Medicare End-stage Renal Disease Research Articles

Influenza vaccine delivery and effectiveness in end-stage renal disease

Influenza vaccination rates in the general population have been associated with improved outcomes, yet high-risk populations, such as end-stage renal disease (ESRD) patients, have received little attention in determining the potential benefits. This report assessed the frequency and effectiveness of influenza vaccination, while also assessing disparities in vaccination rates in the ESRD population. Using the United States Renal Data System research files containing claims for all Medicare ESRD patients, vaccination rates and outcomes among vaccinated and unvaccinated persons for the 1997 to 1998 and 1998 to 1999 influenza seasons were compared after adjustment for baseline demographic factors and health characteristics. Vaccination rates in the ESRD population were less than 50% for each season. Influenza vaccination rates were lower in non-whites, women, younger patients, and peritoneal dialysis patients. Influenza vaccination was associated with a lower risk for hospitalization and death. Despite universal coverage of free influenza vaccination, the ESRD population had a less than 50% vaccination rate for the years 1997 to 1998 and 1998 to 1999 as demonstrated by Medicare billing data. Substantial differences were found in vaccination rates among non-whites and peritoneal dialysis patients. This study confirms that the ESRD populations benefit from influenza vaccination, suggesting that dialysis providers should take advantage of all opportunities to immunize this high-risk group.

Increasing arteriovenous fistulas in hemodialysis patients: Problems and solutions

Increasing arteriovenous fistulas in hemodialysis patients: Problems and solutions

The uneven distribution of kidney transplants: Getting at the root causes and improving care

The uneven distribution of kidney transplants: Getting at the root causes and improving care

Comparison of mortality and intermediate outcomes between medicare dialysis patients in HMO and fee for service

End-stage renal disease (ESRD) is the only disease entitlement for Medicare; therefore, most patients with ESRD have Medicare coverage. Patients with ESRD are prohibited by law from enrolling in health maintenance organizations (HMOs), the only group prohibited within Medicare. However, they may remain in an HMO if they enrolled in such a plan before their kidneys failed. Thus, it is possible to compare patients with ESRD in HMOs with those in fee-for-service (FFS) plans. To determine whether mortality, transplantation rates, and intermediate outcomes differed between Medicare ESRD beneficiaries enrolled in HMO versus FFS providers, a retrospective cohort analysis was performed of patients with ESRD from three Health Care Financing Administration data sets containing administrative and outcome information for Medicare ESRD beneficiaries from 1990 to 1998. On December 31, 1998, a total of 278,510 prevalent patients with ESRD were in FFS plans, and 18,332 patients were in HMOs. HMO patients were older and more likely to be white and male and have diabetes mellitus and comorbid cardiovascular conditions than FFS patients. Unadjusted 2-year survival rates were 48.4% and 49.3% for FFS and HMO patients, respectively. In a multivariate model, HMO status had no significant effect on mortality, which was greater with older age, male sex, and white race. In 1998, unadjusted renal transplantation rates were 23.5% and 15.5% for FFS and HMO patients, respectively; age adjustment abrogated the apparent difference. For FFS and HMO patients, adequate hemodialysis was delivered to 72% and 82%, and 56% and 62% had hematocrits greater than the benchmark, respectively. There was no statistical difference in these outcomes in multivariate comparison. In conclusion, care by HMO for patients with an expensive chronic illness can achieve outcomes similar to those for FFS patients. Claims of poorer care and worse outcomes for patients with ESRD enrolled onto an HMO, an argument used to justify continued prohibition against widespread participation by patients with ESRD, are not supported. © 2002 by the National Kidney Foundation, Inc.

Potential cost savings of erythropoietin administration in end-stage renal disease

Background In a Department of Veterans Affairs randomized controlled trial, a lower dose of recombinant human erythropoietin (epoetin) was shown to attain target hematocrit levels when administered subcutaneously compared with intravenously. Since epoetin is expensive, optimizing the therapeutic effect of epoetin using a strategy that includes subcutaneous administration could lead to substantial cost savings. Methods We used an economic cost projection model to estimate potential savings to the Medicare End-Stage Renal Disease Program that could occur during a transition from intravenous to subcutaneous administration of epoetin among hemodialysis patients. Data included clinical results from the Department of Veterans Affairs randomized controlled trial, the 1998 Centers for Medicare and Medicaid Services’ End-Stage Renal Disease Core Indicators Survey, and the 1997–1998 Medicare claims files. In sensitivity analyses, we varied the expected dose reductions (10% to 50%) and the proportion of patients (25% to 100%) who switched to subcutaneous administration. Results Medicare cost savings were estimated at $47 to $142 million annually as 25% to 75% of hemodialysis patients who received epoetin intravenously switched to subcutaneous administration while reducing the dose by 32%. A minimal reduction (10%) in epoetin dose would result in Medicare cost savings of an estimated $15 to $44 million annually. Conclusion Administering epoetin subcutaneously would provide substantial cost savings to Medicare. For the transition to occur, consensus among stakeholders is needed, especially among patients whose treatment satisfaction and health-related quality of life would be most affected.

Cardioprotection in the ESRD Population: How Do We Get There?

Cardiovascular mortality for end-stage renal disease (ESRD) patients is about 30 times the risk in the general population. About 30% of ESRD patients have hyperlipidemia. The 1998 National Kidney Foundation Task Force on Cardiovascular Disease recommends implementation of effective measures to prevent and treat cardiovascular disease in this population. Our intent was to evaluate the extent of use of cardioprotective drugs in ESRD patients through a quality improvement project. Twenty-eight dialysis facilities throughout Ohio volunteered for this project. Data regarding use of angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) in heart failure, beta-blockers in myocardial infarction (MI), aspirin in coronary artery disease, and 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) were collected using chart abstraction for the period March through May 2000. The results were compared to Ohio hospital discharges from July through September 2000. This latter population was comprised of non--ESRD patients. Dialysis facilities were visited and interviews were conducted with staff members. Information was gathered regarding facility infrastructure, quality improvement process, and existing protocols. 27% of ESRD patients with a history of heart failure were on ACE-I, compared to 75.7% of non-ESRD patients. 34.8% of ESRD patients with a previous MI were taking beta-blockers, compared with 68.0% of non-ESRD patients with a prior MI. Aspirin use in ESRD patients with a previous MI was 52.8%, compared to 88% in non-ESRD patients with a prior MI. 17.3% of ESRD patients were on statins. Hyperlipidemia is found in 30% to 50% of ESRD patients. The use of cardioprotective drugs in the Medicare ESRD patient is lower than in the Medicare non-dialysis counterpart. Reasons for this are related to fragmentation of health care arising from communication and infrastructure issues. Until these issues are addressed and resolved, efforts at initiation of cardioprotective strategies will be slowed.

Cardioprotection in the ESRD Population: How Do We Get There?

Cardiovascular mortality for end-stage renal disease (ESRD) patients is about 30 times the risk in the general population. About 30% of ESRD patients have hyperlipidemia. The 1998 National Kidney Foundation Task Force on Cardiovascular Disease recommends implementation of effective measures to prevent and treat cardiovascular disease in this population. Our intent was to evaluate the extent of use of cardioprotective drugs in ESRD patients through a quality improvement project. Twenty-eight dialysis facilities throughout Ohio volunteered for this project. Data regarding use of angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) in heart failure, beta-blockers in myocardial infarction (MI), aspirin in coronary artery disease, and 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) were collected using chart abstraction for the period March through May 2000. The results were compared to Ohio hospital discharges from July through September 2000. This latter population was comprised of non--ESRD patients. Dialysis facilities were visited and interviews were conducted with staff members. Information was gathered regarding facility infrastructure, quality improvement process, and existing protocols. 27% of ESRD patients with a history of heart failure were on ACE-I, compared to 75.7% of non-ESRD patients. 34.8% of ESRD patients with a previous MI were taking beta-blockers, compared with 68.0% of non-ESRD patients with a prior MI. Aspirin use in ESRD patients with a previous MI was 52.8%, compared to 88% in non-ESRD patients with a prior MI. 17.3% of ESRD patients were on statins. Hyperlipidemia is found in 30% to 50% of ESRD patients. The use of cardioprotective drugs in the Medicare ESRD patient is lower than in the Medicare non-dialysis counterpart. Reasons for this are related to fragmentation of health care arising from communication and infrastructure issues. Until these issues are addressed and resolved, efforts at initiation of cardioprotective strategies will be slowed.

Supportive care for patients with renal disease: Time for action

Supportive care for patients with renal disease: Time for action

Extent and sources of geographic variation in Medicare end-stage renal disease expenditures

Geographic variations in practices and expenditures have been widely documented, leading to concerns that care in some regions is clinically suboptimal and/or economically inefficient. Our objectives are to determine the extent and sources of geographic variation in Medicare expenditures per patient with end-stage renal disease (ESRD) per year. The study population included all patients with ESRD with Medicare as primary payer during 1997 (n = 284,670). Medicare expenditures were summarized at the hospital referral region (HRR) level. Using regression analysis, we estimated the relationship between expenditures and demographics, case mix, dialysis provider characteristics, distribution of patients across renal replacement therapy modalities, standardized hospitalization ratios, and healthcare wages. Spending per patient-year varied threefold across HRRs, ranging from $17,791 to $59,025 (mean, $38,966 ± $6,774 [SD]). The regression equation explained 80% of this variation. Although several demographic and case-mix indicators that have been related to spending at the individual level were statistically significant predictors of spending at the HRR level, they did not show enough geographic variation to explain a large fraction of spending variation. Rather, patient distributions across renal replacement modalities, hospitalization patterns, and healthcare wages were the most powerful predictors of spending. Compared with Medicare generally, both the mean and SD of ESRD expenditures were approximately seven times larger. The substantial geographic variability in expenditures for patients with ESRD indicates the potential for improving efficiency and quality of care. Interventions designed to increase transplantation rates, ensure access to peritoneal dialysis, and reduce hospitalization appear most promising. © 2001 by the National Kidney Foundation, Inc.

Is HCFA's reimbursement policy controlling quality of care for end-stage renal disease patients?

Is HCFA's reimbursement policy controlling quality of care for end-stage renal disease patients?

The impact of dialysis and transplantation on children.

Effective methods to treat end stage renal disease (ESRD) in children have become available in the United States during the last 3 decades. Since the United States Congress created the Medicare ESRD Program in 1972, most children with ESRD have the option of Medicare insurance. Medicare expenditures for children with ESRD range from $14,000 for transplant recipients to $43,000 for dialysis patients per year. The tremendous expense of ESRD treatment has led to research to determine which treatment options are associated with the best health outcomes and the best value (quality/cost) for the money spent treating ESRD. The National Kidney Foundation's Dialysis Outcomes Quality Initiative recommends the use of quality of life and health status measures to gauge the impact of renal replacement therapy on quality of life in the ESRD population. In adult patients with renal failure, several generic and disease-specific quality of life measures have been validated and tested for reliability. In contrast, little research using validated and reliable health status measures has been performed in pediatric patients to measure the impact of ESRD. This article summarizes existing literature on how we currently measure the impact of dialysis and transplantation on children, discusses existing health status measures for children and adolescents, and describes how these measures might be used to improve our care of patients and long-term outcomes for children with kidney failure.

The outcome of the urban renal patient: the importance of social factors and center effects.

Caring for the urban renal patient can be a challenge to providers for many reasons. Although racial and socioeconomic factors have an impact on the health of this population, one must also consider the effect of the urban environment on the ill, especially those with renal disease. This article reviews the state of health among the poor and nonwhite minorities, who tend to inhabit the urban regions of this country, and then highlights the unique characteristics of those with renal disease. The impact of the Medicare end-stage renal disease (ESRD) program and center-specific quality of care on the outcome of the urban patient with ESRD is explored.

Outcomes-Adjusted Reimbursement in a Health-Care Delivery System

This paper considers a health-care delivery system with two noncooperative parties: a purchaser of medical services and a specialized provider. A dynamic principal-agent model that captures the interaction between the two parties is developed. In this model, patients arrive exogenously, receive periodic treatment from the provider, suffer costly complications that require hospital care, and eventually exit the system in death. The provider chooses the intensity of treatment in each period, incurs an associated cost, and is reimbursed by the purchaser according to observed patient outcomes. The purchaser's problem is to determine a payment system that will induce treatment choices maximizing total social welfare. The optimal payment system, referred to as the outcomes-adjusted payment system, is identified. It consists of a prospective payment per patient and a retrospective payment adjustment based on adverse short-term patient outcomes. This system induces the most efficient delivery of medical services by combining the immediate “threat” of a retrospective payment adjustment with the future reward of prospective payments generated by surviving patients. A numerical example is provided in the context of Medicare's End-Stage Renal Disease program. The example compares the optimal system to systems that are currently in place. The results suggest that the purchaser can achieve significant gains in patient life expectancy by switching to the outcomes-adjusted payment system, but this requires accurate information about treatment technology, patient characteristics, and provider preferences. The life-expectancy gains do not involve increased medical expenditures.

Economic cost of expanded criteria donors in cadaveric renal transplantation: analysis of Medicare payments.

The use of expanded criteria donors (ECDs) in cadaveric renal transplantation is increasing in the US. We assess the economic impact of the use of ECDs to the Medicare end stage renal disease program. The United Nations for Organ Sharing renal transplant registry was merged to Medicare claims data for 42,868 cadaveric renal transplants performed between 1991-1996 using USRDS identifiers. Only recipients for whom Medicare was the primary payer were considered, leaving 34,534 transplants. An ECD was defined as (1) age < or =5 or > or =55 years, (2) nonheart-beating donors, donor history of (3) hypertension or (4) diabetes. High-risk recipients (HRR) were age >60 years, or a retransplant. Medicare payments from the pretransplant dialysis period were projected forward to provide a financial "breakeven point" with transplantation. There were 25,600 non-HRR transplants, with 5,718 (22%) using ECDs, and 8,934 HRR transplants, of which 2,200 (25%) used ECDs. The 5-year present value of payments for non-ECD/non-HRR donor/recipient pairings was $121,698 vs. $143,329 for ECD/non-HRR pairings (P<0.0001) and, similarly was $134,185 for non-ECD/HRR pairings vs. $165,716 for ECD/HRR pairings (P<0.0001). The break even point with hemodialysis ranged from 4.4 years for non-ECD/ non-HRR pairings to 13 years for the ECD/HRR combinations but was sensitive to small changes in graft survival. Transplantation was always less expensive than hemodialysis in the long run. The impact of ECDs on Medicare payments is most pronounced in high-risk recipients. Cadaveric renal transplantation is a cost-saving treatment strategy for the Medicare ESRD program regardless of recipient risk status or the use of ECDs.

Introduction: Aging and the Kidney

A June 3rd, 1999 article in the New York Times described the plight of HsingHsing, beloved Washington Zoo giant panda who succumbed to kidney disease, a disease of aging in giant pandas, on November 28.1 Hsing-Hsing was 28 years old; giant pandas in the wild live to about 20 years of Dr Lucy Spelman, a veterinarian at the National Zoo, portrayed Hsing-Hsing's condition as inevitable, given his advanced age. The article goes on to describe some of the ethical issues involved, including reluctance on part of zookeepers to consider dialysis for HsingHsing. ... aggressive treatments, including dialysis, which would ... require daily anesthetic, were not considered prudent because of Hsing-Hsing's age: A transplant was ruled out because no giant panda kidneys are available.1 What the article does not describe is the similar occurrence of renal disease with human aging. In the United States in 1997, the last year for which data are available, 44.5% of prevalent Medicare end-stage renal disease patients were 65 years of age or 0lder.2 The data for incident patients is even more striking: 50.6% or 39,980 of 79,102 new dialysis patients in 1997 were 65 years of age or 0lder.2 The incidence rate per million population for those 65 to 74 years of age is 1,296 compared with 287 patients per million population for the United States as a whole.2 The number of elderly patients with less severe renal disease is even larger. As the world population ages and as elderly patients continue to constitute a disproportionate part of the renal population, nephrologists are becoming gerontologists whether they wish to or not. The genesis of this issue of Advances in Renal Replacement Therapy was a conference on Integrating Geriatrics into Nephrology that was sponsored by the Hartford Foundation and took place in Jasper, Alberta, Canada in August 1998. Approximately 50 prominent gerontologists and nephrologists spent 5 days discussing critical issues in the care of the elderly patient with renal disease. A consensus was reached that these issues, their potential solutions, and future directions for research should be widely disseminated to the renal community. The authors of the manuscripts in this

For-Profit Versus Not-for-Profit Dialysis Care for Children With End Stage Renal Disease

Over the last 2 decades, for-profit dialysis units have become the most common providers of renal replacement therapy for adults with end stage renal disease (ESRD) and have had an increasing role in the dialysis of children. We undertook a study to determine whether dialysis facility profit status influences the choice of dialysis therapy in the pediatric population. Cross-sectional study of national data from the Health Care Financing Administration. Free-standing and hospital-based outpatient dialysis facilities in the United States. A total of 1568 children and adolescents (</=19 years of age) eligible for US Medicare ESRD benefits in 1994. The association between dialysis modality choice and the profit status of the facility. Crude associations were estimated by the OR of a patient being treated with peritoneal dialysis (PD) versus hemodialysis at nonprofit versus for-profit facilities. Adjusted associations were estimated using logistic regression analysis. In bivariate analysis, children with ESRD dialyzed at nonprofit facilities were nearly three times as likely as those at for-profit facilities to be on PD (OR: 2.9; 95% CI: 2.3,3.6). In multivariate analysis, after controlling for patient age, sex, race, cause and duration of ESRD, free-standing versus hospital-based facility, and the pediatric expertise of the facility, patients at nonprofit facilities were more than twice as likely as those dialyzed at for-profit facilities to be on PD (OR: 2.3; 95% CI: 1.6, 3.4). After taking into account the clustering of patients within facilities, the association between nonprofit status and the use of PD persisted (OR: 2.2; 95% CI: 1.5,3.2). Children with ESRD treated at nonprofit facilities are more likely to receive PD than are those treated at for-profit facilities even after controlling for other patient and facility characteristics. This finding suggests that clinical decision making for pediatrics may be influenced by the ownership of the health care facility in which the patient is treated.

Medicare's end-stage renal disease program: current status and future prospects.

The twenty-five years of the end-stage renal disease (ESRD) program have been characterized by remarkable clinical achievements, which have prolonged and improved the quality of life for thousands of patients. As the program enters the next millennium, it faces considerable challenges: As the number and acuity of patients increase, the availability of trained nephrologists will decrease, and total costs will continue to rise. Policymakers will need to work closely with the renal professional and patient communities to develop creative approaches to delivering and financing ESRD care that is of the highest quality, yet is affordable.

Diabetic nephropathy in patients with type II diabetes.

Diabetic nephropathy is the single most common cause of end-stage renal disease (ESRD) in the United States. Patients with diabetes account for 35% of all those enrolled in the Medicare ESRD Program and, at current rates of increase, patients with diabetes will soon account for 50% of all ESRD patients [1]. Most of these patients have Type II diabetes and are elderly [2]. In 1992 the cost of caring for these patients’ renal disease alone exceeded 2 billion dollars per year in the United States [1]. Similarly, European registry data reveal a dramatic increase in the incidence of ESRD due to diabetic nephropathy [2]. In European renal replacement programs, the relative increase in acceptance rates has been considerably greater for patients classed as having Type II diabetes than for those with Type I diabetes. This dramatic increase in Type II diabetes and diabetic nephropathy in both Europe and the United States reflects the epidemic of Type II diabetes worldwide [4]. Also it may reflect the increased survival of patients with Type II diabetes and protein- uria. In Germany the survival rate, five years after the onset of proteinuria, for a patient with Type II diabetes was 35% in the period 1966 to 1975, but rose to 75% from 1976 to 1985 [5].

Familial aggregation of renal disease in a population-based case-control study.

Family history of renal disease has been associated with an increased risk of end-stage renal disease (ESRD). It is uncertain whether this risk is mediated by familial aggregation of risk factors for ESRD, such as diabetes and hypertension. The association of ESRD with familial aggregation of renal disease was examined in a large, population-based case-control study conducted in Maryland, Virginia, West Virginia, and Washington, DC. The number of first-degree relatives who were affected with any type of renal disease was compared between 689 newly treated ESRD patients registered in the Medicare ESRD program (92% of all eligible incident cases presenting between January and July of 1991) and 361 control subjects without ESRD who were selected by random-digit dialing (90% response rate). Patients and control subjects were frequency matched by age; patients with ESRD caused by polycystic kidney disease and other known hereditary kidney diseases were excluded. Analysis was conducted using multiple logistic regression. After controlling for the proband's age, gender, race, family size, socioeconomic status, and personal and family histories of diabetes and hypertension, having one first-degree relative with renal disease increased the odds of ESRD by 1.3 (95% confidence interval, 0.7 to 2.6) and having two or more affected first-degree relatives increased the odds of ESRD by 10.4 (95% confidence interval, 2.7 to 40.2). These data support familial aggregation of renal disease in excess of that predicted by clustering of diabetes and hypertension within families, suggesting that either genetic susceptibility or environmental exposures shared within families increase the risk of developing ESRD. This risk is also much higher when two or more first-degree relatives have renal disease. Unraveling the molecular basis of this increase in risk may provide new avenues for treatment and prevention of ESRD.

GIR6 Predictors of Diagnostic-Related Group Day Outliers in the Medicare End-Stage Renal Disease Population

This study examines Diagnostic-Related Group (DRG) day outliers among End-Stage Renal Disease (ESRD) patients enrolled in Medicare's ESRD Program. Day outlier hospitalizations are cases that remain in the hospital longer than a specified period of time defined by HCFA. The study uses a sample of hospitalizations from the United States Renal Data System. OBJECTIVES: The objectives of the study are to describe the portion of the ESRD population which is most likely to be hospitalized, to examine the distribution of ESRD patients within DRGs, and to identify variables significantly related to DRG day outlier status. METHODS: This study has a retrospective cohort design. To describe the hospitalized segment of the Medicare ESRD population, frequency distributions of patient characteristics are reported. To identify variables which are predictors of DRG day outlier status, a logistic regression is performed. RESULTS: Day outlier hospitalizations represented 3.9% of all hospitalizations by ESRD patients (n=3,921,883). This study shows that white males between the age of 60 and 99 years; with less than a year since their first ESRD service; with admission to MDCs 22, 24 or the DRGs not associated with an MDC; with lung cancer, leukemia, malnutrition, or liver conditions as comorbidities are most likely to have day outlier hospitalizations. CONCLUSIONS: The findings of this study can aid in identifying patients more likely to benefit from disease management programs specifically designed to address the needs of this population. Other benefits possible benefits are an increase in the patient's quality of care, quality of life, as well as an overall increase in health outcomes.