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Kidney Failure and the Federal Government (1991)

Chapter: The Patient Population

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Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

4
The Patient Population

The congressional charge for the study of the Medicare ESRD program included the study of major epidemiologic and demographic changes in the ESRD patient population that may affect access to treatment, quality of care, or the resource requirements of the program. Chapters 4 and 5 address this charge.

This chapter presents data on trends in ESRD incidence, prevalence, and mortality in terms of age, gender, race, and primary diagnosis of the cause of renal failure (as reported by the patient's physician). These data include only treated ESRD patients, not all those reaching permanent renal failure; the difference between "treated" and "total" is not known. Mortality data are presented for this population and for various patient subgroups. The chapter also includes projections of incidence and prevalence of treated ESRD patients to the year 2000. Chapter 5 deals with the special needs and problems of pediatric, elderly, diabetic, hypertensive, and minority ESRD patients.

The data presented in these chapters are drawn primarily from the HCFA Program Management Medical Information System (PMMIS) files and the United States Renal Data System (USRDS) 1990 Annual Data Report. PMMIS and USRDS are described in detail in Chapter 13. In this report, patients are included in the data base from the time of diagnosis of ESRD rather than from the beginning of Medicare entitlement. This is consistent with the USRDS reports but differs from most HCFA reports. For incidence and prevalence, for example, HCFA usually counts patients only during their Medicare entitlement. For survival analyses, however, both HCFA and USRDS usually include patients from the time of diagnosis of ESRD.

Incidence is defined as new ESRD patients entering treatment during a given year. Incidence data are useful when considering issues of access,

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

patterns of referral to treatment, and disease prevention. Prevalence is defined as the total number of ESRD patients present in the population at a specific time; period prevalence refers to an interval, usually a year; point prevalence refers to the population on a given date, usually December 31. Prevalence data are useful for evaluating the health effects of the disease on society, estimating the costs of providing health care services, and determining what resources and manpower are necessary to provide these services.

INCIDENCE AND PREVALENCE

The incidence and prevalence of Medicare ESRD patients have increased dramatically from the start of the Medicare ESRD program (Table 1-1), and this pattern is projected to continue through the 1990s (Table 1-3). The highest rates of increase are among the aged (Figure 4-1) and diabetic (Figure 4-2) populations.

In 1967, the Report of the Committee on Chronic Kidney Disease estimated that a maximum of 700 to 1,000 patients started hemodialysis between March 1960 and March 1967. The age distributions of 247 patients in Public Health Service (PHS)-funded units who started dialysis during this period and of 231 Veterans Administration (VA) patients who began treatment during 1963–67 are shown in Table 4-1. Nearly three-quarters of the PHS patients and over 90 percent of the VA patients were 25–54 years old. Virtually no patients were under 15 or over 65 years of age.

By the early 1970s, the numbers of new patients had reached several thousand per year, the vast majority of whom were still between 25 and 55 years old. Although the rate of increase was dramatic—over 10-fold during this period—the absolute number of new patients was modest.

The Committee on Chronic Kidney Disease (1967) estimated the number of patients with renal failure who would be considered appropriate candidates for renal replacement therapy for the period from 1968 to 1977, based on the then-current criteria for acceptance into renal replacement treatment. Most eligible patients were in the 15-to 54-year age range. The projected population was expected to increase sharply during the early 1970s and then become relatively stable. The report estimated that the most probable level of new patients in 1977 would be about 8,400 and the total dialysis population about 40,000.

It was predicted, however, that as therapy became more readily available, acceptance criteria would be liberalized. In addition, the prevention of early death from diabetes and other diseases would probably lead to increased numbers of renal failure patients. After adjustment for age changes, a 5 percent increase in incident cases of chronic uremia was predicted for the end of the 1970s. The upper, lower, and most likely estimates are shown in Table 4-2.

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

FIGURE 4-1

Number of ESRD Patients by Age Group, 1978–88

NOTE: As of December 31.

SOURCE: USRDS, 1990.

FIGURE 4-2

Number of ESRD Patients by Primary Diagnosis, 1978–88

NOTE: As of December 31. SOURCE: USRDS, 1990.

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

TABLE 4-1 Age of New Dialysis Patients, 1960–67

 

Public Health Service

Veterans Administration

Age Group (years)

Number

%

Number

%

Under 15

3

1.2

0

0.0

15–24

42

17.0

8

3.5

25–34

69

27.9

54

23.4

35–44

61

24.7

99

42.8

45–54

52

21.1

62

26.8

55–64

18

7.3

8

3.5

Over 65

2

0.8

0

0.0

TOTAL

247

100.0

231

100.0

NOTE: These data represent an estimated one-half to two-thirds of all new ESRD patients who were treated during 1960–67.

SOURCE: Committee on Chronic Kidney Disease, 1967, pp. 49 and 51.

What actually happened? After the introduction of the Medicare ESRD program in 1973, the number of newly treated patients increased dramatically. The age distribution of new patients began to shift upward; the proportion of new ESRD patients with chronic diseases such as diabetes mellitus and hypertensive vascular disease also began shifting upward. Before 1973, patients were disproportionately white, middle-class men with high educational status. After 1973, the proportion of women and racial minorities increased, and the distribution of patients tended to follow more closely the demographic features of the American population (Evans et al., 1981). The actual number of new Medicare ESRD patients in 1977 (USRDS, 1990) was 15,832 (estimated to be 90 to 93 percent of the total), or almost twice that projected by the Committee on Chronic Kidney Disease (1967).

COMPOSITION OF THE ESRD POPULATION

Not only has the size of the incident population increased over time, but the characteristics of the population also have changed. As mentioned above, the number and proportion of ESRD patients who are elderly have increased dramatically. Between 1978 and 1988, new Medicare ESRD patients over age 65 increased from 3,637 to 13,866 (USRDS, 1990), or from 24 percent to 38 percent of all new patients. In this same period, new patients over age 75 increased from 799 to 5,061, or from 5.4 percent to 14.0 percent of the total; those over age 85 increased from 54 to 531, or from 0.3 percent to 1.5 percent of the total. Table 4-3 shows these trends.

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

TABLE 4-2 1967 Projections of New End-Stage Renal Disease (ESRD) Patients, 1968–77

Year

Lower Limit

Most Probable

Upper Limit

1968

5,978

6,958

8,152

1969

6,104

7,105

8,324

1970

6,233

7,255

8,499

1971

6,364

7,408

8,678

1972

6,498

7,564

8,861

1973

6,635

7,723

9,048

1974

6,775

7,886

9,239

1975

6,918

8,052

9,434

1976

7,065

8,222

9,633

1977

7,214

8,395

9,836

 

SOURCE: Committee on Chronic Kidney Disease, 1967, pp. 125–127.

More liberal acceptance criteria and possibly decreased death rates from nonrenal complications have led to a notable increase in the diabetic and hypertensive ESRD population. Between 19821 and 1988, the reported number of new Medicare ESRD patients with diabetes as the primary cause of renal failure increased from 5,019 to 11,034 per year (USRDS, 1990), an increase from 23 percent to 31 percent of all new patients.

The incidence of black patients increased at a greater rate than that of whites; between 1978 and 1988, incidence increased an average of 10 percent per year for blacks compared to 8 percent per year for whites. The incidence of Native Americans and Asians/Pacific Islanders increased more rapidly, with average yearly increases of 19 percent and 25 percent, respectively, between 1981 and 1988. Before 1981, reporting for the racial groups Native Americans and Asians was highly incomplete.

More men than women are patients, and the proportions have remained fairly stable between 1978 and 1988.

Incidence rates, defined as the number of newly treated ESRD patients per million population, after adjustment for age, show differences between blacks and whites and between men and women that cannot be seen in the unadjusted data (Table 4-4). In all age groups, except 0–5 years, blacks have higher rates of treated ESRD than do whites. Starting in the teenage years, rates among blacks increase rapidly with age. By age 40, the incidence of ESRD among blacks of both sexes is up to four times greater than that of whites.

For both races, men have higher rates than women, with the exception that among blacks aged 55–84 years, rates of men and women are similar. Among whites of all ages, incidence rates for males are higher than those

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

TABLE 4-3 New End-Stage Renal Disease (ESRD) Patients by Age, Gender, Race, and Primary Diagnosis, 1978–89

 

Year

 

 

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988a

1989a

AGE GROUP (years)

 

0–4

37

39

60

77

101

99

110

120

116

122

115

112

5–14

288

279

307

262

314

281

317

296

309

305

285

273

15–24

1,101

1,112

1,080

1,108

1,164

1,103

1,159

1,186

1,181

1,231

1,254

1,267

25–34

1,763

1,851

2,086

2,178

2,460

2,466

2,624

2,707

2,975

2,837

3,052

3,286

35–44

2,038

2,080

2,240

2,368

2,601

2,838

3,017

3,382

3,647

3,959

4,287

4,615

45–54

2,842

3,116

3,172

3,241

3,546

3,755

3,877

4,222

4,422

4,834

5,318

5,758

55–64

3,464

3,951

4,378

4,737

5,292

5,773

6,283

6,902

7,099

7,733

8,227

8,671

65–74

2,850

2,267

3,785

4,006

4,631

6,067

6,190

7,078

7,703

8,606

9,028

10,272

75–84

748

1,074

1,239

1,310

1,644

2,519

2,696

3,166

3,695

4,167

4,624

5,520

85 & up

56

83

100

101

170

250

275

347

407

474

543

702

GENDER

 

Male

8,522

9,462

10,332

10,779

12,139

13,863

14,719

16,047

17,356

18,634

19,998

22,063

Female

6,669

7,494

8,120

8,612

9,788

11,292

11,833

13,372

14,205

15,639

16,745

18,434

RACE

 

Native American

37

40

70

131

196

260

265

271

335

345

450

486

Asian

31

41

59

133

312

306

384

507

508

556

644

683

Black

3,920

4,591

4,862

5,064

5,976

7,074

7,491

8,284

8,728

9,666

10,412

11,425

White

10,431

11,417

12,528

13,295

15,260

17,132

18,200

20,098

21,577

23,194

24,588

26,981

Other/unknown

772

867

933

768

183

273

212

259

413

512

649

922

PRIMARY DIAGNOSIS

 

Diabetes

1,430

1,635

2,258

3,649

5,050

5,913

7,112

8,192

9,290

10,234

11,247

12,610

Glomeruloneph.

1,918

2,116

2,244

3,500

5,118

5,480

5,775

6,181

6,263

6,500

6,560

6,577

Hypertension

1,845

2,042

2,528

3,965

5,404

5,791

6,459

7,362

7,772

8,829

9,725

10,801

Missing

6,931

7,802

7,802

3,729

1,691

2,897

1,852

1,894

2,239

2,315

2,806

4,271

Other

1,737

1,918

2,125

2,881

3,229

3,642

3,853

4,615

4,393

4,564

4,652

4,764

Unknown

1,330

1,443

1,495

1,667

1,460

1,432

1,501

577

1,604

1,831

1,753

1,474

TOTAL

15,191

16,956

18,452

19,391

21,927

25,155

26,552

29,419

31,561

34,273

36,743

40,497

a Data incomplete for this year. SOURCE: HCFA, 1990b.

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

TABLE 4-4 New End-Stage Renal Disease (ESRD) Patients per Million Population by Age, Gender, and Race, 1987

 

Men

Women

Age Group (years)

Blacks

Whites

Blacks

Whites

Under 5

6 (1+)

6 (1+)

4 (1+)

3 (1+)

5–14

16 (1.9)

10 (1)

9 (1.2)

7 (0.8)

15–24

71 (1.6)

28 (1.2)

55 (1.5)

23 (1.2)

25–34

196 (1.2)

60 (1.2)

105 (1.2)

42 (1.1)

35–44

527 (1.5)

100 (1.3)

232 (1.4)

65 (1.3)

45–54

843 (1.6)

164 (1.4)

564 (1.5)

119 (1.5)

55–64

1,059 (1.6)

304 (1.8)

1,131 (1.8)

214 (1.8)

65–74

1,253 (2.0)

487 (1.9)

1,396 (2.2)

317 (2.2)

75–84

1,138 (3.1)

575 (2.6)

1,133 (3.3)

267 (3.0)

85 and up

696 (5.4)

(3.2)

414 (4.4)

85 (4.2)

TOTAL

335 (1.7)

130 (1.7)

308 (1.9)

94 (1.8)

NOTE: The ratio of the 1987 rate to the 1980 rate is shown in parentheses.

SOURCE: HCFA, 1990a.

for females: after age 75, the incidence among white men is more than twice that of white women between ages 75 and 85, and four times greater after age 85.

The incidence of the underlying cause of ESRD also differs substantially among the principal gender-race subgroups (Table 4-5).2 Among white men, ESRD rates attributed to diabetes mellitus and hypertension are quite similar, with these two diagnoses accounting for the majority of patients. Diabetes mellitus is the most frequently reported underlying cause of ESRD among white women, with incidence rates nearly as high as among white men. Hypertension and glomerulonephritis contribute about 60 percent and 40 percent as many patients, respectively, as diabetes.

For each diagnosis, incidence rates are higher among blacks than among whites. Hypertension accounts for nearly half of all ESRD cases among black men, and the rate of hypertensive ESRD is more than five times higher among black than white men. Compared to white men, black men have over twice the incidence of ESRD due to diabetes and glomerulonephritis, respectively. Compared to white women, black women have incidence rates seven, four, and three times higher for ESRD attributed to hypertension, diabetes, and glomerulonephritis. Among the races, Native Americans have the highest rates of ESRD attributed to diabetes and glomerulonephritis; nearly two-thirds of ESRD among Native Americans is attributed to diabetes. Clearly, the rates and causes of ESRD differ substantially between the races, and the burden of ESRD falls more heavily on blacks and Native Americans than on whites.

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

TABLE 4-5 New End-Stage Renal Disease (ESRD) Patients per Million Population by Primary Diagnosis, Gender, and Race, 1988

 

Men

Women

Primary Diagnosis

Blacks

Whites

Blacks

Whites

Diabetes

109

37

131

32

Hypertension

187

35

123

18

Glomerulonephritis

52

22

32

12

Other

35

23

30

17

Unknown

71

19

43

11

NOTE: Age adjusted.

SOURCE: USRDS, 1990.

The distribution of prevalent treated ESRD patients generally resembles that of incident patients (Table 4-6). However, because of considerably higher mortality rates among elderly and diabetic ESRD patients compared to other age and diagnostic groups, both represent a considerably smaller proportion of the prevalent compared to the incident population. For example, in 1988 the incidence rate of diabetic ESRD was over twice that of glomerulonephritic ESRD, but the prevalence was very similar. Similarly, in 1988, those over age 65 accounted for 38 percent of the incident population but only 26 percent of the December 31 prevalent population.

MORTALITY ISSUES

The mortality experience of the ESRD program, as a matter of clinical, epidemiologic, and policy concern, raises three basic issues: First, has ESRD mortality changed over time? Second, what factors are causally related to observed patterns of mortality? Third, what are the clinical and policy implications of the first two issues. This section addresses mainly the first and second issues; Chapter 10 deals with the third issue.

HCFA is the primary source of mortality data in the ESRD program. The annual HCFA research report on ESRD presents patient survival data that are generally grouped by age, gender, race, and primary disease. The methods of analysis of these data have changed over time, reflecting a continuing search for improved ways to analyze and present the data (HCFA, 1986, 19879, 1988, 1989). The USRDS, in its first two annual data reports, published extensive summaries of HCFA ESRD data (USRDS, 1989, 1990). The second report made several methodological changes to improve its reporting of the data. Other analyses of ESRD mortality have been published, including analysis of gross mortality (Hull and Parker, 1990) and regional and local analyses (Acchiardo et al., 1983; Blagg et al., 1983; Collins et al.,

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

TABLE 4-6 Prevalent End-Stage Renal Disease (ESRD) Patients by Age, Gender, Race, and Primary Diagnosis, 1978–89

 

Year

 

 

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988a

1989a

AGE GROUP (Years)

 

0–4

57

68

87

130

175

214

241

274

284

301

309

301

5–14

736

817

913

951

1,079

1,167

1,254

1,303

1,391

1,484

1,551

1,624

15–24

3,937

4,349

4,722

5,095

5,157

5,686

5,922

6,067

6,308

6,460

6,591

6,704

25–34

6,990

8,231

9,627

10,890

12,193

13,382

14,569

15,730

16,959

17,832

18,757

19,752

35–44

7,906

9,029

10,196

11,501

13,136

15,002

16,886

18,986

21,248

23,417

25,731

28,394

45–54

10,105

11,510

12,715

13,953

15,311

16,605

18,157

19,730

21,275

23,331

25,802

28,404

55–64

10,935

12,940

14,937

16,883

19,018

21,063

26,061

24,964

26,547

28,739

30,715

32,903

65–74

7,147

8,937

10,565

12,075

13,986

16,617

18,594

20,616

22,888

25,230

27,226

30,009

75–84

1,567

2,232

2,836

3,441

4,221

5,613

6,682

7,827

9,065

10,427

11,622

13,334

85 & up

86

140

204

261

367

499

602

759

884

1,128

1,327

1,592

GENDER

 

Male

27,732

32,477

37,199

41,672

46,983

52,891

58,533

64,038

69,658

75,688

81,700

88,941

Female

21,734

25,776

29,603

33,508

37,960

42,957

47,435

52,319

57,191

62,661

67,931

74,076

RACE

 

Native American

102

137

201

320

482

686

856

985

1,144

1,291

1,507

1,729

Asian

102

143

202

333

598

848

1,102

1,424

1,708

2,013

2,353

2,717

Black

12,979

15,616

18,021

20,419

23,480

27,061

30,350

33,683

36,784

40,356

43,972

47,918

White

33,956

39,562

45,176

50,718

57,319

64,303

70,879

77,572

84,456

91,765

98,574

106,858

Other/unknown

2,327

2,795

3,202

3,390

3,064

2,950

2,781

2,693

2,757

2,924

3,225

3,795

PRIMARY DIAGNOSIS

 

Diabetes

3,113

3,861

2,258

7,120

9,938

12,743

16,073

19,457

22,969

26,567

30,265

34,611

Glomeruloneph.

8,670

9,991

2,244

13,844

17,454

20,946

24,297

27,609

30,479

33,151

35,538

37,746

Hypertension

5,229

6,424

2,528

10,242

13,431

16,373

19,189

22,099

24,883

27,827

30,679

33,854

Other/unknown

32,454

37,977

7,802

43,974

44,120

45,786

46,409

47,192

48,518

50,804

53,149

56,806

TOTAL

49,466

58,253

66,802

75,180

84,943

95,848

105,968

116,357

126,849

138,349

149,631

163,017

a Data incomplete for this year. SOURCE: HCFA, 1990b.

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

1990; Degoulet et al., 1982; Lowrie and Lew, 1990; Parker et al., 1983; Shapiro and Umen, 1983; Wolfe et al., 1990).

Various factors complicate the discussion of mortality trends. First, data accuracy and completeness have varied over time. However, HCFA has steadily improved its data collection procedures, and current data are more reliable than those available in the 1970s and early 1980s. These problems limit the ability to compare the mortality experience between time periods.

Second, differences in methodology among analysts and over time for a given analyst make the interpretation of mortality complex. In particular, no standard convention or protocol is used for calculating ESRD mortality rates. For example, such calculations may or may not adjust for differences in the composition of the patient population, such as age or race, even though adjustment provides a more appropriate basis for comparing rates between different populations. In addition, populations may be variously described as all patients present at a point in time (point-prevalent population), in a time period (period-prevalent population), or new patients during a time interval (incident cohort). Mortality rates also differ as a function of the method of calculating mortality. Consequently, the study commissioned a paper by Robert A. Wolfe (see Appendix D of this report) to clarify methodological issues and recommends the formation of a technical working group (Chapter 14) related to ESRD patient mortality.

Third, it is necessary to differentiate between mortality rates for an entire patient population (unadjusted as well as adjusted mortality) and the risk of death attributable to various patient or treatment characteristics such as age, gender, race, diagnosis leading to ESRD, treatment modality, or treatment year. The former may be increasing at the same time that the latter is stable or decreasing.

Fourth, three current hypotheses of major factors causing changes in mortality rates in the ESRD patient population are patient characteristics (e.g., increasing age and complexity), treatment characteristics (e.g., inadequate dialysis), and eroding quality of care resulting from reimbursement reductions. Although it is difficult to distinguish among these factors in most analyses, the practical importance of the conclusions about the causes of mortality varies greatly between providers and the government. This tends to infuse the technical discussions with subjective considerations.

The Medicare ESRD program mortality experience can be summarized as follows:

  • The unadjusted mortality (or gross mortality) rate, defined as the rate of death in all patients treated for ESRD during a year, has been increasing over time.

  • Unadjusted mortality rates in incident cohorts, however, were stable during 1978–82, jumped upward from the 1982 to the 1983 incident cohort, and have remained fairly stable since then.

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×
  • Mortality for the 1978–88 incident and prevalent cohorts, when adjusted for age, gender, race, and primary diagnosis, has been quite stable.3

  • Analyses of subgroups of the ESRD patient population show the mortality of some groups decreasing (i.e., survival improving), some stable, and some increasing.

  • International data show that the United States has higher gross mortality and adjusted mortality rates than some European countries, although these data must be interpreted cautiously because cross-national comparisons have substantial limitations.

Unadjusted Mortality

This section presents data for annual incident and prevalent cohorts of ESRD patients and discusses the effect of increasing incidence on temporal trends of unadjusted mortality. The following section deals with mortality adjusted for various patient characteristics. The purpose of the discussion is to clarify various published analyses of temporal changes in mortality within the program.

In the literature, ESRD patients have been categorized in several ways for mortality analysis. These include the mortality of all patients treated during a given year, often referred to as gross mortality (Hull and Parker, 1990),4 the mortality of incident patient cohorts (HCFA, 1986, 1988, 1989; USRDS, 1989, 1990), and the mortality of those patients who have survived at least one year of ESRD treatment (HCFA, 1987). Each method provides a different result for the Medicare ESRD program mortality experience. The importance of these differences will be explored.

Unadjusted annual mortality of the prevalent ESRD population, also referred to as gross mortality, may be defined as the rate of death among all ESRD patients treated during a year. It has been increasing over time as shown in Table 4-7 for the period 1978–88.5 This trend is in the same direction, although not as large, as that shown by Hull and Parker (1990) for all dialysis patients (Medicare plus non-Medicare).

Various patient characteristics contribute to higher unadjusted or gross mortality, including increasing age of the patient population and more severe illness (e.g., diabetes and other comorbid conditions). The age effect is clear: As with mortality in general, the mortality of ESRD patients increases with age. Increased severity of illness also contributes directly to mortality risk. The increase in many comorbid conditions, although not well documented, has been reported in several studies (Collins et al., 1990; Kjellstrand et al., 1990).

Trends in unadjusted mortality of annual incident patient cohorts are shown in Table 4-7. Mortality of incident patient cohorts is commonly reported in the literature (Disney, 1990; Eggers, 1990; HCFA, 1986, 1988,

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

TABLE 4-7 Gross and Unadjusted One-Year Mortality for All End-Stage Renal Disease (ESRD) Patients, 1978–88

Year

Gross Mortalitya (%)

Prevalent Cohort Unadjusted Mortalityb (%)

Incident Cohort Unadjusted Mortalityc (%)

1978

14.0

11.8

18.8

1979

13.7

11.8

19.1

1980

14.2

12.2

18.8

1981

14.0

12.5

18.6

1982

13.8

12.1

18.8

1983

14.2

12.1

21.3

1984

14.7

12.1

21.2

1985

15.3

13.0

21.6

1986

15.5

13.3

21.6

1987

15.4

13.2

22.5

1988

15.8

13.4

21.7

a Calculated for all patients treated during reference year, life-table method with censoring at end of year (HCFA, 1990a).

b One-year mortality during reference year for prevalent patients who had survived at least one year before start of the index year, life-table method (HCFA, 1990a.)

c One-year mortality after first 90 days of ESRD for all patients by year of incidence, Kaplan-Meier method (USRDS, 1990).

SOURCES: HCFA, 1990a; USRDS, 1990.

1989a; USRDS, 1989, 1990). Unadjusted mortality analyses indicate three things: First, in the period from 1978 through 1982, mortality was stable; second, an abrupt increase in recorded mortality occurred during the 1982–83 period; and third, mortality has remained fairly stable since 1983 (Table 4-7).

The abrupt upward shift in unadjusted incident cohort mortality reported from 1982 to 1983 (Eggers, 1990; USRDS, 1989, 1990) represents a puzzle to analysts of ESRD mortality data that is unlikely to be fully resolved. The increase is partly due to a sharp increase during 1983 in reported new patients in two high-risk groups—the elderly and the Medicare disabled (those who had qualified for disability before kidney failure). It also appears to reflect an artifact of the data reporting system. Evidence supporting this view includes recent analyses by Eggers (P.W. Eggers, HCFA, unpublished data, 1990) showing that a large number of cases, most of whom were elderly, were reported to HCFA on July 1, 1983, and that more incident ESRD cases were recorded in the HCFA PMMIS data set for 1983 than reported by the facilities, a virtual impossibility.

In addition to mortality for the total population, most of these unadjusted incident patient cohort analyses usually present data grouped by patient

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

characteristics such as age, gender, race, and/or primary diagnosis. Mortality for the subgroups usually differs from the total unadjusted mortality.

It is also clear that mortality of new ESRD patients is considerably higher than mortality of those continuing treatment (e.g., those who have already survived for at least one year on treatment) or of the total patient population (gross mortality) (Table 4-7). For example, unadjusted incident cohort mortality for 1988 was 21.7 percent (USRDS, 1990), whereas it was 13.4 percent for one-year survivors. Mortality rates are generally highest during the period immediately after initiation of ESRD treatment, largely because of earlier death of more vulnerable patients.

Adjusted Mortality

Although mortality rates of a patient population may change over time, the risk of death for particular groups of patients does not necessarily follow the same trend. Gross mortality for ESRD patients has increased over time, largely because of an increased proportion of higher risk patients, but there is no a priori reason to believe that the risk of death, for example, of a white male patient, age 45, with no major comorbid conditions, increased between 1978 and 1988.

In order to assess whether the risk of death has changed over time, mortality data must be adjusted for changes in the patient population. For ESRD patients, mortality risk differs by age, race, gender, primary diagnosis, time since diagnosis of renal failure, and comorbid conditions: Various statistical methods, including a Cox proportional hazards model, Poisson regression, and subgroup analysis, can be used to adjust or control for these variables so that populations with different distribution of these variables can be more appropriately compared. HCFA data permit adjustment for age, gender, race, primary diagnosis, and time-related covariates such as year of treatment and time since renal failure. They do not permit adjustment for comorbid conditions and severity of illness, although these factors have important effects on mortality.

ESRD mortality rates for annual incident patient cohorts, when adjusted for age, race, gender, and primary diagnosis, were stable during the 1980s (Eggers, 1990; USRDS, 1990) as shown in Table 4-8. Mortality for prevalent (all) ESRD patients, adjusted for age, was stable or improving.

Subgroup Mortality

Mortality data grouped by patient characteristics generally indicate the following patterns (Table 4-9). Mortality increases with age, males have slightly higher mortality than females, and whites have higher mortality than blacks. By the major primary disease leading to ESRD, diabetes has

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

TABLE 4-8 Mortality for Medicare End-Stage Renal Disease (ESRD) Patients (ever entitled) Adjusted for Age, Race, Gender, and Primary Diagnosis, 1978–88 Patient Cohorts

 

Adjusted Mortality (%)

Year

Incident Cohortsa

Prevalent Cohortsb

1978

21.0

13.8

1979

20.3

13.5

1980

20.1

13.9

1981

20.9

14.2

1982

20.7

13.2

1983

21.7

13.2

1984

21.6

12.0

1985

21.6

13.8

1986

21.1

13.7

1987

21.5

13.6

1988

20.6

13.7

a One-year adjusted mortality calculated from day 91 to 1 year + 90 days for patients, by year of incidence of ESRD. Adjustment is by years of age (1–19, 20–44, 45–64, 65–74, 75 plus), race, gender, and primary diagnosis, Kaplan-Meier method (USRDS, 1990).

b One-year mortality calculated for patients who had survived at least I year before start of the index year. Adjustment is by 5-year age groups, life-table method (HCFA, 1990a).

the highest mortality, hypertension is next, and glomerulonephritis and polycystic disease have the lowest mortality. Mortality rates for transplant patients are lower than those for dialysis patients. The extent to which these differences reflect patient selection is not known.

In spite of the general stability in adjusted mortality, changes have occurred for different subgroups of the ESRD population between 1978 and 1988. There has been general improvement in survival of younger patients and diabetic patients on all modalities of treatment (USRDS, 1990, Tables E.69–E.89). In older patients, race-and diagnosis-adjusted survival is generally steady except for a step increase between 1982 and 1983. Mortality rates, especially in older patients, vary considerably depending on the method of analysis. For example, using age groups with 10-year spans shows a larger trend toward increased mortality than using groups with a span of 5 years or less. This is because age is less adequately controlled as the span increases.

By treatment, there has been improvement in survival for transplant patients of all ages. For example, one-year survival percentages for cadaveric transplant patients in the age groups 0–19, 20–44, and 45–64 increased from 72 to 78, 87 to 94, and 68 to 89, respectively, between 1978 and 1988

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

TABLE 4-9 One-Year Mortality (percent) for All End-Stage Renal Disease (ESRD) Patients, at Year of Incidence, by Age, Gender, Race, and Primary Diagnosis, 1978–88

 

Year

 

 

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

AGE GROUP (years)

 

0–19a

6.8

5.8

5.4

4.0

4.9

3.9

4.8

5.2

4.0

4.1

4.6

20–44

12.9

10.7

11.0

10.0

8.9

9.6

9.5

9.3

8.7

9.5

8.4

45–64

18.7

18.5

17.3

18.4

18.2

19.1

19.6

19.0

18.3

18.0

17.5

65–74

25.5

24.8

27.6

27.8

27.5

29.8

29.0

30.6

29.8

29.6

28.5

75 and older

37.2

35.6

34.2

38.6

38.1

41.1

37.5

38.2

38.3

41.7

39.2

GENDER

 

Female

18.4

17.3

15.6

17.9

17.6

18.4

17.9

18.9

18.4

18.2

17.3

Male

22.4

21.7

21.9

22.4

22.0

23.3

23.3

22.9

22.3

22.0

22.0

RACE

 

Black

20.2

20.1

19.8

20.5

19.8

20.9

20.4

20.8

19.5

19.3

19.3

Nonblack

21.7

20.7

20.4

21.2

21.5

22.4

22.5

22.3

22.3

21.8

21.8

PRIMARY DIAGNOSIS

 

Diabetes

28.5

27.2

27.5

28.9

29.6

28.7

27.1

29.5

27.6

24.8

24.8

Hypertension

17.9

16.9

18.2

18.5

18.9

20.1

21.0

19.3

19.9

20.5

20.5

Kidney diseases

14.4

12.3

13.0

14.0

14.1

14.3

13.9

14.8

4.6

14.9

14.9

Other

22.9

23.4

22.3

21.5

20.3

24.4

24.4

25.2

22.8

21.7

21.7

TOTAL

21.0

20.3

20.1

20.9

20.7

21.7

21.6

21.6

21.1

20.6

20.6

NOTE: Mortality calculated from day 91 to 1 year + 90 days.

a Because of possible data errors for pediatric patients (ages 0–19 years), unadjusted mortality has been used for this group. Because measured differences in incidence patterns for the pediatric population have been very small, the use of unadjusted in place of adjusted data should not have a meaningful effect.

SOURCE: USRDS, 1990, Tables E-52 and E-53.

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

(USRDS, 1990). Dialysis patient survival, however, does not show consistent time trends (Table 4-10), partly because of greater variability among patient age groups. In addition, it is difficult to interpret dialysis mortality because it is influenced by the outward flow of healthier patients to transplantation.

Nevertheless, by age, adjusted by gender, race, and primary diagnosis, there appears to be improved survival among dialysis patients under 45 years old and steady survival for those between ages 45 and 64. Over age 65, there is greater variability in the data; however, a trend toward higher mortality is evident in Table 4-10 for both the 65–74 and the over 75 age groups.

State and Regional Mortality Data

State and regional data, although they often differ from national data, offer insight into the experience of various patient groups. Wolfe and coworkers (1990) reported mortality outcomes for 2,754 dialysis patients using data from the Michigan Kidney Registry for patients between the ages of 20 and 60. Using a Cox regression model, they found a 6 percent per year increase in mortality between annual incident patient cohorts starting center hemodialysis (CH) treatment between 1980 and 1987. (They defined treatment as the modality of dialysis at six months after the onset of ESRD, without regard to whether patients changed to another modality after six months.) This represents a 50 percent increase in the mortality of new patient cohorts during the study years. (Time-dependent covariates, such as treatment year and time since renal failure, were not included in the study; see Wolfe, Appendix D.)

Wolfe and colleagues suggest several possible factors contributing to the observed trend: acceptance of sicker patients for ESRD therapy; selection of healthier patients to treatment modes other than CH, leaving sicker patients on CH (increased proportions of patients were treated with transplantation and peritoneal dialysis during the period of this study); and a degradation of quality of CH therapy. The investigators conclude: ''If these trends continue, or if the most recent results are maintained, then future studies must confront the increase in mortality rates among center hemodialysis patients and determine its cause'' (Wolfe et al., 1990, p. 439). This report differs sharply from the national pattern for the same period and it should be followed up with studies designed to disentangle patient characteristics and treatment modality effects on mortality.

Collins and associates (1990) analyzed the mortality experience of 2,985 hemodialysis patients treated within the Regional Kidney Disease Program in Minnesota. A comparison of the 1976–82 and 1983–87 periods showed that the proportion of patients starting hemodialysis with no major risk

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

TABLE 4-10 One-Year Mortality (percent) for Dialysis Patients at Year of Incidence by Age, Gender, Race, and Primary Diagnosis, 1978–88

 

Year

 

 

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

AGE GROUP (years)

 

0–19a

15.8

14.4

11.7

10.0

11.3

9.4

9.7

9.6

6.3

6.4

6.4

20–44

21.1

19.8

19.5

17.3

16.9

16.6

14.9

13.9

12.2

12.2

9.9

45–64

21.0

20.7

19.2

20.8

20.2

21.1

21.6

20.9

20.1

19.1

18.4

65–74

24.9

25.5

24.8

27.7

27.8

27.5

29.8

29.1

30.6

29.8

29.7

75 and older

37.2

35.6

34.2

38.6

38.1

40.1

37.5

38.2

38.3

41.7

39.2

GENDER

 

Female

22.7

22.6

22.3

22.7

21.8

23.0

22.1

22.2

20.8

21.7

19.8

Male

25.3

24.5

23.7

24.5

24.6

25.4

25.2

24.8

24.1

22.7

22.7

RACE

 

Black

20.1

19.8

17.4

19.5

19.6

20.1

19.5

20.1

19.2

17.6

17.6

Nonblack

26.0

25.3

25.3

25.6

24.9

26.3

25.8

27.2

24.2

22.9

22.9

PRIMARY DIAGNOSIS

 

Diabetes

31.9

32.7

31.6

33.1

32.9

32.1

30.1

32.4

30.3

25.8

25.8

Hypertension

20.5

20.0

20.8

20.8

21.1

22.3

22.6

20.6

21.2

21.0

21.0

Kidney diseases

17.2

15.2

15.4

16.7

16.4

16.7

15.7

16.4

15.9

15.5

15.5

Other

25.6

26.1

24.9

23.7

22.4

26.2

26.2

27.1

24.2

22.5

22.5

TOTAL

24.1

23.5

23.0

23.7

23.4

24.3

23.8

23.7

22.6

21.4

21.4

NOTE: Mortality calculated from day 91 to 1 year + 90 days.

a Because of possible data errors for pediatric patients (ages 0–19 years), unadjusted mortality has been used for this group. Because measured differences in incidence patterns for the pediatric population have been very small, the use of unadjusted in place of adjusted data should not have a meaningful effect.

SOURCE: USRDS, 1990, Tables E-68 and E-69.

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

factors (atherosclerotic heart disease, cerebrovascular disease, peripheral vascular disease, chronic obstructive lung disease, and nonskin malignancies) decreased from 41 percent to 28 percent. Those with two or more such risk factors increased from 59 percent to 72 percent: diabetics increased from 29 percent to 43 percent; and the percentage of patients over age 75 nearly doubled. Between 1982–84 and 1985–88, the average annual unadjusted mortality rate for all dialysis patients (hemodialysis and peritoneal dialysis) increased from 16.7 percent to 25.6 percent, a 55 percent increase.

In spite of increased comorbidities, mortality among diabetics remained stable up to age 75 but increased among older patients. Mortality decreased among nondiabetic patients with no major comorbidities in these years; nondiabetic patients with increased numbers of major risk factors had increased mortality. Thus, higher comorbidity correlated with increased mortality. The investigators conclude that "the increase in the annual gross mortality rate is highly predicted based on the change in the diabetic population and the increase in single and multiple comorbid conditions in the nondiabetic population" (Collins et al., 1990, p. 422).

These regional studies show increased mortality rates among some groups of dialysis patients and point out the importance of controlling for comorbidities in the analysis of mortality. At present, however, HCFA data do not include these comorbidities.

Cross-National Mortality Data

There are usually two major objectives of international comparisons of mortality rates. (See Wolfe, Appendix D.) The first is to document the existence of differences in mortality rates or to evaluate the relative risk of mortality between countries. The second is to identify the reasons for such differences, if they exist. Using the data currently available from different national registries, it is difficult to arrive at a definitive answer to the first objective, and it is impossible to arrive at an answer to the second.

It has been reported that the mortality of U.S. dialysis patients is higher than in many other countries. The measure most commonly used is gross mortality, which has major limitations as described above. Held and co-workers (1990), however, reported that the mortality of U.S. dialysis patients is much higher even after age adjustment. They compared 5-year survival (the inverse of mortality) of new ESRD patients accepted for treatment in the U.S. Medicare program (150,862 patients), the European Dialysis and Transplant Association (EDTA) countries (124,796 patients for 1982–87), and Japan (66,244 patients for 1983–87). The patients over age 65 represented 37, 24, and 30 percent of the patients for the United States, EDTA, and Japan, respectively; the percentages diabetic were 27, 10, and 19, respectively).

Compared to the U.S. experience, survival rates, adjusted for age and

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

diabetes as a primary diagnosis, were higher in the EDTA for all ages above 25 and in Japan for all ages above 15. Five-year survival rates for the ESRD populations, adjusted to the U.S. population age structure, are shown in Table 4-11. The authors suggest that the differences in mortality may be due to one or more of the following: patient selection rates (the U.S. accepts more patients per million for renal replacement treatment); the completeness and representativeness of the different registries; patient compliance; and the adequacy of treatment.

Kjellstrand and associates (1990) reported important factors that influenced mortality rates in U.S. and Swedish dialysis centers. Data included 2,004 cases from the Regional Kidney Disease Program at Hennepin County Medical Center in Minneapolis and 274 patients at the Karolinska Hospital in Stockholm, Sweden. Focusing on 10 comorbid conditions (arteriosclerotic heart disease, chronic heart insufficiency, peripheral vascular disease, cerebral stroke, pulmonary disease, gastrointestinal disease, cirrhosis, malignancy, hypertensive cardiomegaly, and presence of infection), the investigators found that the number of patients without complications remained stable in both centers between the early 1970s and the mid-1980s. Almost all the increase in the number of patients was among patients over age 50 with complications. Survival analyses stratified by patient comorbid conditions showed little difference between the U.S. and the Swedish experiences.

In an analysis of survival in five European areas (Benelux; British Isles—UK and Ireland; Nordic—Denmark, Norway, Sweden, and Finland; Latin—Italy, Spain and France; and Germany and Austria) and the United States, Kjellstrand and associates (1990) reported that over 90 percent of differences in cumulative survival rates among younger dialysis patients correlated with acceptance and transplantation rates. The analysis reported 4-year cumulative survival in dialysis patients aged 15–44 years. This analysis points to effects of comorbid conditions, acceptance rates, and transplantation rates on survival rates in national populations.

Wolfe (Appendix D) has identified several limitations that apply to international comparisons of mortality rates: (1) data are not collected and reported in a consistent way; (2) the level of mortality observed in a national registry is strongly related to the criteria for patient acceptance for treatment; (3) patient-specific data are not available in a unified data base on which analyses can be performed, resulting in the comparison of dissimilar data; (4) etiologies and comorbidities are not adequately reported; (5) age adjustment tends not to fully adjust for age differences—if patients are older in one nation, then they will tend to be older within each age category as well; (6) cross-national differences in withdrawal from treatment and in the reporting of withdrawal may also be relevant since withdrawal is a major cause of death among elderly U.S. patients.

In spite of these limitations, international comparisons provide important information and hypotheses for further analysis which may lead to improve-

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

TABLE 4-11 Five-Year Survival of Dialysis Patients by Country and Diagnosis of Diabetes

Country

% Non-diabetic

% Diabetic

United Statesa

45

26

Europe, 1982–87b

55

31

United Statesa

44

26

Japan, 1983–87c

60

40

a Years and age groupings differ for the age-adjusted comparisons with EDTA and Japan. Therefore, U.S. data are calculated twice to match European and Japanese data.

b Europe consists of the countries of the European Dialysis and Transplant Association. Age ranges for Europe are 0–14, 15–24, 25–34, 35–44, 45–54, 55–64, 65–74, and 75–84 years.

c Age ranges for Japan are 0–14, 15–29, 30–44, 45–59, 60–74, and 75–89 years.

SOURCE: Held et al., 1990.

ments in provision of treatment to ESRD patients. It is important to evaluate more precisely which subgroups (both by patient and by treatment characteristics) of ESRD patients have higher, similar, or lower mortality rates than in other countries. Is quite possible that a lower overall mortality rate is achievable in the United States and that international comparisons may contribute to attaining this goal.

PROJECTIONS TO THE YEAR 20006

In 1984, Eggers and coworkers (1984) suggested that the Medicare ESRD population was unlikely to level off in the near future. They projected that program enrollment would rise to 94,400 by 1990, 117,200 by 2000, and 162,100 by 2030. By 1988, however, the total Medicare enrollment had already increased to more than 133,900 people. The primary reason for Eggers and coworkers' underestimation was an unanticipated increase in the incidence of ESRD patients.

Eggers, at the request of the IOM ESRD study, prepared an estimate of the Medicare ESRD patient population for the year 2000 for this study, updating previous projections (Eggers, 1989) by incorporating new information on incidence and mortality for dialysis as well as transplant patients. His model, based on current eligibility criteria, generates low, middle, and high projections of the ESRD patient population for December 31, 2000, as presented in Table 4-12.

The middle projection anticipates that over 240,000 ESRD patients will be receiving treatment on December 31, 2000. This scenario estimates that

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

TABLE 4-12 Medicare End-Stage Renal Disease (ESRD) Population Projections, Year 2000

 

Estimates

 

Category

Low

Middle

High

Incidence of ESRD patients

47,949

56,877

68,472

Transplant patientsa,b

24,915

14,445

8,237

Cadaver donors

20,186

11,653

6,594

Living donors

4,729

2,792

1,643

Dialysis patientsc

122,953

182,037

231,401

Functioning graft patientsc

86,993

59,414

42,927

Patients leaving Medicare

5,256

3,566

2,562

Deathsa

34,164

43,357

49,351

Total patientsc

209,946

241,452

274,328

a During calendar year 2000.

b Underexisting statutory authority, transplant recipients are limited to 3 years of Medicare eligibility. Increased rates of transplantation, therefore, reduce the projected Medicare patient population, creating the counterintuitive results shown in the table.

c End of calendar year 2000.

SOURCE: Paul W. Eggers, HCFA, unpublished data, 1990.

almost 57,000 new patients will enter the program during the year 2000, an increase of 57 percent from 1988. The low scenario projects that almost 210,000 patients will be undergoing treatment at the end of the year 2000, the high scenario nearly 275,000 patients.

The model is sensitive to underlying assumptions, particularly incidence rates. The projection based on the highest incidence rate results in almost 65,000 more ESRD patients than that using the lowest rate. Changes in the number of transplants performed do not influence the projections of total patient population very much but do affect the distribution by mode of therapy. Failure to increase transplants above the current levels will lead to a decline in the percentage of all ESRD prevalent patients with a functioning graft.

Although these projections are unlikely to predict the future of the Medicare ESRD enrollment with precision, they provide a reasonable estimate of future enrollment based on current treatment and outcome trends. Even the low scenario indicates that historical growth of the ESRD population will continue well into the next century, as shown in Figure 4-3.

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

FIGURE 4-3

Number of ESRD Patients, Actual and Projected, 1974–2000

NOTE: As of December 31. SOURCE: Paul E. Eggers, HCFA, unpublished data, 1990.

NOTES

1.  

Data for primary diagnosis are quite incomplete before 1982.

2.  

Diagnostic categories lack clarity, precision, and uniform application, especially for the diagnosis of hypertension.

3.  

Age adjustment largely compensates for the increased gross mortality observed in 1982 and 1983 because of a large reported increase in elderly ESRD patients in these years.

4.  

In their analysis of dialysis mortality, Hull and Parker (1990) used the total number of patients who died during the year as the numerator and the average of the prevalent populations on the first and last days of the year as the denominator.

5.  

Gross mortality may have been increasing since the inception of the Medicare ESRD program, with the increase of older patients and patients with chronic diseases such as diabetes. These trends in patient incidence, which drive up gross mortality, have continued to the present. Because of the limits of HCFA data, we report the trend quantitatively only since 1978.

6.  

This section is based upon projections by P.W. Eggers of HCFA prepared for this study.

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Acchiardo SR, Moore LW, Latour PA. 1983. Malnutrition as the main factor in morbidity and mortality of hemodialysis patients. Kidney Int 24(Suppl 16):S99–S203.


Blagg CR, Wahl PW, Lamers JY. 1983. Treatment of chronic renal failure at the Northwest Kidney Center, Seattle, from 1960 to 1982. ASAIO J 6:170–175.


Collins AJ, Hanson G, Umen A, Kjellstrand C, Keshaviah P. 1990. Changing risk factor demographics in end-stage renal disease patients entering hemodialysis and the impact on long-term mortality. Am J Kidney Dis 15:422–432.

Suggested Citation:"The Patient Population." Institute of Medicine. 1991. Kidney Failure and the Federal Government. Washington, DC: The National Academies Press. doi: 10.17226/1818.
×

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Since 1972, many victims of endstage renal disease (ESRD) have received treatment under a unique Medicare entitlement. This book presents a comprehensive analysis of the federal ESRD program: who uses it, how well it functions, and what improvements are needed.

The book includes recommendations on patient eligibility, reimbursement, quality assessment, medical ethics, and research needs.

Kidney Failure and the Federal Government offers a wealth of information on these and other topics:

  • The ESRD patient population.
  • Dialysis and transplantation providers.
  • Issues of patient access and availability of treatment.
  • Ethical issues related to treatment initiation and termination.
  • Payment policies and their relationship to quality of care.

This book will have a major impact on the future of the ESRD program and will be of interest to health policymakers, nephrologists and other individual providers, treatment site administrators, and researchers.

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