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Four—Treatment modalities

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Four—Treatment modalities Powered By Docstoc
					Chapter   Four
 Treatment modalities
                                                     translated by Walter Arndt
                                                     Ranier Maria Rilke,
                                                    “Spring Fragment,”




By now the sap returns from the routineness
That redistills itself in rooted dark
Back to the light, and feeds the limpid greenness
Still shying from the wind beneath the bark.
The two major therapies for end-stage                              peritoneal dialysis patients, in contrast, the 2006 distribution
renal disease are dialysis and kidney transplantation. During      was 63 and 37 percent. Medicare covers only 35 percent of
hemodialysis an extracorporeal circuit with a dialysis mem-        incident transplant patients; 34 percent have Medicare as
brane is used to filter and clean the blood; peritoneal dialysis   secondary payor coverage, and 31 percent are covered by
uses the body’s own peritoneal cavity to transfer solutes and      other insurers. These differences may significantly affect both
toxins between the blood and the peritoneal dialysis fluid.        patient benefits — particularly those related to prescription
    The incident hemodialysis population is now nearly eight       drugs — and provider revenue streams from services such
times larger than in 1978, and in 2006 topped 100,000 pa-          dialysis therapy, injectables, treatments and medications for
tients for the first time. The number of new peritoneal dialysis   transplantation, and diagnostic testing.
patients peaked at 9,407 in 1995, and has since fallen to 6,725;       Differences in payor distribution continue in the preva-
this population now accounts for 6.2 percent of new dialysis       lent population, but are less dramatic than those seen with
patients, a ratio that continues to decline from its 1982–1985     incident patients. Eighty-four percent of hemodialysis pa-
peak of 15 percent.                                                tients have Medicare as their primary payor, compared to
    As of December 31, 2006, nearly 328,000 patients were          79 and 54 percent of those on peritoneal dialysis and with
receiving hemodialysis therapy, 26,082 were on peritoneal          a transplant..
dialysis (8.2 percent of the dialysis population), and 151,502         Maps of incident rates by modality illustrate nationwide
had a functioning graft. The annual rate of growth has             changes since 1995–1996, changes which may reflect the
slowed in the prevalent hemodialysis population, from 8.5          recent consolidation of ESRD providers, their varying policies
percent in 1996 to 3.9 percent in 2006, while the peritoneal       regarding therapy, and their individual likelihoods of using
dialysis population has remained quite stable. The greatest        dialytic and transplant therapies in the incident population.
growth has occurred in the transplant population, which has        The rates may also reflect changes in access to organs for
increased 5.5–6.0 percent each year since 2001.                    transplantation. Changes in peritoneal dialysis use, for ex-
    The number of patients who receive a kidney transplant         ample, show distinct geographic patterns that differ from
as their first ESRD therapy reached 2,635 in 2006, and since       the distribution of the hemodialysis population. Although
1996 has grown an average of 7.3 percent each year. In the         there has been a general decline in use of this therapy, shown
prevalent population, the number waiting to receive a trans-       also in maps of the prevalent population, there continue
plant reached nearly 69,000 in 2006, with an annual growth         to be notable exceptions, including the Dakotas, Nebraska,
of 10.1 percent since 1996, though this rate of change has         Oklahoma, Louisiana, Mississippi, and Alabama, where use
fallen to 7–8 percent in the last three years. Chapter Seven       has increased.
presents additional information on the wait-listed dialysis            The growing consolidation of providers into larger chains
population, including the numbers of active and inactive           has long been clear, and two large chains now treat the great
patients on the list.                                              majority of dialysis patients in the U.S. In the early 1990s, just
    In the incident hemodialysis population, Medicare only,        one in seven dialysis patients received treatment in a chain-
Medicare plus Medicaid, and Medicare under HMOs or man-            owned unit; in 2006, the number was nearly seven in ten.
aged care plans continue to cover 75 percent of patients,          The market share of independent units has been relatively
while employer group health plans (EGHPs) and Medicare as          stable, at 18–19 percent since 2000; hospital-based units,
secondary payor cover the remaining 25 percent. Among new          however, are now treating just 11 percent of the prevalent
 4.1
II                                         Incident patient counts (USRDS),
                                           by first modality incident ESRD patients


                                         125
                                                     Hemodialysis (2006: 101,306)                                         4.2
                                                                                                                         II                                         Prevalent patient counts (USRDS), by modality
                                                                                                                                                                    December 31 point prevalent ESRD patients
                                                     Peritoneal dialysis (6,725)
                                                     Total dialysis (108,219)
     Number of patients (in thousands)




                                         100
                                                     Transplant (2,635)                                                                                           350
                                                                                                                                                                             Hemodialysis (2006: 327,754)
                                          75                                                                                                                      300        Peritoneal dialysis (26,082)
                                                                                                                                                                             Transplant (151,502)




                                                                                                                              Number of patients (in thousands)
                                                                                                                                                                             OPTN transplant
                                                                                                                                                                  250        wait-list (68,576)
                                          50

                                                                                                                                                                  200

                                          25
                                                                                                                                                                  150


                                           0                                                                                                                      100
                                                79   81   83    85   87    89   91    93   95   97   99   01   03   05
                                                                                                                                                                   50


                                                                                                                                                                    0
                                                                                                                                                                        79   81   83   85   87   89   91    93   95   97   99   01   03   05



                                                                                                                                     figure 4.1 incident ESRD patients; peritoneal dialysis counts include CAPD & CCPD
                                                                                                                                     only. figure 4.2 December 31 point prevalent patients; peritoneal dialysis counts include
                                                                                                                                     CAPD & CCPD only. OPTN was created in 1986.



                                               dialysis population. With the use of peritoneal dialysis vary-
                                               ing considerably by provider group, further consolidation
                                               may raise concerns over modality choice and its relation
                                               to provider practices.
                                                   With peritoneal dialysis long the dominant home therapy,
                                               home hemodialysis has received little attention in the past
                                               15 years. Its use peaked in 1985, with 5,817 prevalent patients.
                                               A number of government programs, paying home aids to
                                               help deliver the therapy, ended soon afterwards, contribut-
                                               ing to a steady decline in use until by 2002 there were only
                                               1,756 patients. Now, however, there appears to be renewed
                                               interest in the use of daily home therapy. The prevalent
                                               population reached 2,455 in 2006, with 838 new individuals
                                               starting the therapy in 2005–2006. This renewed interest
                                               has been fueled by publication of results for single centers
                                               using daily home hemodialysis, and new products are being
                                               introduced for the delivery of this therapy. In addition, a
                                                                                                                                                                    highlights
                                                                                                                                                                    table 4.a In 2006, the rate of ESRD incidence reached 330 per million popula-
                                               new NIH study is in progress, comparing daily or overnight                                                           tion for hemodialysis, 21.9 for peritoneal dialysis, and 8.0 for transplant. figure
                                               home hemodialysis to in-center therapy, and testing safety                                                           4.3 Chain-owned dialysis providers continue to increase their market share,
                                               and efficacy. Currently, the largest concentration of home                                                           treating 64 percent of incident hemodialysis patients in 2006, up from 55
                                               hemodialysis patients is found in Illinois and Florida, with                                                         percent in 2000. figure 4.4 Medicare as secondary payor coverage varies by
                                               patients in an urban setting accounting for 75 percent of                                                            modality, at 10.0, 20.4, and 33.8 percent for hemodialysis, peritoneal dialysis,
                                               the prevalent population under treatment.                                                                            and transplant, respectively. table 4.b The overall rate of ESRD prevalence in
                                                   During the past decade, then, modality use has changed                                                           2006 reached 1,053 per million population for hemodialysis, 84 for perito-
                                               considerably. Hemodialysis is still dominant, while use of                                                           neal dialysis, and 487 for transplant. The rate for African Americans reached
                                               peritoneal dialysis is concentrated in fewer areas of the                                                            3,979 — nearly six times greater than the rate of 685 among whites, and twice
                                               country. Differences in the accumulation of patients on                                                              as high as the rate among Native Americans.
                                               different modalities need to be carefully considered, not


                                                                                                                                                                                                 contents
                                               only from the vantage point of quality of care, but in terms
                                               of payor distribution and incentives, which may influence
                                               modality choice and the availability of services. Use of
                                               home hemodialysis appears to be resurging, based on new                                                                                       incident modality · 82 counts & rates • patient distribu-
                                               applications of daily home therapies such as short treat-                                                                                   tion by first modality & unit type • patient distribu-
                                               ments of 2–3 hours as well as overnight therapy 5–6 days                                                                                  tion by payor • geographic variations in incident rates
                                               per week. These trends will require increased evaluation                                                                                 prevalent modality · 84 counts & rates • patient distribution
                                               in the future.                                                                                                                          by modality & unit type • patient distribution by payor
                                                                                                                                                                                       • geographic variations in prevalent rates home hemodi-
                                                                                                                                                                                       alysis · 86 patient demographics • patient distribution by
                                                                                                                                                                                       state & by geographic location
82   table 4.a In 2006, nearly 100,000 new ESRD              II
                                                                       4.a                                 Incident counts & rates per million population, 2006, by age, gender,
     patients began therapy on hemodialysis,                                                               race, ethnicity, & primary diagnosis incident ESRD patients; unknowns dropped
     6,600 were placed on peritoneal dialysis,
     and 2,419 received a preemptive transplant                                                                            Number of patients                          Rate per million population
     (these numbers exclude patients with missing                                                                             HD          PD          Tx        Unk.        HD         PD        Tx   Unk.
                                                                                         0-19                                  643        393        183         12     7.3            4.7     2.2    0.2
     demographic information). The rate of ESRD
                                                                                         20-44                              11,698      1,200        696         33   108.8           11.2     6.5    0.3
     incidence reached 330 per million population
                                                       Age




                                                                                         45-64                              36,738      2,763      1,216         70   566.8           40.9    16.7    1.0
     for hemodialysis, 21.9 for peritoneal dialysis,                                     65-74                              23,445      1,297        296         40 1,362.7           71.6    15.5    2.1
     and 8.0 for transplant. Considerable differ-                                        75+                                27,011        947         28         21 1,687.2           54.6     1.5    1.1
     ences by race persist in these rates, with the                                      Male                               55,548      3,595      1,438        101   415.0           25.7     9.8    0.7
                                                       Gen.




     rate for African Americans beginning ther-                                          Female                             43,987      3,005        981         75   263.7           18.8     6.4    0.5
     apy on hemodialysis, for example, reaching                                          White                              65,024      4,791      1,919        139   251.5           18.9     7.7    0.6
     962 per million population, compared to 252                                         African American                   29,496      1,401        203         19   962.2           41.6     5.8    0.6
                                                       Race




                                                                                         Native American                     1,074         70         37           *  449.0           26.5    12.3       *
     among whites. The incident rate for those
                                                                                         Asian                               3,941        338        260         15   342.0           26.7    18.3    1.1
     receiving a preemptive transplant, in contrast,
                                                                                         Hispanic                           12,456        720        183         12   492.2           22.8     5.0    0.4
                                                       Eth.




     is greatest in the Asian population, at 18.3                                        Non-Hispanic                       87,079      5,880      2,236        164   316.4           21.7     8.4    0.6
     per million population, compared to 12.3, 7.7,                                      Diabetes                           44,901      2,699        521         36   148.4            8.9     1.7    0.1
     and 5.8 among Native Americans, whites, and
                                                       Primary diagnosis




                                                                                         Hypertension                       27,700      1,462        239         19    91.8            4.9     0.8    0.1
     African Americans, respectively.                                                    Glomerulonephritis                  6,463        885        480         18    21.4            3.0     1.6    0.1
                                                                                         Cystic kidney                       1,804        403        394         21     6.0            1.3     1.3    0.1
                                                                                         Other urologic                      1,477         93         58           *    4.9            0.3     0.2       *
                                                                                         Other cause                        12,280        803        481         41    40.8            2.7     1.6    0.1
                                                                                         Unknown/missing                     4,910        255        246         36     8.1            0.4     0.4    0.1
                                                                                         All                                99,535      6,600      2,419        176   329.5           21.9     8.0    0.6


     figure 4.3 Chain-owned dialysis providers              II
                                                                      4.3                                  Incident patient counts, by first modality
     continue to increase their market share,                                                              & unit type incident dialysis patients
     treating 64 percent of incident hemodialy-
                                                                                                           Hemodialysis                                         Peritoneal dialysis
     sis patients in 2006, up from 55 percent in                                                      75                                                    5
                                                                  Number of patients (in thousands)




     2000. This change is concurrent with a fall                                                                   Chain
                                                                                                      60           Non-chain                                4
     in the number of new hemodialysis patients
                                                                                                                   Hospital-based
     treated in hospital-based units, from 21 to 15                                                                Unknown
                                                                                                      45                                                    3
     percent. The percentage of incident perito-
     neal dialysis patients treated in chain-owned                                                    30                                                    2
     units, in contrast, has remained stable for
     several years, and with the recent sale of the                                                   15                                                    1
     providers most likely to employ this modal-
     ity (Gambro has been purchased by DaVita,                                                         0                                                    0
                                                                                                           89 91 93 95 97 99 01 03 05                           89 91 93 95 97 99 01 03 05
     and RCG by Fresenius), future use of this
     therapy is in question.
                                                                                                                                                                                                          4
                                                                                                                                                                                    incident




                                                                                                                                                    2008 USRDS ANNUAL DATA REPORT
                                                                                                                                                                                    modality




                                                                          4.5
                                                                         II             Geographic variations in unadjusted incident rates (per
                                                                                                                                                                                IIESRD
                                                                                                                                                                                    treatment
                                                                                                                                                                                    modalities


                                                                                                                                                                                                                 83
                                                                                        million population), by first modality & HSA incident ESRD patients

 II
    4.4                       Incident patient distribution, by first    Hemodialysis: 1995–1996                                      Hemodialysis: 2005–2006
                              modality & payor incident ESRD patients

                        100
                              Hemodialysis

                         80

                         60
                                    Other/unknown
                         40         Medicare secondary payor
                                    Medicare HMO
                         20         Medicare & Medicaid                          167       243     278    321     386     421                206           243                      278    321    386    455
                                    Medicare
                          0                                              Peritoneal dialysis: 1995–1996                               Peritoneal dialysis: 2005–2006
                              Peritoneal dialysis
                        100

                         80
  Percent of patients




                         60

                         40

                         20

                                                                                 13.8      17.4   21.3    25.8    32.6    51.9               13.7        17.4                       21.3   25.8   32.6   42.9
                          0
                            Transplant
                        100                                              Transplant: 1995–1996                                        Transplant: 2005–2006

                         80

                         60

                         40

                         20

                          0
                           78     82    86   90     94   98   02   06            2.58      4.65   5.97    7.34    9.58   13.14               3.80        4.65                       5.97   7.34   9.58   14.51



figure 4.4 Nearly one in two new hemodialysis                           figure 4.5 The choice of initial modality continues to vary across the country. The incident rate
patients is covered solely by Medicare, 14.4                            for patients beginning ESRD therapy on hemodialysis, for example, is greatest on the East
percent are dually-enrolled (Medicare/Med-                              Coast and in the southeastern states, while the rate for patients with a preemptive transplant
icaid), and 11.5 percent are covered by a Medi-                         is highest in the Upper Midwest. In the 2005–2006 hemodialysis population, the mean rate
care HMO provider — up from 8.7 percent in                              in the upper quintile is 2.5 times greater than in the lower; regions with the highest transplant
2005. Medicare covers 45.4 and 27.8 percent,                            rates have a mean rate 3.8 times greater than those with the lowest.
respectively, of peritoneal dialysis and trans-
plant patients, while 10.4 and 4.7 percent are
                                                                              table 4.a incident ESRD patients; unknowns dropped. Rates by age
dually-enrolled and 7.2 and 2.8 percent have                                  adjusted for gender & race, rates by gender adjusted for age & race,
HMO coverage. Medicare as secondary payor                                     rates by race & ethnicity adjusted for age & gender, & rates by
coverage also varies by modality, at 10.0, 20.4,                              primary diagnosis adjusted for age, gender, & race. *Values for cells
                                                                              with ten or fewer patients are suppressed. figure 4.3 incident dialysis
and 33.8 percent for hemodialysis, peritoneal                                 patients; peritoneal dialysis includes CAPD & CCPD only. figure 4.4
dialysis, and transplant, respectively.                                       incident ESRD patients; peritoneal dialysis includes CAPD & CCPD
                                                                              only. figure 4.5 incident ESRD patients, by HSA, unadjusted. Excludes
                                                                              patients residing in Puerto Rico & the Territories. For details on how
                                                                              to read the map legends, please see page xvi in the Introduction.
84   table 4.b At the end of 2006, nearly 320,000             II
                                                                         4.b                                 Prevalent counts & rates per million population, 2006, by age, gender,
     ESRD patients were receiving hemodialysis                                                               race, ethnicity, & primary diagnosis December 31 point prevalent ESRD patients
     therapy, 25,438 were being treated with peri-
     toneal dialysis, and 147,389 had a functioning                                                                           Number of patients                              Rate per million population
     graft (these numbers exclude patients with                                                                                  HD          PD           Tx           Unk.        HD         PD        Tx     Unk.
                                                                                           0-19                                 1,201        815   5,001                57       13.4          9.6      59.4   0.6
     missing demographic information). Patients
                                                                                           20-44                               44,656      5,633  43,043               269      415.7         52.7     403.8   2.5
     age 45–64 constitute the largest portion of
                                                        Age




                                                                                           45-64                              130,134     11,229  75,877               391    2,012.8        163.2   1,054.8   5.6
     the prevalent population by age, from 41 per-                                         65-74                               72,921      4,667 19,515                 89    4,361.2        259.5   1,074.8   4.9
     cent of those on hemodialysis to 52 percent                                           75+                                 71,050      3,094   3,953                29    4,569.5        179.2     212.8   1.7
     of those with a transplant. The overall rate                                          Male                               174,899     13,311  87,353               488    1,288.5         94.6     597.1   3.4
                                                        Gen.




     of ESRD prevalence in 2006 reached 1,053                                              Female                             145,063     12,127 60,036                347      867.2         75.9     385.4   2.2
     per million population for hemodialysis, 84                                           White                              176,940     16,787 110,267               542      684.6         66.1     440.6   2.2
     for peritoneal dialysis, and 487 for transplant.                                      African American                   124,184      6,743  28,213               236    3,978.9        195.9     822.4   6.6
                                                        Race




                                                                                           Native American                      4,809        330   1,537                11    2,000.1        124.7     562.6   3.9
     The rate for African Americans, however,
                                                                                           Asian                               14,029      1,578   7,372                46    1,184.0        119.6     524.5   3.3
     reached 3,979 — nearly six times greater than
                                                                                           Hispanic                            44,578      2,903  16,917               119    1,717.8         93.5     511.6   3.4
                                                        Eth.




     the rate of 685 among whites, and twice as                                            Non-Hispanic                       275,384     22,535 130,472               716    1,001.6         83.3     488.5   2.7
     high as the rate among Native Americans.                                              Diabetes                           140,630      8,568  34,323               185      462.1         28.2     113.1   0.6
                                                        Primary diagnosis




                                                                                           Hypertension                        91,440      6,173  22,563               127      300.9         20.4      74.2   0.4
                                                                                           Glomerulonephritis                  33,241      4,615  40,067               204      109.7         15.3     132.4   0.7
                                                                                           Cystic kidney                        7,969      1,340  13,947                56       26.2          4.4      45.8   0.2
                                                                                           Other urologic                       6,896        634   5,508                29       22.8          2.1      18.3   0.1
                                                                                           Other cause                         27,622      3,062  21,301               159       91.3         10.2      70.7   0.5
                                                                                           Unknown/missing                     12,164      1,046   9,680                75       20.1          1.7      16.0   0.1
                                                                                           All                                319,962     25,438 147,389               835    1,053.1         83.9     486.6   2.8


     figure 4.6 Between 2000 and 2006, the per-              II
                                                                        4.6                                  Prevalent patient counts, by modality & unit
     centage of prevalent patients treated by chain-                                                         type December 31 point prevalent dialysis patients
     owned providers rose from 58.1 to 66.4 per-                                                             Hemodialysis                                              Peritoneal dialysis
     cent for hemodialysis, and from 54.8 to 64.9                                                      250                                                        20
                                                                   Number of patients (in thousands)




     for peritoneal dialysis. Hospital-based units,                                                                  Chain
                                                                                                       200           Non-chain
     in contrast, now treat just 11.4 and 13.2 per-                                                                                                               15
                                                                                                                     Hospital-based
     cent of prevalent hemodialysis and peritoneal                                                                   Unknown
                                                                                                       150
     dialysis patients, down from 18.1 and 21.5 per-                                                                                                              10
     cent in 2000. This year the USRDS acquired                                                        100
     new cross-reference data that allow us to iden-
                                                                                                                                                                   5
     tify units that were previously missing their                                                      50
     hospital-based designation, and to update our
     patient counts for these units. Numbers in                                                          0                                                         0
                                                                                                             89 91 93 95 97 99 01 03 05                                89 91 93 95 97 99 01 03 05
     this figure, and in Figure 4.3, thus differ from
     those presented in previous ADRs.
                                                                                                                                                                                                        4
                                                                                                                                                                                    prevalent




                                                                                                                                                    2008 USRDS ANNUAL DATA REPORT
                                                                                                                                                                                    modality




                                                                           4.8
                                                                          II             Geographic variations in unadjusted prevalent rates (per million
                                                                                                                                                                                IIESRD
                                                                                                                                                                                    treatment
                                                                                                                                                                                    modalities


                                                                                                                                                                                                               85
                                                                                         population), by modality & HSA December 31 point prevalent ESRD patients

 II
    4.7                       Prev. pt distribution, by modality          Hemodialysis: 1996                                            Hemodialysis: 2006
                              & payor Dec. 31 point prevalent ESRD pts

                        100
                              Hemodialysis

                         80

                         60
                                    Other/unknown
                         40         Medicare secondary payor
                                    Medicare HMO
                         20         Medicare & Medicaid                           382       512     634    762    1,006 1,259                432           512                      634    762   1,006 1,467
                                    Medicare
                          0                                               Peritoneal dialysis: 1996                                     Peritoneal dialysis: 2006
                              Peritoneal dialysis
                        100

                         80
  Percent of patients




                         60

                         40

                         20

                          0                                                       53.5      68.4   86.8   103.2 126.5 164.3                  51.5        68.4                       86.8   103.2 126.5 167.6

                        100
                            Transplant
                                                                          Transplant: 1996                                              Transplant: 2006

                         80

                         60

                         40

                         20

                          0
                           78     82    86   90     94   98   02    06            281       333     361    390     433     470               319           333                      361    390    433   530



figure 4.7 Nine in ten prevalent hemodialysis                           figure 4.8 Rates by modality in the prevalent ESRD population show the same general patterns
patients had some type of Medicare cover-                                as those for incident patients. The rate for hemodialysis patients is greatest in the south and
age in 2006; 43 percent were covered only                                southeastern portions of the country, while for patients with a functioning graft the rates
by Medicare, while one-third were dually-                                are greatest in the northern states. In the 2006 hemodialysis population, the mean rate in
enrolled in both Medicare and Medicaid — a                               the upper quintile was 3.3 times higher than in the lower; regions with the highest transplant
number varying little since the mid-1990s.                               rates have a mean rate just 1.7 times greater than those with the lowest.
Medicare also covers nine of ten peritoneal
dialysis patients, though 50 percent are cov-
ered solely by Medicare, and just 24 percent                                   table 4.b December 31 point prevalent ESRD patients; unknowns dropped.
                                                                               Rates by age adjusted for gender & race, rates by gender adjusted for age
are dually-enrolled. In the transplant popu-                                   & race, rates by race & ethnicity adjusted for age & gender, & rates by
lation, in contrast, just 34 percent are cov-                                  primary diagnosis adjusted for age, gender, & race. figure 4.6 December
ered by Medicare alone. Transplant patients                                    31 point prevalent dialysis patients; peritoneal dialysis includes CAPD
younger than 65 and not disabled lose their                                    & CCPD only. figure 4.7 December 31 point prevalent ESRD patients;
                                                                               peritoneal dialysis includes CAPD & CCPD only. figure 4.8 December 31
entitlement three years after the transplant.                                  point prevalent ESRD patients, by HSA, unadjusted. Excludes patients
                                                                               residing in Puerto Rico & the Territories. For details on how to read
                                                                               the map legends, please see page xvi in the Introduction.
                                                            II
                                                                    4.c                      Home hemodialysis: incident patient
                                                                                             distribution inc. home HD pts, 2005–2006

                                                                                                                                 Column       figure 4.9 Illinois and Florida accounted for
                                                                                                                                              56 percent of the incident home hemodialysis
86
                                                                                                                     Total       percent
                                                                              0-19                                        .               .   population in 2005–2006, with 29.4 and 26.3
                                                                              20-44                                     95            11.3    percent, respectively. Eight percent of patients
                                                      Age
                                                                              45-64                                    271            32.3    receiving home hemodialysis therapy resided
                                                                              65-74                                    165            19.7    in Ohio, and 3–4 percent in Texas, Georgia,
                                                                              75+                                      307            36.6    California, New York, and Michigan.
                                                                              Male                                     472            56.3
                                                      Gen.



                                                                              Female                                   366            43.7
                                                                              White                                    551            65.8
                                                                                                                                               II
                                                                                                                                                    4.9                                  Percentage of inc. home HD pts in the
                                                                                                                                                                                         top 10 states inc. home HD pts, 05–06
                                                                              African American                         257            30.7
                                                      Race




                                                                              Native American                             *            0.1
                                                                                                                                                                                    30
                                                                              Asian                                     20             2.4




                                                                                                                                                Percent of U.S. home HD patients
                                                                              Other/unknown                               *            1.1                                          25
                                                                              Hispanic                                  81             9.7
                                                      Eth.




     table 4.c Of the 838 patients beginning ESRD                             Non-Hispanic                             757            90.3                                          20
     therapy on home hemodialysis in 2005–2006,                               Diabetes                                 302            36.0
     nearly one-third were age 45–64, and 37 per-                                                                                                                                   15
                                                      Primary diagnosis




                                                                              Hypertension                             290            34.6
     cent were age 75 and older. Fifty-six percent                            Glomerulonephritis                        43             5.1                                          10
     of these new patients were male, two in three                            Cystic kidney                             15             1.8
     were white, and one in ten was Hispanic. Pri-                            Other urologic                            13             1.6                                           5
     mary diagnoses of diabetes and hyperten-                                 Other cause                               86            10.3
                                                                                                                                                                                     0
     sion each accounted for 35–36 percent of the                             Unknown/missing                           89            10.6                                                IL FL OH TX GA CA NY MI TN MD

     population.                                                              All                                      838           100.0


     figure 4.10 New ESRD patients treated with            II
                                                                   4.10                      Incident dialysis patients, by modality           II
                                                                                                                                                    4.11                                 Incident home HD patients, by
     home hemodialysis therapy are far more                                                  & assistance incident dialysis patients, 2006                                               geographic location incident home HD pts
     likely to be receiving assistance (see caption
     for definition) than those treated with center                                    100                                                                                         100
                                                                                                                                                                                                                       Urban
     hemodialysis or with peritoneal dialysis. In
                                                                                        80                                                                                          80
     2006, 57 percent of incident home hemodi-
                                                                                                                                                Percent of patients
                                                                 Percent of patients




     alysis patients were on assistance, compared                                       60                                                                                          60
     to 16 and 5 percent, respectively, of those on
     center hemodialysis and peritoneal dialysis.                                       40                                                                                          40
     These data may seem to imply that home
     hemodialysis patients are astonishingly                                            20             Assistance                                                                   20                                  Rural
     disabled. Many of those classified as home                                                        No assistance                                                                      Unknown
     patients, however, may be institutionalized                                         0                                                                                           0
                                                                                             Center HD Home HD       PD        All                                                       78   82   86   90   94   98   02   06
     and receive their dialysis in the nursing home
     setting.
                                                                                                                                              figure 4.11 In 2006, the percentage of incident
                                                                                                                                              home hemodialysis patients living in urban
                                                                                                                                              locations reached 87 percent, up from 62 per-
                                                                                                                                              cent in 1992. The percentage living in rural
                                                                                                                                              locales, in contrast, fell from 35 percent in
                                                                                                                                              1992 to just 9.9 percent in 2006.
                                                                                                                                                                                                                             4
                                                                                                                                                                                                                    home




                                                                                                                                                                                    2008 USRDS ANNUAL DATA REPORT
                                                                                                                                                                                                                    hemodialysis




      II
              4.d                      Home hemodialysis: prevalent patient
                                       distribution prev home HD patients, 2006

                                                                        Column
                                                                                    table 4.d Of the nearly 2,500 prevalent patients
                                                                                    treated with home hemodialysis in 2006, 44
                                                                                                                                                                                                                IIESRD
                                                                                                                                                                                                                    treatment
                                                                                                                                                                                                                    modalities

                                                                                    percent were age 45–64, and six in ten were
                                                                                                                                                                                                                                   87
                                                             Total      percent
                        0-19                                    21            0.9   male. Sixty-six percent were white, and just
                        20-44                                  494           20.1   6.4 percent were Hispanic. And primary diag-
                                                                                    noses of diabetes and hypertension accounted
Age




                        45-64                                1,084           44.2
                        65-74                                  462           18.8   for 30 and 27 percent, respectively, of the prev-
                        75+                                    394           16.0   alent home hemodialysis population.
                        Male                                 1,479           60.2
Gen.




                        Female                                 976           39.8
                        White                                1,614           65.7
                                                                                     II
                                                                                          4.12                                 Percentage of prv. home HD pts in the
                                                                                                                               top 10 states prv. home HD patients, 2006
                        African American                       754           30.7
Race




                        Native American                         12            0.5
                                                                                                                          20
                        Asian                                   65            2.6
                                                                                      Percent of U.S. home HD patients




                        Other/unknown                             *           0.4
                        Hispanic                               156            6.4                                         15
Eth.




                        Non-Hispanic                         2,299           93.6
                        Diabetes                               737           30.0
                                                                                                                          10
Primary diagnosis




                        Hypertension                           661           26.9
                        Glomerulonephritis                     457           18.6
                        Cystic kidney                          133            5.4                                          5                                               figure 4.12 Seventeen percent of prevalent
                        Other urologic                          84            3.4                                                                                          home hemodialysis patient in 2006 lived in
                        Other cause                            290           11.8
                                                                                                                           0                                               Illinois, while Florida, Texas, and Califor-
                        Unknown/missing                         93            3.8                                               IL FL TX CA NY OH GA VA WA MO              nia accounted for 8.5, 7.8, and 6.5 percent,
                        All                                  2,455          100.0                                                                                          respectively.

     II
             4.13                      Prevalent dialysis patients, by modality      II
                                                                                          4.14                                 Prevalent home HD patients, by              figure 4.14 The percentage of prevalent home
                                       & assistance prev. dialysis patients, 2006                                              geographic location prev. home HD pts       hemodialysis patients residing in urban loca-
                                                                                                                                                                           tions has been rising slowly since the late
                                 100                                                                                     100                                               1980s, and reached 74 percent in 2006. This
                                                                                                                                                                           growth has been paralleled by a decline in the
                                  80                                                                                      80                                 Urban
                                                                                                                                                                           rural location, which is now at 24 percent.
                                                                                      Percent of patients
           Percent of patients




                                  60                                                                                      60

                                  40                                                                                      40
                                                                                                                                                               Rural
                                  20            Assistance                                                                20
                                                No assistance                                                                  Unknown
                                   0                                                                                       0
                                       Center HD Home HD     PD       All                                                      78   82   86   90   94   98   02    06



figure 4.13 Differences by modality in the per-
centage of patients receiving assistance are                                           table 4.c & figure 4.9 incident home hemodialy-
                                                                                       sis patients, 2005–2006 combined. *Values for
less striking in the prevalent population than                                         cells with ten or fewer patients are suppressed.
among incident patients. In 2006, 10 percent                                          “.” Zero values in this cell. figure 4.10 incident
of prevalent home hemodialysis patients were                                           dialysis patients, 2006. Peritoneal dialysis con-
                                                                                       sists of CAPD & CCPD only. figure 4.11 incident
on assistance, compared to 6 percent of those                                          home hemodialysis patients. table 4.d & figure 4.12
on center hemodialysis and 2 percent of those                                          December 31 point prevalent home hemodialy-
treated with peritoneal dialysis.                                                      sis patients, 2006. figure 4.13 December 31 point
                                                                                       prevalent dialysis patients, 2006. Peritoneal dialy-
                                                                                       sis consists of CAPD & CCPD only. figure 4.14
                                                                                       December 31 point prevalent home hemodialysis
                                                                                       patients. • In figures 4.10 & 4.13, assistance is
                                                                                       defined as a patient who has any one of the fol-
                                                                                       lowing pre-existing conditions, as identified on
                                                                                       the Medical Evidence form: inability to ambulate,
                                                                                       inability to transfer, needs assistance with daily
                                                                                       activities, institutionalized, assisted living, nursing
                                                                                       home, or other institution.
     chapter summary



                                     108 2635    thousand
                                     Patients beginning
                                     ESRD therapy on
                                     dialysis in 2006 (4.1)
                                                                       Patients beginning
                                                                       ESRD therapy with a
                                                                       transplant in 2006 (4.1)




                                     328 26 152 69
88


                                                 thousand                          thousand                          thousand                    thousand
                                     Prevalent patients on             Prevalent patients on             Prevalent patients with a   Patients wait-listed for a
                                     hemodialysis, 2006 (4.2)          peritoneal dialysis, 2006 (4.2)   transplant, 2006 (4.2)      kidney transplant, 2006 (4.2)


     962                             42                                5.8                                                 64%
         African American                     African American              African American                                 2006
     449                             27                                12.3                              5.5 times
         Native American                       Native American              Native American                 higher
     342                             27                                18.3
                    Asian                                     Asian                    Asian
     252                             19                                7.7                                                 12%       14.4        10.4         4.7
                           White                              White                           White                          1989      HD           Tx         PD

     Rate of new ESRD pts starting   Rate of new ESRD pts starting     Rate of new ESRD pts starting     Incident hemodialysis       Incident patients dually-
     therapy on hemodialysis in      therapy on peritoneal dialysis    therapy with a transplant in      patients treated in         enrolled in Medicare/Medicaid,
     2006 (per million pop.; 4.a)    in 2006 (per million pop.; 4.a)   2006 (per million pop.; 4.a)      chain-owned units (4.3)     2006 (%, 4.4)


     3979                            196                               822                                                 66%
         African American                African American                  African American                                  2006
     2000                            125                               563                               4.7 times
         Native American                 Native American                   Native American                  higher
     1184                            120                               525
                    Asian                           Asian                             Asian
     685                             66                                441                                                 14%         33          24          15
                           White                              White                           White                          1989      HD           Tx         PD

     Prevalent ESRD patients on      Prevalent ESRD patients on        Prevalent ESRD patients with      Prevalent hemodialysis      Prevalent patients dually-
     hemodialysis in 2006 (per       peritoneal dialysis in 2006       a functioning transplant in       patients treated in         enrolled in Medicare/Medicaid,
     million population; 4.b)        (per million population; 4.b)     2006 (per million pop.; 4.b)      chain-owned units (4.6)     2006 (%, 4.7)




                                                                                                                                     410    in
                                                                                                                                     Prevalent U.S. home HD pts
                                                                                                                                     treated in Illinois, Florida,
                                                                                                                                     Texas, or California (4.13)

				
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