both modalities, the live birth rate is greatest in the youngest patients. Hemoglobins increase in 68 percent of patients following their pregnancy (Figure 6.59). The average increase is .02 g/dl—from 0.24 before the pregnancy to .26 after. Two years after the start of a pregnancy, the probability of survival is 20 percent higher in non-diabetic patients compared to diabetics, at 0.7 and 0.9, respectively (Figure 6.60).

6.50 Admissions per 1,000 pt years at risk

S

3.0 2.5 2.0

Breast

1.5 Cervical, uterine, & ovarian

1.0 0.5 0.0

93

94

95

96

97

98

99

00

01

02

03

Cancer hospitalization period prevalent female rates, by diabetic status dialysis patients age 20 & older 3.0 Breast

Cervical, uterine, & ovarian

2.5 2.0 1.5 1.0 Diabetic Non-diabetic

0.5 0.0

93

95

97

99

01

03

93

95

97

99

01

03

6.51 Cancer hospitalization period prevalent female

rates, by race dialysis patients age 20 & older

Admissions per 1,000 pt years at risk

s134

Cancer & pregnancy in women with ESRD

3.5 Breast

Cervical, uterine, & ovarian

3.0 2.5 2.0 1.5 1.0

White Other

0.5 0.0

93

95

97

99

01

03

93

95

97

99

01

03

6.52 Treatment rates period prevalent female dialysis

for cancer patients with cancer, age 20 & older

50 Breast

Cervical, uterine, & ovarian Radiation Chemotherapy Either

40 Percent of patients

6

MORBIDITY & MORTALITY

30 20 10 0

93

95

97

99

01

03

93

95

97

99

01

03

10/13/2005 8:02:36 AM

MORBIDITY & MORTALITY 2005 Annual Data Report 6.53

6.54 Comorbid conditions prevalent female

Average age prevalent female at pregnancy patients age 14–45

of pregnant patients patients age 14–45

35

Average age (in years)

Dialysis 31 Transplant 29

27 General population 91

93

95

97

99

Percent of pregnant patients

33

25

6

25 20 15 10 5 0

01

Dialysis Transplant

30

ASHD

CHF

CVA/TIA

PVD Cardiac COPD other

GI

Liver dis. Arrhyth- Cancer Diabetes mia

s135 6.55 Obstetrician visits prevalent female

prior to delivery patients age 14–45

6.56

4 2 12 Transplant 10 8 6 4 91

93

95

97

99

01

30

15

5 0 80 Transplant

Race

30

20

10

91

93

95

97

99

0

01

91

93

95

6.59 Hemoglobin before prevalent female

& after pregnancy patients age 14–45

Primary diagnosis

8 6 4

20

2

R =.0261

15 10 5 0

0

2

5 10 15 20 Hemoglobin before pregnancy (g/dl)

0

Transplant < mean > mean

White Other

Diabetes HTN

6.60

30

20

10

0

Survival after point prevalent female start of pregnancy ESRD patients age 14–45 1.0

Survival probability

Rate per 1,000 patient years at risk

0 40 Transplant

20

10

40

0.9 0.8

06 morbidity morte 05.indd 135

91 93 95 97 99 01

91 93 95 97 99 01

Non-diabetic Diabetic

0.7 0.6

91 93 95 97 99 01

Preeclampsia Early labor

10

40

Live birth rates, by age, prevalent female race, & primary diagnosis patients age 14–45 12 Dialysis: Age

White Other All

60

0

Infection Hemorrhage

20

10

Percent of pregnancies

6

2

6.58

20

8

Complications in prevalent female pregnancy, by modality patients age 14–45 40 Dialysis

Hemoglobin after pregnancy

10

6.57

25 Dialysis White Other

Rate per 1,000 patient years at risk

Number of visits in three months prior to delivery

12 Dialysis

Pregnancy rates, prevalent female by modality & race patients age 14–45

0

3 6 9 12 15 18 21 Months after start of pregnancy

24

97

99

01

age for general population taken from NVSS (Mathews et al., 2002). {Figure 6.54} comorbidity assessed from claims during followup for all pregnant patients, 99–2002. {Figure 6.55} OB visits assessed from claims during 9 days prior to delivery for all pregnant patients with live births from 99–2002. {Figure 6.57} complications include antepartum & postpartum conditions. Preeclampsia determined from claim diagnosis codes. {Figure 6.59} hemoglobin measurements from EPO claims immediately before & after pregnancy. {Figure 6.60} survival from start of pregnancy to either start of next pregnancy or death, for all pregnant patients, 99– 2002. {Figures 6.5 & 6.55–56, & 6.58} “other” reflects combined races due to low counts.

10/13/2005 8:02:44 AM

Morbidity in ESRD, CKD, & non-CKD patients

F

igures 6.6–69 compare inpatient morbidity and mortality event rates in four patient cohorts: ESRD patients (dialysis and transplant), and non-ESRD Medicare patients (with and without CKD). ESRD patients were point prevalent on January , 2002. For the prevalent CKD and non-CKD cohorts, diabetes and CKD were defined during a oneyear entry period in 200. The followup period for ascertainment of clinical events in all four groups extended from January , 2002, to December 3, 2003. Clinical events were defined by inpatient ICD-9-CM diagnosis codes, and the rates presented were adjusted for race, gender, and diabetes. Several general patterns are present that are common to all event types. Within each age category, event rates tend to increase as follows: non-CKD < transplant < CKD < dialysis. Increments in event rates with increasing age are greater in the dialysis population than in the other three popula6.61 Adjusted rates of myocardial prevalent adult

6.62 Adjusted rates of congestive prevalent adult

Inpatient events per 1,000 pt yrs at risk

infarction, by age Medicare patients

heart failure, by age Medicare patients

100 Dialysis Transplant CKD Non-CKD

75

50

25

0

20-44

45-64 Age group

65+

6.63 Adjusted rates of prevalent adult Inpatient events per 1,000 pt yrs at risk

Dialysis Transplant CKD Non-CKD

25

20-44

06 morbidity morte 05.indd 136

45-64 Age group

Dialysis Transplant CKD Non-CKD

400 300 200 100 0

20-44

45-64 Age group

65+

vascular disease, by age Medicare patients

75

0

500

6.64 Adjusted rates of peripheral prevalent adult

stroke, by age Medicare patients

50

Inpatient events per 1,000 pt yrs at risk

s136

tions. Rates in the youngest group of dialysis patients usually exceed those seen in the oldest group of non-CKD patients. The data in these figures also allow one to compare rates of different clinical events within each of the four cohorts defined above. In dialysis patients, congestive heart failure is the most frequent clinical event, followed by peripheral vascular disease and bacteremia/septicemia. Among transplant and CKD patients, congestive heart failure is the most frequent clinical event, followed by peripheral vascular disease and pneumonia. Among non-CKD patients, congestive heart failure is the most frequent event, followed by pneumonia and peripheral vascular disease. These data show that both the presence and the severity of chronic kidney disease appear to be risk multipliers for common, serious medical conditions. This risk multiplier effect is most obvious in dialysis populations, where the likelihood of develop-

65+

Inpatient events per 1,000 pt yrs at risk

6

MORBIDITY & MORTALITY

250

Dialysis Transplant CKD Non-CKD

200 150 100 50 0

20-44

45-64 Age group

65+

10/13/2005 8:02:47 AM

MORBIDITY & MORTALITY 2005 Annual Data Report 6.66 Adjusted rates of bacteremia/ prevalent adult

Adjusted rates of prevalent adult pneumonia, by age Medicare patients

septicemia, by age Medicare patients

200 Dialysis Transplant CKD Non-CKD

150

100

50

0

20-44

45-64 Age group

65+

Inpatient events per 1,000 pt yrs at risk

Inpatient events per 1,000 pt yrs at risk

40 Dialysis Transplant CKD Non-CKD

20

10

20-64

65+ Age group

Deaths per 1,000 patient years at risk

mortality, by age Medicare patients

400 Dialysis Transplant CKD Non-CKD

200

100

0

06 morbidity morte 05.indd 137

20-44

45-64 Age group

Dialysis Transplant CKD Non-CKD

100

50

0

20-44

45-64 Age group

65+

s137

60 Dialysis Transplant CKD Non-CKD

40

20

0

20-44

45-64 Age group

65+

ing one of these life-threatening events is very high.

6.69 Adjusted rates of prevalent adult

300

150

cancer, by age Medicare patients

fracture, by age Medicare patients

0

200

6.68 Adjusted rates of prevalent adult

6.67 Adjusted rates of hip prevalent adult

30

Inpatient events per 1,000 pt yrs at risk

Inpatient events per 1,000 pt yrs at risk

6.65

6

65+

{Figures 6.6–69} prevalent adult Medicare patients. ESRD (dialysis & transplant): patients point prevalent on January , 2002 & with Medicare as a primary payor. CKD & non-CKD (general Medicare patients): included patients survive a one-year entry period in 200, have continuous Medicare coverage with no HMO coverage, & do not have ESRD; CKD & diabetic status are defined during the oneyear entry period. Followup is a maximum of two years, from January , 2002, to December 3, 2003. Events are defined by the first cause-specific inpatient ICD-9-CM diagnosis code during followup. Rates are adjusted for gender, race, & diabetic status. The reference cohort consists of all included patients (ESRD, CKD, & non-CKD).

10/13/2005 8:02:51 AM

6

MORBIDITY & MORTALITY

Withdrawal & hospice care in the Medicare ESRD population 6.71 Reasons for withdrawal ESRD

6.70 Dialysis withdrawal & hospice ESRD

from dialysis patients

status in deceased ESRD pts patients

20 Percent of deaths

50

Hospice Withdrawal Withdrawal using hospice 13.5%

15

21.8% Percent of patients

25

10 41.9% of 21.8%

5

40 30 20 10 0

0

Access failure

Tx failure

s138

Chronic Acute failure medical to thrive comp.

Other

6.72 Withdrawal & hospice status, ESRD

by age, gender, & race patients

Percent of patients

100 Age 80 60 40 20 0

6.73

Gender

85+ 80-84 75 -79 70-74 65-69 45-64 20-44 0-19

Withdrawal

Race

Other Asian N Am Black White

Female Male Hospice

Withdrawal

Hospice

Withdrawal

Hospice

Causes of death among ESRD withdrawal & hospice patients patients

Percent of patients

25 Withdrawal Hospice All

20 15 10 5 0

Cardiac Card. arrest Cancer Septicemia

Stroke

Dementia Cachexia

Other

Unknown

<1%*

*Other diagnoses, each accounting for <1%

B

ecause of the shortened life expectancy and high comorbidity of ESRD patients, ESRD is included in the list of chronic diseases for which hospice is recommended. Only 3.5 percent of dying ESRD patients use hospice, compared to the national average of over 22 percent. The American Society of Nephrology and the Renal Physicians Association have published a clinical practice guideline and position statement endorsing hospice care for ESRD patients as an essential part of quality end-of-life care (RPA/ASN 2000, 2002).

06 morbidity morte 05.indd 138

Here we describe patterns of use of dialysis withdrawal and hospice care among 5,239 deceased patients in the USRDS 200–2002 two-year Medicare cohort. Withdrawal and hospice status of the deceased cohort are depicted in Figure 6.70. Almost 22 percent withdrew from dialysis, and 3.5 percent used hospice. Of those who withdrew, only 4.9 percent utilized hospice. “Chronic failure to thrive” (an outdated term previously used in geriatrics to describe symptoms of dementia, functional decline, and/or depression) is the most common reason given for withdrawal (42.9 percent), followed by the non-specific “acute medical complications” and “other” (Figure 6.7). As described in Figure 6.72, most patients who used withdrawal or hospice were white, and their use increased with age. The mean age of those who withdrew or used hospice was about 74, compared to 69 for those who used neither. To analyze the site of death and costs during the last six months of life, we used a subset of 9,687 subjects of the above cohort who were on dialysis for the entire six months prior to death. Table 6.e shows the site of death for this cohort by withdrawal and hospice use. Three times as many hospice patients died at home compared to non-hospice patients, but only 23 percent of hospice patients died in the hospital compared to 69 percent of non-hospice patients. Among hospice patients, the mean Medicare costs and number of hospital days during the last week of life were half of those for all patients who died (Table 6.f). Using the two-year cohort, Tables 6.c–d list the ten states with the highest and lowest percentage of patients who used hospice, among those who withdrew from dialysis. There is marked variation, between states, in the the percentage using hospice after withdrawal, from 6.7 percent in Maine to 54.6 percent in Iowa, even though they had a similar percentage who withdrew (39. percent and 37. percent, respectively). The three maps in Figures 6.74–76 illustrate geographic variations in use of withdrawal and hospice, and the percentage of those who used hospice among those who withdrew. In Figure 6.77, the mean age of all those deceased is shown in the left map, and mean age among those who used hospice in the right map. Although there is some correlation between mean age by state and hos-

10/13/2005 8:02:54 AM

MORBIDITY & MORTALITY 2005 Annual Data Report 6.74 Geographic variations in the % of ESRD

patients who withdraw, by state patients

6.75 Geographic variations in the % of ESRD

patients using hospice, by state patients

6.76 Percent of patients withdrawing ESRD patients who used hospice, by state

16.6 + (21.5) 14.8 to <16.6 12.3 to <14.8 9.8 to <12.3 below 9.8 (7.2)

38.0 + (39.8) 28.9 to <38.0 23.3 to <28.9 17.6 to <23.3 below 17.6 (14.0)

6

46.1 + (55.0) 38.6 to <46.1 34.7 to <38.6 31.6 to <34.7 below 31.6 (26.0)

s139 6.77 Geographic variations ESRD

in mean age, by state patients

Overall

Patients who use hospice

71.0 + (71.8) 70.2 to <71.0 68.7 to <70.2 67.6 to <68.7 below 67.6 (67.0)

6.c Highest % of withdrawing ESRD

74.7 + (75.7) 74.1 to <74.7 73.0 to <74.1 72.0 to <73.0 below 72.0 (71.0)

6.d

patients who use hospice patients Count:

Percent: Total Withdrawal Withdrawal withdrawal using hospice using hospice Arizona 517 339 65.6 Florida 1,674 1,096 65.5 Nevada 84 51 60.7 Colorado 273 161 59.0 Iowa 335 183 54.6 Ohio 959 523 54.5 Michigan 1,200 649 54.1 Texas 2,018 1,015 50.3 Illinois 973 472 48.5 Utah 159 74 46.5

Lowest % of withdrawing ESRD patients who use hospice patients Count:

Percent: Total Withdrawal Withdrawal withdrawal using hospice using hospice Maine 144 24 16.7 New Hampshire 119 26 21.8 Virginia 750 198 26.4 Montana 90 25 27.8 Hawaii 77 22 28.6 Massachusetts 581 168 28.9 South Carolina 275 81 29.5 West Virginia 198 60 30.3 South Dakota 89 27 30.3 Tennessee 521 162 31.1

pice use by state, and more use of dialysis in many Sunbelt states or those with mean older ages, other local factors also play a role. These include local access to hospice care, hospice policies and reimbursement among facilities, and variation in education of clinicians, patients, and families regarding the benefits of hospice care. These findings demonstrate that ESRD patients lag significantly behind oncology patients in hospice use, despite the fact that they have comparable morbidity, and incident ESRD patients have on average a five-year survival that is half of that for patients with cancer (33 percent vs 65 percent; National Center for Health Statistics, 2000). End-of-life care conversations held early in the course of maintenance dialysis, and improved education of the nephrology community and patients regarding the benefits of hospice care, are needed. {Figures 6.70–77 & Tables 6.c–f} incident & prevalent ESRD patients dying in 200–2002. Cohort for Tables 6.e–f includes only patients whose ESRD began at least six months prior to the date of death.

*excludes Alaska, with only 26 withdrawals

6.e

Site of hospice ESRD days & death patients

Six-month cohort

6.f

Count Percent 91,687

Hospice: yes

12,058

13.2

Hospice: no

79,629

86.8

Withdrawal: yes

19,517

21.3

Withdrawal: yes Hospice: yes Withdrawal: yes Hospice: no

8,200

42.0

11,317

58.0

06 morbidity morte 05.indd 139

Site of Site of death death (%) Hospital 63 Home 16.7 Other 11.1 Unknown 8.4 Hospital 22.9 Home 37.6 Hospital 69.0 Home 13.6 Hospital 49.2 Home 25.3 Hospital Home Hospital Home

22.5 45.3 68.5 10.8

Mean days in hospice 2.0 ± 12.6

N

Costs & site of death ESRD for deceased patients patients Withdrawal 19,517

Hospice 12,058

Mean costs: last six months of life $52,305 $48,979 14.2 ± 30.5 0 4.4 ± 15.5

Mean costs: last week of life $4,918 $3,339 Mean hospital days: last week of life 2.8 1.4

All 91,687 $53,021 $6,612 3.0

10.1 ± 21.9 0

10/13/2005 8:03:01 AM

6

MORBIDITY & MORTALITY

Incident & prevalent stroke

T

Incident stroke in Incident dialysis patients

6.78 Rate of incident stroke, by incident dialysis age, race, & modality patients, 2000

60 Hemodialysis: n=20,006 White Black Other

Rate per 100 patient years

50 40 30 20 10 0

6.79

67-74

75-84

85+

Time to hospitalization incident dialysis following incident stroke patients, 2000

67-74

1.0

0.8

0.8

0.4

HD: stroke HD: no stroke PD: stroke PD: no stroke

0.2 0.0

0

3

6 9 12 15 18 Months after first stroke

21

85+

incident stroke patients, 2000

1.0

0.6

75-84

6.80 Survival rates following incident dialyis

Probability of survival

s140

Probability of hospitalization

Peritoneal dialysis: n=730

0.6 0.4 0.2 0.0

24

HD: stroke HD: no stroke PD: stroke PD: no stroke 0

3

6 9 12 15 18 Months after first stroke

21

24

recurrent Stroke in incident ESRD patients

6.81 Rate of recurrent stroke, incident dialysis Rate per 100 patient years

by age, race, & modality patients, 2000

200 Hemodialysis: n=4,539

Peritoneal dialysis: n=109

White Black Other

150

100

50

0

67-74

75-84

85+

6.82 Time to first hospitalization incident dialysis

second stroke patients, 2000

1.0

1.0

0.8

0.8

0.6 HD: stroke HD: no stroke PD: stroke

0.4 0.2 0.0

0

2 4 6 8 10 Months after second stroke

06 morbidity morte 05.indd 140

12

75-84

6.83 Survival rates following incident dialysis

Probability of death

Probability of hospitalization

following second stroke patients, 2000

67-74

0.6 HD: Stroke HD: no stroke PD: stroke

0.4 0.2 0.0

0

2 4 6 8 10 Months after second stroke

12

he epidemiology of stroke in ESRD patients has begun to receive more attention in the literature, but stroke still ranks below other cardiovascular disease outcomes in identification of modifiable risk factors, clinical trials, and implementation of preventive measures. This is surprising, given its substantial impact on cognition, function, quality of life, and mortality. In these analyses we define both stroke and TIA as stroke (TIA constitutes approximately 30 percent of the combined stroke/ TIA counts here), and include claims from both Medicare Parts A and B—i.e., not only strokes that occur during hospitalization, because some patients with strokes may choose not to be hospitalized. Stroke rates here are thus substantially higher than those reported in the literature. The rate of incident stroke in both incident and prevalent hemodialysis populations is markedly elevated compared to the non-ESRD population, and increases with age (Figures 6.78, 6.84, 6.85). In incident hemodialysis patients ages 67-74, the rate is 27.2 and 29.3 strokes per 00 patient years in whites and blacks, respectively. The prevalence of stroke in white peritoneal dialysis patients is slightly lower than that of hemodialysis patients, but for those age 85 and older, rates for black peritoneal dialysis patients are double those of black hemodialysis patients, at 87.4 versus 45.8 (Figure 6.84). Among transplant patients, stroke prevalence rates are about onethird to one-half of those for hemodialysis patients, except again in blacks age 85 and older, in whom the rate is similar to that of peritoneal dialysis patients. Incident stroke in the 2000 ESRD population is associated with high rates of hospitalization and mortality over a two-year followup period (Figures 6.79–80). At the end of one and two years of followup, about 85 and 95 percent of hemodialysis and peritoneal dialysis patients have been hospitalized at least once, compared to 64 and 83 percent hospitalized among hemodialysis patients without incident stroke. Survival following incident stroke in dialysis patients is abysmal, similar to the poor survival associated with other cardiovascular events in ESRD patients. Less than 50 percent are alive at 2 months, compared to more than 70 percent in those without

10/13/2005 8:03:07 AM

MORBIDITY & MORTALITY 2005 Annual Data Report

{Figures 6.78 & 6.8, 6.84–87} per 00 patient years. {Figures 6.78–83} incident dialysis patients, 2000, without stroke claims in previous two years. For Figures 6.79–82, event occurring at least 30 days after initial stroke; Figures 6.78 & 6.8, racial PD data missing due to low counts. Figures 6.82–83, “PD no stroke” category missing due to low counts. {Figure 6.84} period prevalent ESRD patients, 2003. {Figures 6.85–87} point prevalent ESRD patients, 2003, with Medicare as primary payor for two years.

06 morbidity morte 05.indd 141

Rate per 100 patient years

6.84

Prevalent stroke, by period prevalent age, race, & modality ESRD patients, 2003

100 Hemodialysis: n=257,822 White Black 80 Other

Peritoneal dialysis: n=21,350

Transplant; n=33,635

60 40 20 0

18-45 46-64 65-74 75-84

85+

18-45 46-64 65-74 75-84

85+

18-45 46-64 65-74 75-84

85+

s141

Rate per 100 patient years

6.85

Incident stroke, by point prevalent age, race, & modality ESRD patients, 2003 30 Hemodialysis: n=87,726 White Black Other 20

Peritoneal dialysis: n=6,602

Transplant: n=21,082

10

0

18-45 46-64 65-74 75-84

85+

18-45 46-64 65-74 75-84

85+

18-45 46-64 65-74 75-84

85+

6.86 Association of diabetes & hypertension point prevalent

with incident stroke, by age & modality ESRD patients, 2003

Rate per 100 patient years

60 Hemodialysis: n=87,726

Peritoneal dialysis: n=6,602

Transplant: n=21,082

Diabetes (DM) Hypertension DM + hypertension Neither

40

20

0

18-45 46-64 65-74 75-84

85+

18-45

46-64

65-74

75-84

18-45

46-64

65-74

75-84

6.87 Incident stroke & percent of incident stroke point prevalent

patients with AFIB, by age & type of stroke ESRD patients, 2003

20 Stroke Rate per 100 patient years

incident stroke, and two-thirds are dead at two years followup, compared to half without stroke. The mortality rate for peritoneal dialysis patients with incident stroke is slightly lower than that of hemodialysis patients until 2 months of followup, after which it surpasses the hemodialysis rate and reaches 74 percent at two years. The rate of recurrent stroke by age in incident dialysis patients is over twice that of incident stroke; in white and black hemodialysis patients age 67–74 it is 73. and 90.4 strokes per 00 patient years, respectively (Figure 6.8). Among black and other race patients, as well as all peritoneal dialysis patients age 75–84, the rate approaches 0. Hospitalization and mortality rates in the year following recurrent stroke are similar to those for incident stroke (Figures 6.82–83). The associations of diabetes and hypertension with incident stroke are not unexpected; hypertension and diabetes together have a stronger effect than either alone, but diabetes by itself is more strongly associated with stroke than hypertension in both hemodialysis and peritoneal dialysis patients (Figure 6.86). The oldest diabetic peritoneal dialysis patients have the highest rate of incident stroke, similar to their high rates of other cardiovascular outcomes. The majority of incident strokes and vascular episodes in prevalent ESRD patients are ischemic, occurring twice as often as TIAs and ten times as often as hemorrhagic strokes (Figure 6.87). The percent of patients with each type of stroke who also have atrial fibrillation is only slightly higher in those with ischemic stroke than hemorrhagic, and increases substantially with age. These data point to the remarkably high disease burden associated with stroke in dialysis patients, and the need to design effective interventions for stroke prevention. Aggressive management of diabetes, hypertension, and atrial fibrillation are starting points, but the roles of elevated lipids, homocysteine, and inflammatory markers in the evolution of stroke in ESRD patients also need to be further explored.

6

40 Percent of stroke patients with AFIB Ischemic Hemorrhagic TIA

15

30

10

20

5

10

0

18-45

46-64

65-74

75-84

85+

0

18-45

46-64

65-74

75-84

85+

10/13/2005 8:03:11 AM

6

MORBIDITY & MORTALITY

Dementia

6.90 Event-free hosp. in patients with point prev.

prevalent dementia in prevalent patients

& w/o dementia, by modality ESRD pts

6.88 Occurrence of prevalent dementia, point prevalent by age, race, & modality ESRD patients

Peritoneal dialysis

Transplant

0.8 Event-free probability of hospitalization

25 2001: Hemodialysis White 20 Black Other 15

Percent of patients

10

s142

5 0 25

2003

20 15

0.2

75-84

85+

45-64

65-74

75+

45-64

0.8 0.6

0

6

12 Months

18

24

& w/o dementia, by modality ESRD pts

Peritoneal dialysis

Transplant

Hemodialysis

1.0

Without dementia

0.8 0.6 Event-free probability of death

4 2 0

2003 8 6 4

0.4 With dementia

0.2 0.0

Peritoneal dialysis

1.0

Without dementia

0.8 0.6 0.4

2

With dementia

0.2 0.0 45-64

T

65-74

75-84

85+

he epidemiology of dementia in ESRD patients has received little attention. Here we describe the prevalence and incidence of dementia in point prevalent ESRD populations. Because dialysis patients are not routinely assessed for dementia, these rates are largely underestimates. The prevalence of dementia in hemodialysis patients rose 7 percent between 200 and 2003, but incidence grew 5 percent, a high rate relative to the rise in prevalence (total prevalence and incidence not shown). This is likely due to their low two-year survival rate of 30 percent (Figure 6.9), diabetes becoming the most common primary diagnosis (diabetes doubles the risk of

06 morbidity morte 05.indd 142

45-64

65-74

75+

45-64

65+

dementia in non-ESRD patients), and possibly to improved reporting of dementia. As in the non-ESRD population, age is strongly associated with prevalent dementia in hemodialysis patients (Figures 6.88– 89). In 2003, incident dementia rates among blacks grew from .4 percent in those age 44–65, to 0.3 percent in patients age 85 and older; among whites, the rates were .2 and 6.4 percent respectively. Dementia rates in peritoneal dialysis patients are much lower than in hemodialysis patients, and very low in transplant patients (Figures 6.88 and 6.93). In 200 and 2003, the prevalence and incidence of dementia across all age groups

0

6

12 Months

18

24

6.92 Cumulative Medicare per member point prev. costs in pts with & w/o dementia ESRD pts

Cumulative per member costs (1,000s of $)

0

With dementia

6.91 Survival probability in pts with point prev.

Alzheimer’s Vascular dementia Other

6

Without dementia

0.4

65+

by age, dementia type, & modality ESRD patients

8 2001: Hemodialysis

Peritoneal dialysis

1.0

0.0 65-74

With dementia

0.0

5 45-64

Without dementia

0.4

0.2

6.89 Occurrence of prevalent dementia, point prevalent

Percent of patients

0.6

10

0

Hemodialysis

1.0

100 80

With dementia

60 40

Without dementia

20 0

0

6

12 Months

18

24

10/13/2005 8:03:16 AM

MORBIDITY & MORTALITY 2005 Annual Data Report incident (new) dementia in prevalent patients

6.93 First diagnosis of dementia, point prevalent by age, race, & modality ESRD patients

12 2001: Hemodialysis

Peritoneal dialysis

Transplant

White Black Other

10 8 6

Percent of patients

4 2 0 12

2003

10 8 6 4 2 0

6.94

45-64

65-74

75-84

85+

45-64

65-74

75+

45-64

65+

First diagnosis of dementia, by point prevalent age, dementia type, & modality ESRD patients 4 2001: Hemodialysis

Peritoneal dialysis

Transplant

Alzheimer’s Vascular dementia Other

3 2

Percent of patients

1 0 4

2003

3 2 1 0

6.g

45-64

65-74

75-84

85+

45-64

65-74

75+

45-64

65+

were higher in blacks than in whites (Figures 6.88 & 6.93), a pattern also seen in the non-ESRD population. Alzheimer’s disease comprises 65–70 percent of all dementias in the non-ESRD U.S. population; in the hemodialysis population, in contrast, vascular dementia (due to cerebral ischemia) is almost as common as Alzheimer’s (Figure 6.89). This may reflect the high cardiovascular risk factor profile most dialysis patients bring to dialysis initiation, and the approximate 30 percent prevalence of stroke in hemodialysis patients over age 65 (Figure 6.84). Dementia in ESRD patients is associated with substantial adverse outcomes: over two years, a .8 unadjusted risk of hospitalization, and a striking two-fold increased risk of death—70 percent of those with dementia die, versus 4 percent of those without (Figures 6.90–9). In 2002, approximately 9,00 more Medicare dollars were spent for an ESRD patient with prevalent dementia than for one without (Figure 6.92). Factors associated with incident dementia on logistic regression are age, stroke (AOR of 2.3), diabetes, black race, and hypertension (Table 6.g). Improved stroke prevention measures such as more aggressive combined management of diabetes, hypertension, and atrial fibrillation may help decrease the risk of dementia in ESRD patients. These data suggest the need for a standard cognitive evaluation, prior to dialysis initiation and annually thereafter, to assess the patient’s ability to comply with medications and fluid intake, and to make informed decisions regarding initiation and continuation of maintainence dialysis.

6 s143

{Figures 6.88–94} 200 cohort: point prevalent patients alive during 2000–200, with dialysis modality defined on December 3, 200. Transplant patients received graft during 2000–200, & had a functioning graft on 3 December 200. The 2003 cohort is defined analogously. {Figures 6.90–9} 200 cohort; patients followed from December 3, 200, until earliest of hospitalization (for Figure 6.90), change in modality, death, or December 3, 2003. {Figure 6.92} 200 cohort: patients followed from December 3, 200 until December 3, 2003. {Figures 6.93–94} 200 cohort: incident dementia defined as no dementia diagnosis in 999–2000, followed by dementia diagnosis in 200. The 2003 cohort is defined analogously. {Table 6.g} pooled 200 & 2003 cohorts.

Odds ratios of point prevalent incident dementia ESRD patients

Hemodialysis 45-64 65-74 75-84 85+ Female Male White Black Other race Diabetes Hypertension Other cause Stroke

06 morbidity morte 05.indd 143

OR 1.00 2.59 3.93 6.20 1.00 0.92 1.00 1.30 0.86 1.46 1.24 1.00 2.31

CI p-value (reference) (2.39-2.81) 0.00 (3.63-4.26) 0.00 (5.55-6.91) 0.00 (reference) (0.87-0.97) 0.00 (reference) (1.22-1.38) 0.00 (0.75-0.98) 0.03 (1.36-1.58) 0.00 (1.14-1.34) 0.00 (reference) (2.16-2.47) 0.00

Peritoneal dialysis 45-64 65-74 75+

OR 1.00 3.73 5.76

CI p-value (reference) (2.34-5.94) 0.00 (3.55-9.35) 0.00

Female Male White Black Other race Diabetes Hypertension Other cause Stroke

1.00 1.07 1.00 1.49 1.06 1.78 1.39 1.00 2.51

(reference) (0.75-1.52) (reference) (0.98-2.27) (0.53-2.14) (1.14-2.79) (0.87-2.21) (reference) (1.59-3.97)

0.73 0.06 0.86 0.01 0.17 0.00

Transplant 45-64 65+

OR 1.00 3.72

CI p-value (reference) (2.47-5.61) 0.00

Female Male White Black Other race Diabetes Hypertension Other cause Stroke

1.00 1.38 1.00 1.62 0.78 2.29 0.82 1.00 3.59

(reference) (0.89-2.13) (reference) (1.04-2.52) (0.28-2.15) (1.43-3.66) (0.43-1.56) (reference) (2.10-6.13)

0.15 0.03 0.63 0.00 0.54 0.00

10/13/2005 8:03:19 AM

6 s144

MORBIDITY & MORTALITY

Chapter summary

Figure 6. Cause-specific hospital admission rates have changed dramatically since 993. Infectious and cardiovascular hospitalizations are up 23 and 0 percent, respectively, while those related to vascular access have fallen 25 percent.

introduction

Figure 6.4 Five-year survival probabilities for ESRD patients continue to rise, despite the greater disease burden now carried by the incident population.

overall hospitalization & mortality

Figures 6.2–4 The remarkably high rate of inpatient catheter insertions should serve as a reminder that practitioners need to move toward greater compliance with K/DOQI vascular access guidelines, which call for increased use of fistulas as the primary vascular access.

causespecific hospitalization

Figures 6.5–7 Interval analyses of cause-specific mortality show that rates tend to be high at six months, fall over the next six months, and then rise steadily during the following four years. Figures 6.8–26 Clear across all causes of death is the lower mortality rate for transplant patients. At five years after initiation, the rate of mortality due to sudden death is 75 per ,000 patient years in dialysis patients, and only 4 for patients with a transplant.

causespecific mortality

Figure 6.29 Hospital admissions for pulmonary infection in hemodialysis patients have grown 24 percent since 993, while a slight fall in vascular access infections occurred in 2003—possibly due to lower use of catheters. Figure 6.3 Compared to those on the modality less than two years, hemodialysis patients with a vintage of five or more years had a 20 percent higher mortality rate in 2003. In the peritoneal dialysis population, this difference reaches 94 percent.

hospitalization & mortality, by modality

06 morbidity morte 05.indd 144

Comparisons of Bayesian mortality and hospitalization ratios highlight the difficulty of using any single year to assess a provider network.

Bayesian mortality & hospitalization ratios

Figure 6.56 Since 99 the pregnancy rate in the dialysis population has increased 20–23 percent overall and in non-white patients, while falling 3.9 percent in whites. In the transplant population, in contrast, the rate has fallen 48.6 percent overall, 66 percent for non-whites, and 38 percent for whites.

cancer & pregnancy in women with ESRD

Figures 6.6–68 Both the presence and the severity of chronic kidney disease appear to be risk multipliers for common, serious medical conditions. This risk multiplier effect is most obvious in dialysis populations, where the likelihood of developing one of these life-threatening events is very high.

morbidity in the CKD, ESRD, & general populations

Figure 6.70 Only 3.5 percent of dying ESRD patients use hospice, compared to the national average of over 22 percent. ESRD patients lag significantly behind oncology patients in hospice use, despite the fact that they have comparable morbidity.

withdrawal & hospice

Figures 6.79–80 Incident stroke in the 2000 ESRD population is associated with high rates of hospitalization and mortality over a two-year followup period.

stroke

Figures 6.90–9 Dementia in ESRD patients is associated with substantial adverse outcomes: over two years, a .8 unadjusted risk of hospitalization, and a striking two-fold increased risk of death—70 percent of those with dementia die, versus 4 percent of those without.

dementia

10/13/2005 8:03:20 AM