an introduction to end-stage renal disease united states

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an introduction to end-stage renal disease in the united states

Sitting in the morning sunI’ll be sitting when the evening comesWatching the ships roll inAnd I watch ‘em roll away again

Otis Redding & Steve Cropper, “(Sittin’ on) the Dock of the Bay”

précis

2011 USRDS ANNUAL DATA REPORT

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précis » an introduction to esrd in the u.s.INTRODUCTION

Pr

INTRODUCTION

Peritoneal dialysis now accounts for 6–7 percent of the inci-

dent and prevalent dialysis populations, a level far lower

than the 12–18 percent in the 1980s and 1990s; there are

signs, however, that use of this therapy is growing. The

number of kidney transplants reached 17,736 in 2009, while

the prevalent transplant population increased 4.2 percent,

to 172,553, despite continued growth in the number of

patients on the transplant wait list. The median time on the

kidney-only and kidney-pancreas wait lists was 1.7 years.

In the rest of this Précis we highlight data from Volume

Two. We show, for instance, that rates of new ESRD cases

remain quite stable, at 355 per million population in 2009.

While ESRD due to diabetes has also been stable over the

last decade, at a rate of 154, ESRD caused by hypertension

has grown 10 percent. The prevalence of ESRD continues to

grow at a rate of 2 percent per year, reaching 1,738 in 2009.

Patients who see a nephrologist for more than 12

months before starting dialysis are the most likely to use

a fistula or internal graft at the first outpatient dialysis

treatment. Since nephrologists are central to discussions

with patients and families about ESRD treatment options,

greater pre-ESRD referral would help ensure increased use

of fistulas, which are associated with the lowest rates of

adverse events.

The treatment of anemia has changed during the last

four years, after changes in product labeling from the

FDA and in payment structures from CMS. Hemoglobin

levels at the initiation of dialysis have fallen below 10 g/dl,

a level not seen since December, 2000, while the percent-

age of patients using an erythropoiesis stimulating agent

(ESA) prior to initiation has also fallen — to 22 percent, a

level not seen since April, 1996. Hemoglobin levels at

six months following the start of ESRD therapy are now

lower than in 2001, yet the ESA dose is substantially higher.

Hemoglobin levels in the prevalent dialysis population

have decreased as well.

Hospitalizations continue to be an area of concern,

with admissions for infection in hemodialysis patients

43 percent higher than in 1993. New data on rehospitaliza-

tions show that rates are twice as high for ESRD patients

as in the general Medicare population. Mortality rates

continue to improve, though more slowly for the first year

of treatment than for the years following. Rates for ESRD

patients, however, are 2.0–2.5 times greater than for gen-

eral Medicare patients with cancer, diabetes, congestive

heart failure, or CVA/TIA.

This year we present new data on the Medicare Part D

prescription drug benefit, which started in 2006. ESRD and

non-ESRD CKD patients have higher Part D coverage with

the low income subsidy than do general Medicare patients

and, not surprisingly, out-of-pocket expenditures are

greatest for ESRD patients, at nearly $6,000 per year com-

pared to $1,985 in the general Medicare population and

$3,550 for those with a diagnosis of CKD.

The kidney transplant wait list continues to grow,

reaching 80,848 in 2009; 17,736 transplants were per-

The size of the ESRD population reached a new high in 2009, with 571,414 patients under treatment. The number

of patients returning from a failed transplant rose to 5,606, while the number restarting dialysis increased to 3,492.

150 trends in patient counts & spending

152 incidence, prevalence, modality, pre-esrd care

154 patient care

155 hospitalization

156 cardiovascular disease in patients with esrd

157 mortality

158 prescription drug coverage

160 transplantation

162 pediatric esrd

163 esrd providers

165 costs of esrd

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formed that year. Living donor donation rates appear to be

rebounding, while donations from deceased donors have

been stable. Risk factor monitoring among transplant

patients has improved, yet rates of influenza vaccinations

are still relatively low.

Highlighted data on pediatric ESRD patients show

that the number with cystic kidney disease has increased,

while there are fewer patients with glomerular disease.

Rates of hospitalization for pneumonia are greatest over-

all in patients younger than 10, and, in the hemodialy-

sis population, mortality is greatest in the first months

of therapy.

Dialysis providers continue to consolidate, with Frese-

nius Medical Care announcing the purchase of additional

units in July, 2011; the company thus maintains its position

as the largest provider of dialysis care in the United States.

Dialysis Clinic, Inc. continues to have the lowest standard-

ized hospitalization and mortality ratios among the large

providers, while, among the smaller providers, hospital-

based units have the highest standardized mortality ratios.

We conclude the Précis with data on the costs of ESRD

patient care, which rose very little in 2009. Costs per per-

son per year remain highest for hemodialysis patients, at

$82,285, compared to $61,588 and $29,983 for peritoneal

dialysis and transplant patients.» Figure p.1; see page 378 for analytical methods. Period prevalent

general (fee-for-service) Medicare patients. Diabetes, CKD, & congestive heart failure determined from claims, 1998–1999 & 2008–2009; costs are for calendar years 1999 & 2009.

p1ii Distribution of general (fee-for-service) Medicare patients & costs for CKD, CHF, diabetes, & ESRD, 1999 & 2009

General Medicare: population, 1999(n = 29,650,971; mean age 69.8)

General Medicare: costs, 1999($148 billion)

General Medicare: population, 2009(n = 31,156,428; mean age 69.2)

General Medicare: costs, 2009($289 billion)

DM 17.96%CHF 13.3%

CKD 3.6%

ESRD 0.99%

DM 32.6%CHF 38.3%

CKD 11.5%

ESRD 7.3%

DM 26.2%CHF 12.7%

CKD 10.4%

ESRD 1.3%

DM 41.97%CHF 36.3%

CKD 24.9%

ESRD 8.1%

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précis » an introduction to esrd in the u.s.TRENDS IN PATIENT COUNTS & SPENDING

paii Summary statistics on reported ESRD therapy in the United States, by age, race, ethnicity, gender, & primary diagnosis, 2009

A Incident counts: include all known ESRD patients, regardless of any incomplete data on patient characteristics and of U.S. residency status.

B Includes only residents of the 50 states and Washington D.C. Rates are adjusted for age, race, and/or gender using the estimated July 1, 2005 U.S. resident population as the standard population. All rates are per million population. Rates by age are adjusted for race and gender. Rates by gender are adjusted for race and age. Rates by race are adjusted for age and gender. Rates by disease group and total adjusted rates are adjusted for age, gender, and race. Adjusted rates do not include patients with other or unknown race.

C Patients are classified as receiving dialysis or having a functioning transplant. Those whose treatment modality on December 31 is unknown are assumed to be receiving dialysis. Includes all Medicare and non-Medicare ESRD patients, and patients in the U.S. Territories and foreign countries.

D Deaths are not counted for patients whose age is unknown.

E Age is computed at the start of therapy for incidence, on December 31 for point prevalence, at the time of transplant for transplants, and on the date of death for death.

F Includes patients whose modality is unknown.

G Unadjusted total rates include all ESRD patients in the 50 states and Washington D.C.

H Total transplants as known to the USRDS; 57 transplants with unknown donor type excluded from counts.

I Adjustments using the Bureau of Labor Statistics inflationary adjustment and the CMS inflation adjustment for the medical component.

* Values for cells with ten or fewer patients are suppressed. “.” Zero patients in this cell.

IncidenceA December 31 point prevalence Kidney transplantsAdj. Adj. Deceased Living ESRD

Count % rateB CountC % rateB DialysisC % TxC % donor donor deathsD

0-19E 1,400 1.2 16 7,738 1.4 86 2,247 0.6 5,491 3.2 612 407 11520-44 14,300 12.3 131 100,031 17.5 924 55,904 14.0 44,127 25.6 2,982 2,296 4,63445-64 44,699 38.4 610 256,803 44.9 3,433 167,147 41.9 89,656 52.0 5,786 2,931 27,18965-74 26,998 23.2 1,407 116,607 20.4 6,066 89,802 22.5 26,805 15.5 1,699 676 23,93875+ 28,970 24.9 1,762 90,233 15.8 5,545 83,759 21.0 6,474 3.8 212 78 34,242Unknown 28 * * 0.0 . 0.0 White 76,377 65.6 277 347,268 60.8 1,279 223,178 56.0 124,090 71.9 6,602 4,680 60,708African American 32,314 27.8 976 180,685 31.6 5,284 147,290 36.9 33,395 19.4 3,535 843 24,799Native American 1,442 1.2 523 7,682 1.3 2,735 5,730 1.4 1,952 1.1 184 107 1,076Asian/Pacific Islander 5,647 4.9 403 30,365 5.3 2,101 19,679 4.9 10,686 6.2 830 707 3,092Other/unknown 615 0.5 5,414 0.9 2,984 0.7 2,430 1.4 140 51 443Hispanic 16,240 14.0 501 87,866 15.4 2,538 64,930 16.3 22,936 13.3 1,659 931 10,394Non-Hispanic 100,155 86.0 345 483,548 84.6 1,685 333,931 83.7 149,617 86.7 9,632 5,457 79,724Male 65,996 56.7 452 323,276 56.6 2,140 220,500 55.3 102,776 59.6 6,775 3,887 50,212Female 50,393 43.3 282 248,127 43.4 1,408 178,352 44.7 69,775 40.4 4,516 2,501 39,906Unknown * 11 * 0.0 * 0.0 .Diabetes 50,970 43.8 154 215,245 37.7 647 175,166 43.9 40,079 23.2 3,496 1,337 41,055Hypertension 32,688 28.1 101 140,498 24.6 429 113,173 28.4 27,325 15.8 2,340 999 25,490Glomerulonephritis 7,612 6.5 24 84,883 14.9 263 40,166 10.1 44,717 25.9 2,121 1,524 5,924Cystic kidney disease 2,662 2.3 8 27,254 4.8 83 10,664 2.7 16,590 9.6 866 702 1,522Urologic disease 1,590 1.4 5 13,108 2.3 41 7,271 1.8 5,837 3.4 252 180 1,538Other known cause 14,810 12.7 46 62,315 10.9 195 36,785 9.2 25,530 14.8 1,535 1,160 10,270Unknown cause 4,245 3.6 13 21,563 3.8 66 13,741 3.4 7,822 4.5 443 270 3,429Missing cause 1,818 1.6 4 6,548 1.1 13 1,895 0.5 4,653 2.7 238 216 890All 116,395 355.4 571,414 100.0 1,738 398,861F 172,553 11,291 6,388 90,118 Unadjusted rateG 371 1,810.6 Total transplantsH 17,736

Wait-list for kidney & kidney/pancreas transplantsNew Median

listings N, as of time on in 2009 12.31.09 list (yrs)0-17 769 775 0.8018-34 4,184 8,769 1.4835-49 9,482 23,295 1.7450-64 14,029 35,191 1.7165+ 5,641 14,508 1.72Male 20,420 48,163 1.63Female 13,685 34,375 1.77White 20,499 44,564 1.54African American 9,957 28,878 1.89Native American 406 983 1.72Asian/Pacific Islander 2,453 6,215 1.84Other/unknown 791 1,899 1.56Hispanic 5,713 15,183 1.79Non-Hispanic 28,393 67,356 1.66Diabetes 11,651 27,631 1.56Hypertension 7,001 18,693 1.77Glomerulonephritis 5,854 15,270 1.91Cystic kidney disease 2,449 5,262 1.54Urologic disease 571 1,491 2.17Other known cause 4,834 10,675 1.64Unknown cause 1,047 2,592 1.82Missing cause 699 925 0.97Blood type A 11,253 23,673 1.48B 4,992 13,382 1.81AB 1,343 2,433 1.28O 16,518 43,051 1.79PRA 0% 13,815 39,883 1.861-9 2,274 6,645 1.8410-79 3,928 13,490 2.0980+ 1,896 9,769 2.88Unknown 12,193 12,752 0.20Total 34,106 82,539 1.69

Medicare & non-Medicare spending*Medicare spending for ESRD, 2009(billions of dollars)

SAF paid claims (Part A & B) 25.112% incurred but not reported 0.50HMO-Medicare risk 3.13Organ acquisition 0.28

Total Medicare costs 29.03Non-Medicare spending for ESRD, 2009(billions of dollars)

EGHP (MSP) 2.99Patient obligations 4.84Non-Medicare patients 5.64

Total non-Medicare costs 13.47Total ESRD costs (billions), 2009 42.50Change in Medicare spending, 2008 to 2009

Total 6.77%Per patient year 5.63%

Adjusted for inflationI 6.1 to 2.4%Medicare spending per patient year, 2009

ESRD $70,216 Hemodialysis $82,285 Peritoneal dialysis $61,588 Transplant $29,983

* Does not include Medicare Part D.

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p2ii Counts of new & returning dialysis patients

p3ii Patient counts, by modality

In 2009, 116,395 new dialysis and transplant patients initiated ESRD therapy, for an adjusted rate per million population of 355. More than 571,000 patients were receiving treatment on December 31, 2009, for an adjusted rate of 1,738 per million population. Nearly 399,000 of these patients were being treated with dialysis, while 172,553 had a functioning graft; 90,118 ESRD patients died during the year. A total of 17,736 transplants were performed during 2009, including 6,388 from living donors. More than 34,000 patients were added to the transplant wait list, 85,539 were on the kidney-alone and kidney/pancreas wait lists at the end of 2009, and the median time on the list (for pediatric and adult patients combined) was 1.7 years.

With Medicare spending for ESRD at $29 billion, and non-Medicare spending at $13.5 billion, total ESRD costs in 2009 reached $42.5 billion. Medicare costs per per-son per year were more than $70,000 overall, ranging from $29,983 for transplant patients to $82,285 for those receiving hemodialysis therapy. » Table p.a; see page 378 for analytical methods. Dialysis & transplant patients, 2009.

The size of the prevalent dialysis popula-tion increased 4 percent in 2009, reaching 398,861, and is now 40 percent larger than in 2000. The size of the transplant popu-lation rose 4.2 percent, to reach 172,553 patients, while the number of incident patients rose 3.3 percent, to 116,395. These data suggest longer lifespans for preva-lent patients, ultimately influencing the steady growth of this population and the annual expenditures these patients incur. » Figure p.3. Incident & December 31 point prevalent ESRD patients.

The number of new dialysis patients rose 3.5 percent in 2009 — up from a 1.2 percent growth in 2008 — to 112,782. Just over 5,600 patients with graft fail-ure returned to dialysis from transplant, a one-year increase of 2.7 percent. The number of patients restarting dialysis increased 6.6 percent, to 3,492. Overall, the CMS Annual Facility Survey showed 121,880 patients starting or restarting dialysis in 2009, up 3.6 percent from 2008. » Figure p.2; see page 378 for analytical meth-ods. CMS Annual Facility Survey.

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précis » an introduction to esrd in the u.s.INCIDENCE, PREVALENCE, MODALITY, PRE-ESRD CARE

13ii Adjusted incident rates of ESRD & annual percent change (page 186)

16ii Incident counts & adjusted rates of ESRD, by race (page 186)

112ii Prevalent counts & adjusted rates of ESRD, by race (page 188)

19ii Adjusted prevalent rates of ESRD & annual percent change (page 188)

After a 0.9 percent decline in 2008, the adjusted incident rate of end-stage renal disease rose 1.1 percent in 2009, to 355 per million population. Prior to the slight decline in 2007 and 2008, the rate of new ESRD cases had increased or remained stable each year since 1996. » Figure 1.3; see page 379 for analytical methods. Incident ESRD patients. Adj: age/gender/race; ref: 2005 ESRD patients.

The adjusted rate of prevalent cases of ESRD rose 2.1 percent in 2009 — up slightly from the 1.9 percent growth in 2008 — to 1,738 per million population. This rate is nearly 23 percent higher than that seen in 2000. The annual rate of increase has remained between 1.9 and 2.4 percent since 2003. » Figure 1.9; see page 379 for analytical methods. December 31 point prevalent ESRD patients. Adj: age/gender/race; ref: 2005 ESRD patients.

By race, rates for African Americans and Native Americans in 2009 were 976 and 523 per million population, respec-tively — 3.5 and 1.9 times greater than the rate of 277 found among whites. Since 2000, the rate of new ESRD cases has grown 7.2 percent among whites and 6.4 percent among Asians, while remaining stable in the African Ameri-can population. » Figure 1.6; see page 379 for analytical methods. Incident ESRD patients. Adj: age/gender; ref: 2005 ESRD patients.

By race, rates of prevalent ESRD remain greatest in the African Ameri-can and Native American populations, at 5,284 and 2,735 per million popula-tion in 2009, compared to 1,279 and 2,101 among whites and Asians. The rate among Hispanics reached 2,538 in 2009, 1.5 times greater than that in the non-Hispanic population. » Figure 1.12; see page 379 for analytical methods. December 31 point prevalent ESRD patients. Adj: age/gender ref: 2005 ESRD patients.

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115ii Incident patient distribution, by first modality & payor (page 190)

116ii Prevalent patient distribution, by modality & payor (page 191)

119ii Access use at first outpatient hemodialysis, by pre-ESRD nephrology care, 2009 (page 192)

120ii Mean hemoglobin at initiation, by pre-ESRD ESA treatment (page 193)

Nine in ten prevalent hemodialysis patients had some type of Medicare cov-erage in 2009, with 40 percent covered solely by Medicare, and 32 percent under Medicare/Medicaid. In the transplant population, in contrast, just 32 percent are covered solely by Medicare. Trans-plant patients younger than 65 and not disabled lose their entitlement after three years with a functioning graft. » Figure 1.16; see page 379 for analytical methods. December 31 point prevalent ESRD patients.

Forty-five percent of new hemo-dialysis patients are covered solely by Medicare, 13.5 percent have dual Medicare/Medicaid coverage, and 15.3 percent are covered by a Medicare HMO provider. Medicare covers 41 and 22 percent of new peritoneal dialysis and transplant patients, while 9.8 and 4.2 percent are dually-enrolled, and 9.8 and 3.5 percent have HMO coverage. » Figure 1.15; see page 379 for analytical methods. Incident ESRD patients.

Among hemodialysis patients who have seen a nephrologist for more than a year prior to starting ESRD therapy, less than half initiate treatment using a catheter; these patients have the greatest likeli-hood at initiation of having an arteriove-nous fistula (AV) or maturing fistula, at 30 and 19.2 percent, respectively. Patients with no pre-ESRD nephrology care most frequently start treatment with a catheter, at 82 percent. » Figure 1.19; see page 379 for ana-lytical methods. Incident hemodialysis patients, 2009.

In the incident ESRD population, the mean hemoglobin at initiation has continued to fall from its peak in 2006, reaching 9.85 g/dl overall, 9.94 for patients receiving pre-ESRD treatment with an erythropoiesis stimulating agent (ESA), and 9.81 for patients without ESA treatment; 22 percent of new patients at the end of 2009 had received a pre-ESRD ESA. » Figure 1.20; see page 379 for analytical methods. Incident ESRD patients.

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Removal 0.36 0.22 0.02 0.01 0.05 0.04 0.12 0.11ComplicationsInfection of access 1.67 1.45 0.22 0.18 0.42 0.39 0.51 0.56Sepsis 2.89 2.32 0.54 0.52 0.74 0.61 0.52 0.44Angioplasty 0.28 0.47 0.77 1.10Declot 0.08 0.12 0.38 0.48Peritonitis (PD pts only) 0.63 0.61


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précis » an introduction to esrd in the u.s.PATIENT CARE | HOSPITALIZATION

22ii Patient distribution, by mean monthly hemoglobin (g/dl; page 198)

24ii Mean monthly hemoglobin after initiation, by year (page 198)

215ii Cumulative number of Part D medications in ESRD patients, by race/ethnicity & low income subsidy (LIS) status, 2008 (page 202)

During 2009, 40 percent of prevalent dialysis patients had a mean monthly hemoglobin within the previous KDOQI target of 11–12 g/dl. The mean EPO dose per week averaged 18,206 units, down from a peak of nearly 20,000 during 2004–2007, when a greater proportion of patients had hemoglobins nearing 12 g/dl. » Figure 2.2; see page 381 for analytical methods. Period prevalent dialysis patients.

When compared to 2005 incident patients, those starting dialysis in 2009 did so with slightly lower hemoglobins one month post-initiation, at 10.6 and 10.3 g/dl, respectively. At six months, the mean monthly hemoglobin in 2009 patients was within the KDOQI target of 11–12 g/dl, at 11.5. » Figure 2.4; see page 381 for ana-lytical methods. Incident dialysis patients.

Dialysis and transplant patients received an average of 13.6 and 12.4 distinct medications, respectively, through their Part D plan in 2008. White dialysis patients received the greatest number, at 14.1, and LIS patients received more than did their non-LIS counterparts. » Figure 2.15; see page 381 for analytical methods. Point prevalent Medicare enrollees alive on January 1, with Part D enrollment, October 1–December 31, 2007 & 2008.

2c ii Access events & complications in prevalent dialysis patients (ESRD CPM data; rate per patient year; page 201)

Among prevalent hemodialysis patients in 2007 (the most recent year of available CPM data), the most common access-related event was replacement with a catheter, at 0.86 events per year for patients already using a catheter, and 0.12 and 0.24, respectively, for those with an arteriovenous (AV) fistula or graft. Sepsis is more common than infection, regardless of access type. In 2007, for example, the rate of sepsis among catheter patients was 1.6 times higher than rates of infection; among AV fistula patients, the rate was three times higher.

In peritoneal dialysis patients, the rate of access replace-ment with another peritoneal access has decreased by a factor of two since 1998, while rates of replacement with an internal hemodialysis access or hemodialysis catheter have each fallen, but to a lesser degree. » Table 2.c; see page 381 for analytical methods. Cath-eter, fistula, graft: prevalent hemodialysis patients age 20 & older, ESRD CPM & claims data. Peritoneal dialysis device: prevalent peri-toneal dialysis patients age 20 & older.

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Cardiovascular index hosp. (107,157) Infectious index hosp. (87,380) Index hosp for VA infection (21,609)

Rehosp-other

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31ii Change in adjusted all-cause & cause-specific hospitalization rates, by modality (page 207)

34ii Cause-specific rehospitalization rates 30 days post live hospital discharge, by age (page 210)

The rate of admissions for infection in the ESRD population is now 43 percent greater than in 1993, while the rate for vascular access procedures has fallen 48 percent. Hospitals have made signifi-cant progress in using less costly settings to address vascular access interventions, but equivalent progress in lowering the rate of infectious complications is lacking. In the peritoneal dialysis popu-lation there has been little change in the overall rate of hospitalization for infec-tion. Admissions for peritonitis, in con-trast, have fallen. » Figure 3.1; see page 382 for analytical methods. Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2005.

The percent of patients who are rehospitalized and alive following an all-cause index hospitalization was 33 percent overall in 2009, and highest in patients age 20–44, at 41.5 percent. For cardiovascular, infectious, or vas-cular access hospitalizations, the per-centages rehospitalized and discharged

alive were again highest in the younger cohort, at 45, 35, and 33 percent, respec-tively. » Figure 3.4; see page 382 for analytical meth-ods. Period prevalent hemodialysis patients age 20 & older, 2009; unadjusted. Includes live hospital discharges from January 1 to December 31, 2009.

In hemodialysis matched to perito-neal dialysis populations, first-year hos-pitalization rates (from day 90) in 2008 were 26 percent higher for hemodialysis patients than for peritoneal patients, at 1.9 and 1.5, respectively, per patient year. Hospital days per patient year followed suit, and were 30 percent higher in the matched hemodialysis population, at 12.4 compared to 9.5 days in peritoneal dialysis patients. » Figure 3.7; see page 383 for analytical methods. Incident hemodialysis & peritoneal dialysis patients age 20 & older. Adj: age/gender/race/primary diagnosis; ref: 2005 incident hemodialysis & peri-toneal dialysis patients. Rates show first-year admissions from day 90 to one year after initiation.

37ii Adj. 1st-year hosp adm rates & days (from day 90) in matched HD & PD dialysis pts

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précis » an introduction to esrd in the u.s.CARDIOVASCULAR DISEASE IN PATIENTS WITH ESRD | MORTALITY

Beta Spirono- Clopid- Pentoxi- Dipyrid- Amio- N ACEI/ARB blocker Digoxin lactone Eplerenone ogrel Warfarin Cilostazol fylline amole Statins darone

CHF

Hemodialysis 50,962 47.6 64.9 6.7 1.0 0.0 20.0 13.8 1.0 1.0 1.0 38.0 6.1

Peritoneal dialysis 1,701 45.8 64.2 7.2 3.1 0.1 19.1 13.1 0.9 0.9 1.4 42.7 6.7

Transplant 3,330 43.2 75.6 6.4 4.7 0.2 14.6 19.6 0.9 0.8 0.6 53.9 4.7

AMI

Hemodialysis 4,711 56.8 77.4 6.3 0.9 0.0 48.2 12.4 1.4 1.3 1.3 57.2 6.9

Peritoneal dialysis 190 47.9 78.4 4.2 1.6 0.0 53.7 10.0 0.5 1.1 0.0 61.1 6.8

Transplant 342 52.3 83.3 4.7 2.3 0.0 54.4 14.0 0.6 1.5 1.8 67.0 4.1

PAD

Hemodialysis 46,908 42.2 57.6 4.2 0.6 0.0 21.5 13.5 2.1 1.5 1.1 38.8 4.7

Peritoneal dialysis 1,521 40.8 55.6 3.5 1.8 0.1 24.4 8.7 3.6 2.2 1.2 46.8 4.3

Transplant 4,723 41.8 65.0 2.4 2.2 0.1 16.9 13.6 2.6 1.5 1.0 54.2 2.1

CVA/TIA

Hemodialysis 14,320 47.6 62.1 4.4 0.7 0.0 24.9 13.9 1.4 1.1 3.7 42.4 5.0


Transplant 1,351 42.0 67.7 3.2 2.7 0.1 21.5 17.6 1.3 1.3 4.7 56.6 1.8

AFIB

Hemodialysis 17,372 38.3 62.6 15.4 0.8 0.0 16.8 41.7 1.2 1.0 0.8 38.1 18.8


Transplant 2,028 42.9 75.7 14.7 3.3 0.0 9.0 57.2 0.7 0.9 0.7 53.4 12.5

ICDs/CRT-D

Hemodialysis 687 56.8 77.6 11.6 2.6 0.0 31.0 19.1 1.0 1.6 0.6 46.7 16.6


Transplant 50 56.0 84.0 20.0 14.0 0.0 16.0 34.0 2.0 2.0 0.0 56.0 14.0

Revascularization (PCI)

Hemodialysis 3,784 57.8 78.6 4.4 0.8 0.1 84.3 9.9 2.0 0.8 0.7 64.1 5.7


Transplant 351 48.7 77.5 3.7 1.7 0.0 90.0 10.0 1.4 0.9 0.6 71.2 3.1

Revascularization (CABG)

Hemodialysis 673 58.1 82.8 5.3 1.2 0.0 36.0 11.3 0.7 0.6 1.8 70.0 17.8


Transplant 69 50.7 91.3 7.2 2.9 0.0 44.9 18.8 1.4 0.0 1.4 71.0 15.9

4bii Cardiovascular disease & pharmacological interventions (row percent), by diagnosis and modality, 2008 (page 221)

Despite two negative statin trials in dialysis patients (4D and AURORA) there has been no apparent dampening in enthusiasm for the use of these agents. In 2008, statins were used in 57 percent of hemodialysis patients with AMI, and 64 and 70 percent of those undergoing PCI and CABG. Recent publication of results from the SHARP trial might be expected to further increase statin use across the spectrum of CKD.

Only 2–4 percent of patients with PAD receive cilostazol, an approved therapy; 17–24 percent receive clopidogrel, and 39–54 percent statin therapy. As noted in a recent KDIGO Controversies Conference Summary, PAD should be a special cardio-vascular target for further improvement in all stages of kidney disease. » Table 4.b ; see page 385 for analytical methods. January 1 point prevalent ESRD patients with a first cardiovas-cular diagnosis or procedure between January 1 & November 30, 2008.

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51ii Adjusted all-cause mortality rates, by modality & year of treatment (page 227)

56ii Adjusted all-cause mortality rates in the ESRD & general populations, by age & gender, 2009 (page 231)

Between 1993 and 2003 there was little improvement in first-year death rates in the ESRD population. Between 2004 and 2008, however, these rates fell more than 10 percent. And over similar intervals, second- to fifth-year death rates decreased 12–14 percent. Month-by-month mortality rates in the first year of hemodialysis have shown similar improvements, overall and for mortality due to cardiovascular disease and infection. Mor-tality due to other causes, in contrast, has increased since 1998, a finding which requires further investigation. Still striking are the high rates of all-cause mortality in the early months of therapy. » Figure 5.1; see page 386 for analytical methods. Incident ESRD patients. Adj: age/gender/race/primary diagnosis; ref: incident ESRD patients, 2005. Adjusted rates of mortality in the prevalent ESRD population

age 65 and older rise, not surprisingly, by age, are commonly greater in men than in women, and are 1.8–2.6 times greater for dialysis patients than for those with a transplant. In the trans-plant population, rates among patients age 65–79 are lower than rates of mortality among patients with cancer in the gen-eral Medicare population. » Figure 5.6; see page 386 for analytical methods. January 1 point prevalent ESRD & general Medicare patients age 65 & older. Adj: age/gender/race/comorbidity; ref: 2009 ESRD patients.

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précis » an introduction to esrd in the u.s.PRESCRIPTION DRUG COVERAGE

61ii Sources of prescription drug coverage in Medicare enrollees, 2008 (page 235)

615ii Per person per year Medicare & out-of-pocket costs for Part D enrollees, 2008 (page 240)

620ii Part D non-LIS enrollees who reach each coverage phase, 2008 (page 242)

Fifty-eight to 59 percent of elderly CKD and general Medicare patients were enrolled in Part D in 2008, compared to 72, 61, and 53 percent of hemodialysis, peritoneal dialysis, and kidney transplant patients. » Figure 6.1; see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, 2008.

At $5,536 and $6,183, the per person per year (PPPY) total cost of medications covered by Medicare Part D is 2.3–2.5 times higher, respectively, in dialysis and transplant patients than in the gen-eral Medicare population. Proportional to total Part D costs, however, out-of-pocket costs are lower in ESRD patients, representing 8–10 percent of PPPY costs, compared to 19 percent in the general Medicare population. » Figure 6.15; see page 387 for analytical methods. All patients enrolled in Part D.

In 2008, 42–48 percent of CKD, hemo-dialysis, peritoneal dialysis, and trans-plant patients reached the coverage gap, and 8–13 percent reached catastrophic coverage, compared to 23 and 3 percent, respectively, in the general Medicare population. » Figure 6.20; see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, excluding those in employer-sponsored & national PACE Part D plans.

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By frequency Total days By net costs Total days Total costs Generic name supply Generic name supply $Metoprolol 18,519,761 SevelamerH Cl 17,804,550 255,639,977 Sevelamer HCl 17,804,550 Cinacalcet 12,051,808 213,384,687 Insulin 15,630,838 Calciumacetate 13,198,502 49,785,847 Amlodipine 15,120,000 Insulin 15,630,838 49,270,601 Calciumacetate 13,198,502 Lanthanumcarbonate 3,001,874 48,825,125 Cinacalcet 12,051,808 Clopidogrel 8,855,704 33,549,441 Lisinopril 11,575,329 Atorvastatin 7,398,132 21,884,604 Clonidine 10,286,086 Esomeprazole 4,254,689 20,854,548 Simvastatin 10,151,596 Amino acids 8% 231,171 18,831,418 Levothyroxine 9,014,532 Pantoprazole 5,442,180 17,187,145 Clopidogrel 8,855,704 Sevelamercarbonate 992,319 14,049,386 Furosemide 7,905,050 Lansoprazole 2,723,129 13,609,627 Carvedilol 7,897,755 Nifedipine 6,461,228 11,887,174 Omeprazole 7,875,290 Pioglitazone 2,332,897 11,483,495 Atorvastatin 7,398,132 Clonidine 10,286,086 10,971,889 Warfarin 7,157,863 Valsartan 4,377,843 10,503,139 Nifedipine 6,461,228 Omeprazole 7,875,290 8,586,724 Hydrocodone/acetaminophen 6,367,414 Amlodipine 15,120,000 8,129,829 Gabapentin 5,950,037 Oxycodone 1,140,867 8,008,673 Pantoprazole 5,442,180 Metoprolol 18,519,761 7,879,893 Hydralazine 4,673,601 Doxercalciferol 724,126 7,467,454 Zolpidem 4,465,733 Thalidomide 42,735 7,191,397 Valsartan 4,377,843 Fluticasone/salmeterol 1,221,841 7,182,088 Esomeprazole 4,254,689 Quetiapinefumarate 1,017,911 5,872,095 Metoclopramide 4,132,211 Simvastatin 10,151,596 5,794,211

By frequency Total days By net costs Total days Total costs Generic name supply Generic name supply $Prednisone 6,830,943 Valganciclovir 842,247 34,925,147 Metoprolol 5,972,951 Tacrolimus 1,403,900 21,935,093 Insulin 5,554,451 Mycophenolate mofetil 1,321,958 20,350,510 Amlodipine 4,119,216 Insulin 5,554,451 20,175,462 Furosemide 3,856,362 Cinacalcet 694,297 11,235,709 Sulfamethoxazole/trimethoprim 3,843,886 Atorvastatin 3,229,589 8,846,123 Atorvastatin 3,229,589 Epoetin alfa 236,674 7,172,394 Simvastatin 2,545,228 Esomeprazole 1,336,219 6,531,041 Omeprazole 2,427,009 Sirolimus 281,839 5,650,531 Lisinopril 2,392,100 Lansoprazole 966,799 4,984,923 Clonidine 2,283,255 Cyclosporine 974,249 4,839,859 Nifedipine 1,937,098 Pantoprazole 1,469,335 4,703,303 Levothyroxine 1,864,654 Clopidogrel 1,107,259 3,982,579 Atenolol 1,749,685 Darbepoetin alfa 74,900 3,451,173 Pantoprazole 1,469,335 Nifedipine 1,937,098 3,127,638 Calcitriol 1,429,963 Mycophenolate sodium 216,435 2,869,074 Allopurinol 1,423,202 Pioglitazone 578,779 2,763,435 Tacrolimus 1,403,900 Omeprazole 2,427,009 2,460,936 Warfarin 1,340,296 Tamsulosin Hcl 943,147 2,347,391 Esomeprazole 1,336,219 Metoprolol 5,972,951 2,265,657 Famotidine 1,318,865 Oxycodone 314,366 2,213,325 Alendronate sodium 1,164,793 Clonidine 2,283,255 2,131,198 Potassium chloride 1,131,872 Amlodipine 4,119,216 2,104,311 Clopidogrel 1,107,259 Ezetimibe 814,814 1,955,440 Ranitidine 1,080,357 Losartan 987,860 1,736,504 Pr

P R É C I S

page159

6c ii Top 25 drugs used by Part D-enrolled dialysis patients, by frequency & net cost, 2008 (page 244)

6d ii Top 25 drugs used by Part D-enrolled transplant patients, by frequency & net cost, 2008 (page 245)

In 2008, cardiovascular and gastroin-testinal medications, phosphate binders, insulin, and cinacalcet were the predom-inant drugs used in the dialysis popula-tion. Metoprolol, a beta blocker, con-tinued to be the most frequently used drug, reflecting the extensive use of beta blockers for CHF and atrial fibrillation, and after myocardial infarction, PCI, and CABG. Sevelamer HCl was the predomi-nant phosphate binder, and, at $255 mil-lion, topped the list in terms of net Part D costs, with cinacalcet coming in at $213 million. Costs for calcium acetate, insu-lin therapies, and lanthanum carbonate costs were each close to $50 million.

Sevelamer carbonate represented 5.3 percent of sevelamer use in 2008. Together, costs for sevelamer hydro-chloride and carbonate reached $270 million — about 21 percent of the $1.26 billion in Part D costs in the dialysis population. » Table 6.c; see page 388 for ana-lytical methods. Part D claims for all dialysis patients, 2008.

Among transplant patients, prednisone (a generic immunosuppressant) was the most frequently used medication in 2008, followed by metoprolol and insu-lin. Trimethoprim-sulfamethoxazole, used for prophylaxis against pneumo-cystis carinii pneumonia, was sixth on the list. Except for tacrolimus, no trade name immunosuppressant made the top 25 list in terms of frequency, not surprising given that most are covered under Medicare Part B. Valganciclovir, which is used for prophylaxis against cytomegalovirus and does not have an available generic, topped the list by cost, though not by frequency. The immuno-suppressants tacrolimus, mycopheno-late mofetil, sirolimus, cyclosporine, and mycophenolate sodium do appear on the list by cost, implying that their costs are relatively higher than the frequency of their use. » Table 6.d; see page 388 for ana-lytical methods. Part D claims for all transplant patients, 2008.

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précis » an introduction to esrd in the u.s.TRANSPLANTATION

71ii Trends in transplantation: unadjusted rates, wait list, & total transplants, patients age 20 & older (page 249)

74ii Outcomes for wait-listed adult patients within three years of listing, by blood type (page 250)

In 2009, the most recent year of avail-able data, 17,736 kidney transplants were performed in the United States — 323 more than in the previous year, ending a two-year decline in the annual number of transplants performed. There were 420 more living donor transplants per-formed in 2009 compared with 2008, an increase of 7 percent, compared with a 1 percent decline in deceased donor transplants. The number of living-unre-lated transplants rose 11 percent, com-pared with a 3 percent increase in living-

related transplants. » Figure 7.1; see page 388 for analytical methods. Unadjusted incident & transplant rates: limited to ESRD patients age 20 & older, thus yielding a computed incident rate higher than the overall rate presented elsewhere in the ADR. Wait list counts: patients age 20 & older listed for a kidney or kidney-pancreas transplant on December 31 of each year. Wait time: patients age 20 & older entering wait list in the given year. Transplant counts: patients age 20 & older as known to the USRDS.

The percentage of adult patients receiving a deceased donor transplant within three years of listing has fallen considerably since 1991, and varies by blood type. It continues to be highest for those of blood type AB — at 50 percent for patients listed in 2006 — and lowest for those of type O or B. The percentage receiving a living donor transplant has been rising, and varies little by blood type. » Figure 7.4; see page 388 for analytical meth-ods. Pts age 18 & older listed for a first-time kidney or kidney-pancreas transplant.

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Female

91 95 99 03 07

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LymphoceleHypotension

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Septicemia Pneumonia

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712ii Deceased donor transplants, by age, gender, race, & primary diagnosis (page 252)

714ii Living donor transplants, by age, gender, race, & primary diagnosis (page 252)

722ii Primary diagnoses of cardiac & infectious hospitalizations in the first & second years post-transplant (page 254)

732ii Follow-up care & screening in the first 12 months post-transplant, by age (page 255)

Since 2000, the number of deceased donor transplants among patients age 65 and older has more than doubled, to 1,911, and there has been an increase of 47 percent among patients age 50–64. Among those age 18–34, in contrast, transplants have fallen 24 percent, to 1,166. Among African Americans and Asians, the number of transplants has grown 45 and 92 percent, respectively. » Figure 7.12; see page 388 for analytical methods. Pts age 18 & older. Includes kidney-alone & kidney-pancreas transplants.

Among patients younger than 50, the number of living donor transplants has fallen 3–7 percent since 2000. For those age 50–64, in contrast, the number is now 41 percent higher, and for patients age 65 and older it has more than dou-bled. While living donor transplants among whites and African Americans have increased just 9–10 percent in this period, they have tripled among Asians. » Figure 7.14; see page 388 for analytical methods. Patients age 18 & older. Includes kidney-alone & kidney-pancreas transplants.

In the first and second years after trans-plant, 22–23 percent of cardiovascular hospitalizations are due to CHF. Hospital-izations for coronary atherosclerosis and CVA/TIA rise from 6.2 and 5.0 percent in year one to 12 and 10 percent in year two. UTI, septicemia, and pneumonia are the most common diagnoses among transplant patients admitted for infection. » Figure 7.22; see page 389 for analytical methods. First-time, kidney-only tx recipients, age 18 & older, with Medicare primary payor coverage, transplanted in 2005–2009.

In 2008, 24 percent of recipients age 18–49 received an influenza vaccina-tion in the 12 months post-transplant, compared to 32 percent of those 60–64, and 45 percent of those age 65 and older. Lipid screening rates range from 84 percent in the youngest adults to 93 percent in those age 60–64. Since 2003, nearly all recipients have received a CBC test in the year after transplant. » Figure 7.32; see page 389 for analytical methods. Patients age 18 & older receiving a first-time, kidney-only transplant.

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précis » an introduction to esrd in the u.s.PEDIATRIC ESRD | ESRD PROVIDERS

81ii Incident & prevalent counts & adjusted rates in the pediatric ESRD population, by primary diagnosis (page 259)

83ii Hospital admissions for pneumonia, by modality, age, & race, 2006–2009 (page 262)

810ii Adjusted all-cause mortality in the first months of ESRD, by age & modality, 2001–2008 (page 265)

The overall incidence of ESRD in the pediatric population rose slowly between 1984 and 1990, a period when expertise in pediatric dialysis and transplantation was growing. Consistent with findings in the adult population, incidence due to glomerular disease has been declining gradually since 1990, and the number of patients has remained remarkably consistent. Both the incidence of ESRD

due to cystic kidney disease and the number of children with this diagno-sis, however, have been rising, a finding that merits investigation to determine whether the disease is truly increasing or if earlier recognition and treatment have led to more children coming to ESRD. » Figure 8.1; see page 390 for analytical methods. ESRD patients age 0–19. Adj: age/gender/race; ref: 2005 ESRD patients.

Overall rates of admission for pneu-monia are greatest in patients age 0–4, at 91 per 1,000 patient years at risk. By modality, pneumonia admissions for transplant patients age 0–4 reach 96, compared to 29 for those of the same age on hemodialysis, and 84 for those treated with peritoneal dialysis. » Figure 8.3; see page 390 for analytical methods. Period prev-alent ESRD patients age 0–19, 2006–2009; unadjusted.

In the first month of therapy, mortality in patients age 0–4 reaches 153 deaths per 1,000 patient years at risk, compared to 24 for ages 5–9, and 5.3 for ages 10–14. Overall, all-cause mortality in pediatric patients reaches 48 in the first month after initiation, peaks at 57 in the next two months, then falls to 28 in months 9–<12. » Figure 8.10; see page 390 for analytical methods. Incident pts age 0–19, 2001–2008 (8.10–12) & 2000–2004 (8.13). Adj: age/gender/race/primary diagnosis. Ref: incident ESRD pts age 0–19, 2004–2005.

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erosclerotic events when patients are treated with a com-

bination lipid lowering therapy (Lancet, June 2011). Eye

examinations are another important preventive care tool,

used to detect diabetic retinopathy. Fewer than one in four

prevalent dialysis patients with diabetes received an eye

exam in 2008–2009. Rates of vaccination, both for infl u-

enza and for pneumococcal pneumonia, have improved

over the years; patients dialyzing in units owned by DaVita

are the most likely to receive these vaccinations.

Medicare payments vary considerably across pro-

vider groups. Per person per year (PPPY) expenditures

for dialysis rose just 1.5 percent in 2009, to $17,851 overall,

but ranged from a low of $17,016 in hospital-based units

to a high of $18,717 in units owned by SDOs. PPPY costs

for ESAs totaled $6,175 overall, and were again lowest in

hospital-based facilities.

We conclude with an analysis of mortality and hospital-

ization ratios. Standardized hospitalization ratios (SHRs)

and standardized mortality ratios (SMRs) in 2009 are sim-

ilar across providers; SHRs, however, are slightly higher in

independent facilities, while hospital-based facilities tend

to have slightly higher SMRs. Among the large dialysis

organizations, DCI continues to have the lowest statistically

signifi cant SHRs and SMRs. SDOs in the East North Central,

Middle Atlantic, and New England census divisions have

statistically signifi cant higher SHRs. In hospital-based units,

statistically signifi cant higher SHRs and SMRs exist in the

East South Central, South Atlantic, and West South Central

divisions. The USRDS will continue to assess provider out-

comes over time to determine areas for improvement. » Figure 10.1; see page 391 for analytical methods. CMS Annual

Facility Survey, 2009.

101 ii Distribution of patients, by unit affi liation, 2009

Dial

ysis

Clin

ic, In

c. (1

3,02

3 / 2

13)

Fresenius(122,216 / 1,742)

Large dialysis organizations (245,538 patients / 3,511 units) SDOs (44,793 / 605)

Hospital-based (38,596 / 796)

Independent (58,090 / 848)

American Renal Assoc.Innovative Dialysis Systems

Liberty Dialysis

National Renal Institutes

Renal Research Institute

Satellite Healthcare

Renal Advantage

U.S. Renal Care

Dial. Corp. of America

DaVita(110,299 / 1,556)

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105ii Distribution of prevalent EPO-treated dialysis patients, by hemoglobin level & unit affiliation, 2009 (page 275)

104ii Dialysis unit distribution, by affiliation & time managed (time under chain management), 2009 (page 274)

101ii Distribution of patients, by unit affiliation, 2009 (page 273)

At the end of 2009, 122,216 prevalent patients were being treated by Fresenius in 1,742 units, 110,299 were receiving care in one of DaVita’s 1,556 units, and 13,023 patients were being treated by Dialysis Clinic Inc. (DCI), with 213 units. These three major providers manage the major-ity of the 5,760 dialysis units across the

United States. Small dialysis organiza-tions (SDOs), comprising 20–199 units, treated 44,793 patients in 605 units, while independent and hospital-based provid-ers treated 58,090 and 38,596 patients in 848 and 796 units, respectively. » Figure 10.1; see page 391 for analytical methods. CMS Annual Facility Survey, 2009.

In 2009, the proportion of EPO-treated prevalent dialysis patients with a hemoglobin of 10–<12 g/dl varied little by pro-vider, ranging from 72 to 79 percent, and reaching 78 percent overall. Twenty-five percent of DCI patients had a hemo-globin greater than 12 g/dl, compared to 18–19 percent of those receiving treatment in Fresenius or independent units. » Figure 10.5; see page 391 for analytical methods. Period prevalent dialysis patients, 2009.

The percentage of units remaining under consistent ownership for five or more years was nearly 60 in 2009. Major unit pur-chases by DaVita and Fresenius in 2005 and 2006 reduced the proportions of their units with five or more years of ownership to 51 and 60 percent, down from approximately 70 percent in 2004 (2010 Annual Data Report). The most consistent owner-ship remains that of Dialysis Clinic, Inc., with nearly 90 percent of units in 2009 owned for five years or longer. » Figure 10.4; see page 391 for analytical methods. CMS Annual Facility Survey, 1988–2009.

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précis » an introduction to esrd in the u.s.ESRD PROVIDERS | COSTS OF ESRD

1018ii All-cause standardized hospitalization & mortality ratios, by unit affiliation, 2009 (page 278)

1019ii All-cause standardized hospitalization & mortality ratios in large dialysis organizations, 2009 (page 278)

For 2009, standardized hospitalization ratios (SHRs) are almost equal in small and large dialysis organizations (SDOs and LDOs), as are standardized mortal-ity ratios (SMRs). Independent facilities have the highest SHR, and hospital-based facilities the highest SMR. By unit affilia-tion among the LDOs, DCI continues to have the lowest ratios for both hospital-ization and mortality. » Figures 10.18–19; see page 391 for analytical methods. January 1 point prevalent hemodialysis patients, 2009, with Medicare as primary payor (SHRs); Janu-ary 1 point prevalent hemodialysis patients, 2009 (SMRS). SHRS & SMRS are calculated based on national hospitalization & death rates. Adj: age/ gender/race/dialysis vintage.

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116ii Total Medicare ESRD expenditures, by modality (page 284)

119ii Total Medicare spending for injectables (page 284)

1119ii Total PPPY outpatient expenditures, by dialysis modality & race, 2009 (page 287)

117ii Total Medicare ESRD expenditures per person per year, by modality (page 284)

After rising 11 percent between 2007 and 2008, total Medicare expenditures for hemodialysis and transplant rose only 0.2 and 0.4 percent in 2009, to $20.8 and $2.4 billion, while costs for peritoneal dialysis fell 3.3 percent, to $1.1 billion. Per person per year costs fell less than 1 percent across modalities, to $82,285 for hemodialysis, $61,588 for peritoneal dialysis, and $29,983 for transplant. » Figures 11.3–7; see page 392 for analytical methods. Period prevalent ESRD patients; patients with Medicare as secondary payor are excluded.

Of the $2.78 billion spent in 2009 on injectables for dialysis patients, ESAs accounted for 68 percent, or $1.89 bil-lion. The proportions of total costs for IV vitamin D, IV iron, and other inject-ables were 18.3, 10.3 and 3.6 percent, or $509 million, $286 million, and $99 mil-lion, respectively. » Figure 11.9; see page 392 for analytical methods. Period prevalent dialy-sis patients.

In 2009, per person per year (PPPY) outpatient dialysis expen-ditures were 5.5 percent higher in African Americans than in whites, at $32,030 and 30,365, respectively. When comparing costs by modality in unmatched dialysis populations, those for hemodialysis were 26 percent higher than those for peritoneal dialysis. This difference was sustained among hemodialysis patients matched to peritoneal patients, at 25 percent for whites and 29 percent for African Americans. » Figure 11.19; see page 392 for analytical methods. Period prevalent dialysis patients, 2009.

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précis » an introduction to esrd in the u.s.COSTS OF ESRD

11aii Top 25 Part D prescription drugs used in the ESRD population, by frequency & net cost, 2008 (page 288)

2008By frequency Total days By net cost Total daysGeneric name supply Generic name supply Total cost ($)

Metoprolol 25,663,315 Sevelamer HCl 18,166,544 259,937,292 Insulin 22,046,311 Cinacalcet HCl 12,917,238 227,739,180Amlodipine besylate 20,111,872 Insulin 22,046,311 72,401,078 Sevelamer HCl 18,166,544 Calcium acetate 13,555,312 50,883,011 Lisinopril 14,610,979 Lanthanum carbonate 3,051,539 49,570,220 Calcium acetate 13,555,312 Clopidogrel bisulfate 10,440,202 39,218,355 Simvastatin 13,364,770 Valganciclovir HCl 873,053 35,882,030 Clonidine HCl 12,998,841 Atorvastatin calcium 11,130,735 32,110,987 Furosemide 12,974,752 Esomeprazol 5,813,896 28,444,470 Cinacalcet HCl 12,917,238 Tacrolimus 1,565,003 24,380,444 Levothyroxine sodium 11,608,757 Mycophenolate mofetil 1,527,613 23,518,229 Atorvastatin calcium 11,130,735 Pantoprazole sodium 7,215,758 22,786,850 Omeprazole 10,798,684 Lansoprazole 3,851,157 19,372,437 Clopidogrel bisulfate 10,440,202 Amino acids 8% 236,310 19,220,832 Carvedilol 9,285,287 Nifedipine 8,652,391 15,412,684 Prednisone 9,245,683 Pioglitazone HCl 3,026,120 14,762,220 Warfarin sodium 9,043,691 Sevelamer carbonate 1,013,798 14,325,838 Nifedipine 8,652,391 Clonidine HCl 12,998,841 13,502,872 Hydrocodone /acetaminophen 7,783,768 Valsartan 5,404,893 12,619,827 Gabapentin 7,328,747 Epoetin alfa 399,146 12,129,765 Pantoprazole sodium 7,215,758 Omeprazole 10,798,684 11,535,907 Isosorbide mononitrate 6,156,904 Oxycodone HCl 1,568,344 11,069,757 Atenolol 5,878,508 Amlodipine besylate 20,111,872 10,636,509 Esomeprazole 5,813,896 Metoprolol 25,663,315 10,578,992 Allopurinol 5,737,338 Doxercalciferol 917,007 8,926,997

1121ii PPPY expenditures for ESAs, by dialysis modality & race, 2009 (page 287)

1122ii PPPY expenditures for IV vitamin D, by dialysis modality & race, 2009 (page 287)

1123ii PPPY expenditures for IV iron, by dialysis modality & race, 2009 (page 287)

This table displays the top 25 Part D prescriptions used in ESRD patients by frequency, as measured in total days supply, and by net cost, a reflection of both frequency of use and cost. In 2008, cardiovascular and gastrointestinal medications, phosphate binders, insu-lin products, levothyroxine, cinacalcet, prednisone, and pain medications were the predominant drugs used in the ESRD population. Metoprolol, a beta blocker, continues to be the most frequently used drug, reflecting the extensive use of beta blockers for congestive heart failure and atrial fibrillation, and after myocardial infarction, percutaneous coronary intervention, and coronary artery bypass graft. Sevelamer HCl is the predominant phosphate binder, and, at $260 million, topped the list in terms of net Part D costs, with cinacalcet coming in at $228 million. Costs for calcium ace-tate, and lanthanum carbonate each near $50 million. » Table 11.a; see page 392 for ana-lytical methods. Period prevalent ESRD patients enrolled in Part D, 2008.

Per person per year (PPPY)costs for erythropoiesis stimulating agents (ESAs) are higher for hemodialysis patients than for those on peritoneal dialy-sis, and greater in African Americans than in whites. In unmatched popu-lations, costs for hemodialysis com-pared to peritoneal dialysis are 75 and 44 percent greater in whites and African Americans, respectively; costs for the matched hemodialysis patients are 74 and 50 percent higher.

PPPY expenditures for IV vitamin D are 74 percent greater for African Ameri-cans than for whites.

IV iron costs in matched hemodialy-sis patients are 5.0–5.6 times higher than those for peritoneal dialysis patients. Costs for IV antibiotics in 2009 were highest in patients on peritoneal dialysis, at $14.48 and $18.16 among whites and African Americans, respectively. » Figures 11.20–23; see page 392 for analytical methods. Period prevalent dialysis patients, 2009.

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an introduction to end-stage renal disease united states

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