Skip Navigation Archive: U.S. Department of Health and Human Services U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality www.ahrq.gov
Archival print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to www.ahrq.gov for current information.

National Healthcare Quality Report, 2013

Chronic Kidney Disease

Importance

Mortality
Total ESRD deaths (2011) 92,221 (USRDS, 2013b)
Prevalence
Total ESRD cases (2011) 615,899 (USRDS, 2013b)
Incidence
Number of new ESRD cases (2011) 115,643 (USRDS, 2013b)
Cost
Total ESRD Medicare program expenditures (2011) $29.5 billion (USRDS, 2013b)
Overall Medicare expenditures for chronic kidney disease (all stages), including Part D (2011) $45.5 billion (USRDS, 2013b)

Measures

The NHQR and NHDR track several measures of chronic kidney disease management to assess the quality of care provided to patients who have progressed to chronic kidney disease stage 5, kidney failure, also known as ESRD. A previous core measure, adequacy of dialysis, was retired because it achieved a rate above 95%.

Three measures are highlighted here:

  • Nephrology care before kidney failure.
  • Hemodialysis facility patient death rate.
  • Registration for transplantation.

Findings

Management: Nephrology Care Before Kidney Failure

Early referral to a nephrologist is important for patients with progressive chronic kidney disease who are approaching kidney failure. Patients who begin nephrology care more than a year before kidney failure are less likely to begin dialysis with a catheter, experience infections related to vascular access, or die during the months after dialysis initiation (USRDS, 2013a).

Mindful management during the transition to ESRD permits informed selection of a renal replacement therapy from the range of options, including conservative management (no dialysis), hemodialysis, peritoneal dialysis, and kidney transplantation. Early and mindful management also permits, as applicable, timely placement and maturation of vascular access for dialysis and workup for kidney transplantation.

Figure 2.10. New end stage renal disease patients age 18 and over who saw a nephrologist at least 12 months prior to initiation of renal replacement therapy, by age and sex, 2005-2010

Text description is below image

 

Text description is below image

[D] Select for Text Description.

Source: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2005-2010.
Denominator: Denominator includes all new ESRD patients age 18 and over with valid CMS-2728 Medical Evidence form, and a nonmissing value for the question: did you see a nephrologist at all?.
Numerator: Patients who saw a nephrologist at least 12 months prior to initiation of renal replacement therapy.

  • In 2010, only 29% of total new ESRD patients age 18 and over began nephrology care at least 12 months prior to initiation of renal replacement therapy. However, this was an increase from 2005, when the total percentage was 25% (Figure 2.10).
  • In all years, the percentage of ESRD patients who began nephrology care at least 12 months prior to initiation of renal replacement therapy was higher for patients age 45 and over than for patients ages 18-44.
  • In 2010, 29% of both males and females began nephrology care at least 12 months prior to initiation of renal replacement therapy. There was no statistically significant improvement in this measure for males or females from 2005 to 2010.
  • The 2010 top 5 State achievable benchmark was 51%.xii Males and females both show progress toward the benchmark but could not achieve it for more than 30 years. Most age groups show progress toward the benchmark, albeit slow. For example, adults age 75 and over would take 14 years to reach the benchmark. Adults ages 18-44 show virtually no progress toward the benchmark and would take more than a century to reach it.

Figure 2.11. End stage renal disease patients age 18 and over who saw a nephrologist at least 12 months prior to initiation of renal replacement therapy, by State, United States, 2010

Text description is below image

[D] Select for Text Description.

Source: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, United States Renal Data System, 2010.
Denominator: New end stage renal disease patients age 18 and over.
Note: Data are not available for the U.S. territories American Samoa, Guam, Northern Mariana Islands, or Virgin Islands because they do not meet the criteria for statistical reliability, data quality, or confidentiality.

  • The percentage of ESRD patients who began nephrology care at least 12 months prior to initiation of renal replacement therapy varies across U.S. States and the District of Columbia (Figure 2.11).
  • The five jurisdictions with the lowest percentage of ESRD patients who began nephrology care at least 12 months prior to initiation of renal replacement therapy are the District of Columbia, California, Maryland, Illinois, and Nevada.

Also, in the NHDR:

  • In all years, Whites were more likely than Blacks and non-Hispanics were more likely than Hispanics to begin nephrology care at least 12 months prior to initiation of renal replacement therapy.

Outcome: Hemodialysis Patient Death Rate

Hemodialysis patient mortality varies across dialysis facilities and, correspondingly, across States. The standardized mortality ratio (SMR) is designed to summarize the observed death rate at a facility relative to the death rate that was expected based on national death rates during that year for patients with the same characteristics as those in a given facility.

The SMR adjusts for many patient characteristics known to be associated with mortality: age, race, ethnicity, sex, diabetes status, duration of ESRD, nursing home status, comorbidities at ESRD incidence, body mass index (BMI) at incidence, calendar year, and race-specific State population death rates. The remaining variation in death rates across facilities is at least partly explained by factors relating to the processes and quality of care received at a given facility.

While this adjustment accounts for many factors that may explain differences in mortality between facilities aggregated by State, it cannot account for all factors. For example, since the SMR accounts for age and diabetes, an older average age or large percentage of diabetic patients at a facility would not elevate the SMR. Other factors, such as nutritional status, factors relating to the process of care, or comorbid conditions that developed after ESRD incidence, are not accounted for.

An SMR greater than 1 indicates that a facility death rate typically exceeds the national death rate for patients with the same characteristics as those in the facility. An SMR less than 1 indicates that a facility death rate is typically below the national death rate for patients with the same characteristics as those in the facility.

Focus on U.S. Territories

Few data sources can assess quality of care received by residents of U.S. territories. The data that do exist suggest that care in U.S. territories is suboptimal (Nunez-Smith, et al., 2011). Data compiled by the University of Michigan Kidney Epidemiology and Cost Center are used in this analysis, as they include information about U.S. citizens residing in U.S. territories.

The figure below shows dialysis facility SMRs aggregated by U.S. State and four territories, Guam, Puerto Rico, Northern Mariana Islands, and Virgin Islands (there are no data for the fifth territory, American Samoa).

Figure 2.12. Standardized mortality ratios on hemodialysis, by State or territory, 2010-2011

Text description is below image

[D] Select for Text Description.

Source: University of Michigan Kidney Epidemiology and Cost Center, 2010-2011 Dialysis Facility Report.
Denominator: Number of deaths that would be expected among Medicare dialysis patients (adult and pediatric) at the facility during the reporting period, given the patient mix at the facility, aggregated by State.
Note: For this measure, ratios for 2010 and 2011 are averaged. Lower ratios are better.

  • SMRs vary across U.S. States and territories, from a low in Montana to a high in Guam. Montana's SMR of 0.84 indicates facility death rates that are typically 16% below the national death rate. Guam's SMR of 1.97 indicates facility death rates that are 97% above the national death rate. This finding is consistent with studies suggesting that patient care in the U.S. territories is suboptimal (Nunez-Smith, et al., 2011) (Figure 2.12).
  • The three jurisdictions with the highest SMRs are the territories Guam, Puerto Rico, and Northern Mariana Islands, with facility death rates that are typically 30% or more above the national death rate. Completing the top five jurisdictions with the highest SMRs are West Virginia at 19% and Arkansas at 13% above the national death rate.

Management: Registration for Transplantation

Kidney transplantation is a renal replacement therapy that replaces the failing kidney with a healthy donor kidney. ESRD patients who receive a kidney transplant have lower mortality and hospitalization rates than those on dialysis. First-year all-cause mortality rates in hemodialysis patients, for example, are nearly five times higher than rates among transplant patients (USRDS, 2013a).

If a patient is determined to be a good candidate for transplant, he or she is registered with a transplant program to wait for a match with the most suitable donor. The supply of donor kidneys, however, continues to lag behind demand. While there were 17,671 kidney transplants in 2011, by the end of the year, 55,371 active adult candidates remained on the waiting list. Waiting times continue to increase, with the median waiting time reaching 4.3 years for patients newly listed in 2007 (USRDS, 2013a). Despite these challenges, registration is a vital first step toward kidney transplantation.

Figure 2.13. Dialysis patients under age 70 who were registered for transplantation within a year of ESRD initiation, by age and sex, 2001-2009

Text description is below image

 

Text description is below image

[D] Select for Text Description.

Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2001-2009.
Denominator: New end stage renal disease patients (receiving hemodialysis or peritoneal dialysis) in the given year who were under age 70 and had a known State of residence in the 50 States or the District of Columbia.
Numerator: Patients who were either wait-listed or received a deceased-donor kidney within 1 year of their ESRD initiation date.
Note: Patients who received a transplant at any time from a live donor or residing in American territories were excluded. Percentages are estimated using the Kaplan-Meier methodology.

  • From 2001 to 2009, the total percentage of dialysis patients under age 70 who were registered for transplantation within 1 year of progressing to ESRD increased from 14.3% to 17.4% (Figure 2.13).
  • The percentage of patients under age 40 who were registered for transplantation within 1 year of progressing to ESRD continued to decrease, from a high of 50.4% in 2006 among patients ages 0-19 and 27.9% among patients ages 20-39 to 46.2% and 26.8%, respectively, in 2009.
  • Conversely, the percentage of patients over age 39 who were registered for transplantation within 1 year of progressing to ESRD continued to increase, from a low of 15.8% in 2002 among patients ages 40-59 and 6.8% in 2001 among patients ages 60-69 to 18.3% and 12.2%, respectively, in 2009.
  • In 2009, as in all previous years, patients ages 20-69 were less likely than patients ages 0-19 to be registered for transplantation within 1 year of progressing to ESRD, and females were less likely than males to be registered for transplantation within 1 year of progressing to ESRD.
  • The 2008 top 5 State achievable benchmark for registration for transplantation within 1 year of progressing to ESRD was 27%.xiii Patients ages 0-19 have already surpassed the 2008 achievable benchmark and patients ages 20-39 have reached it. At the current rate of improvement, however, patients ages 40-59 would need 28 years and patients ages 60-69 would need 21 years to achieve the benchmark.

Also, in the NHDR:

  • In all years, Blacks and AI/ANs were less likely than Whites to be registered for transplantation within 1 year of progressing to ESRD. However, APIs were more likely than Whites to be registered.

Return to Contents

Diabetes

Importance

Mortality
Number of deaths (2011 prelim.) 73,282 (Hoyert & Xu, 2012)
Cause of death rank (2011 prelim.) 7th (Hoyert & Xu, 2012)
Prevalence
Total number of people with diabetes (all ages, 2010)xiv 25.8 million (CDC, 2011c)
Number of people with diagnosed diabetes (all ages, 2010) 18.8 million (CDC, 2011c)
Number of people with undiagnosed diabetes (age 20 years and over, 2010) 7.0 million (CDC, 2011c)
Incidence
New cases (age 20 years and over, 2010) 1.9 million (CDC, 2011c)
Cost
Total cost (2012) $245 billion (ADA, 2013)
Direct medical costs (2012) $176 billion (ADA, 2013)
Indirect costs (2012) $68.6 billion (ADA, 2013)

Measures

Diabetes is one of the leading causes of hospitalization in the United States, with more than 600,000 discharges in 2009 (CDC, 2011a).With appropriate and timely ambulatory care, it may be possible to prevent many hospitalizations for diabetes and related complications. Routine monitoring of blood glucose levels, along with foot and dilated eye examinations and tests for hemoglobin A1c (HbA1cxv ), has been shown to help prevent or mitigate complications of diabetes, such as diabetic neuropathy, retinopathy, and vascular and kidney disease.

The NHQR and NHDR track several measures of diabetes management and outcomes to assess the quality of care provided to patients with diabetes. These measures examine the extent to which patients receive care needed to prevent complications, including serious problems such as the development of kidney failure.

Three measures are highlighted here:

  • Receipt of four recommended diabetes services.
  • Hospital admissions for uncontrolled diabetes.
  • End stage renal disease due to diabetes.

Findings

Management: Receipt of Four Recommended Diabetes Services

A composite measure is used to track the national rate of receipt of four recommended annual diabetes interventions: at least two HbA1c tests, a foot examination, a dilated eye examination, and a flu shot. These are basic process measures that provide an assessment of the quality of diabetes care. In 2011, to be more consistent with current recommendations, the frequency of HbA1c tests was increased to two per year and receipt of a flu shot was added to the measure.

Figure 2.14. Adults age 40 and over with diagnosed diabetes who reported receiving four recommended services for diabetes in the calendar year (2+ hemoglobin A1c tests, foot exam, dilated eye exam, and flu shot), by residence location and age, 2008-2010

Text description is below image

 

Text description is below image

[D] Select for Text Description.

Key: MSA = metropolitan statistical area.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2008-2010.
Denominator: Civilian noninstitutionalized population with diagnosed diabetes, age 40 and over.
Note: Data include people with both type 1 and type 2 diabetes. Rates are age adjusted to the 2000 U.S. standard population using two age groups: 40-59 and 60 and over. The noncore residence location sample size in 2008 did not meet requirements for statistical reliability, data quality, or confidentiality and is not included.

  • In 2010, overall, among adults age 40 and over with diagnosed diabetes, only about one-fourth reported receiving all four recommended services (Figure 2.14).
  • In 2009, residents of micropolitan (small town) and noncore (the most rural) areas were less likely than residents of large fringe metropolitan (suburban) areas to report receiving recommended care for diabetes. This finding is consistent with what we know about the relationship between a variety of health measures and the level of urbanization, that residents of suburban areas tend to have, for example, better access to care and report better health status than residents living in more urban or more rural areas (Ingram & Franco, 2012). In 2010, however, residents of micropolitan and noncore areas were just as likely as residents of large fringe metropolitan areas to report receiving recommended care for diabetes.
  • In all years, adults ages 40-59 were less likely than adults age 60 and over to report receiving recommended care for diabetes.

Also, in the NHDR:

  • In 2009, Blacks and Hispanics were less likely than Whites to report receiving recommended care for diabetes. In 2010, however, Blacks and Hispanics were just as likely as Whites to report receiving recommended care for diabetes.

Outcome: Admissions for Uncontrolled Diabetes

Individuals who do not achieve good control of their diabetes may develop symptoms that require correction through hospitalization. Admission rates for uncontrolled diabetes may be reduced by better outpatient treatment and patients' tighter adherence to diet and medication.

Figure 2.15. Hospital admissions for uncontrolled diabetes without complications per 100,000 population, age 18 and over, by age and residence location, 2004-2010

Text description is below image

 

Text description is below image

[D] Select for Text Description.

Key: MSA = metropolitan statistical area.
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, version 4.1, 2004-2010.
Denominator: U.S. resident population age 18 and over.
Note: For this measure, lower rates are better.

  • From 2004 to 2009, there were no statistically significant changes in the annual overall adult admission rate for uncontrolled diabetes. In 2010, the rate decreased to 19.2 admissions per 100,000 population. (Figure 2.15).
  • In all years, adults ages 45-64 and 65 and over had higher admission rates for uncontrolled diabetes than adults ages 18-44.
  • From 2009 to 2010, hospital admission rates for uncontrolled diabetes decreased among patients of all ages and among residents of large central (inner city) and medium metropolitan, micropolitan (small town), and noncore (the most rural) areas. Conversely, from 2009 to 2010, residents of large fringe (suburban) and small metropolitan areas experienced a slight increase in hospital admission rates.
  • The 2008 top 4 State achievable benchmark was 5 admissions for uncontrolled diabetes per 100,000 population.xvi Residents of micropolitan and noncore areas show progress toward the benchmark but could not achieve it for about 9 and 15 years, respectively.

Also, in the NHDR:

  • In all years, the rate of hospital admissions for uncontrolled diabetes was higher for Blacks and Hispanics and lower for APIs and Whites.
  • In all years, the rate of hospital admissions for uncontrolled diabetes was higher for adults living in communities with median household incomes in the first (lowest), second, and third quartiles than for people living in communities in the fourth quartile (highest).

Outcome: End Stage Renal Disease Due to Diabetes

Diabetes is the most common cause of kidney failure. Keeping blood glucose levels under control can prevent or slow the progression of kidney disease due to diabetes. In addition, when kidney disease is detected early, medication can slow the disease's progress. If kidney disease is detected late, however, it commonly progresses to chronic kidney disease stage 5, also known as ESRD.

Once the patient has progressed to ESRD, some type of renal replacement therapy is necessary—conservative management (no dialysis), hemodialysis, peritoneal dialysis, or kidney transplantation. While some cases of kidney failure due to diabetes cannot be avoided, other cases reflect inadequate control of blood glucose or delayed detection and treatment of early kidney disease due to diabetes.

Figure 2.16. Adults age 20 and over with end stage renal disease due to diabetes, per million population, by age and sex, 2004-2010

Text description is below image

 

Text description is below image

[D] Select for Text Description.

Source: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System, 2004-2010.
Denominator: U.S. resident population.
Note: For this measure, lower rates are better. Rates are adjusted by age, sex, race, and interactions of age, sex, and race. When reporting is by age, the adjustment is by sex, race, and interactions of sex and race. When reporting is by sex, the adjustment is by age, race, and interactions of age and race.

  • From 2004 to 2010, there were no statistically significant changes in the overall rate of new cases of ESRD due to diabetes (Figure 2.16).
  • In all years, adults age 45 and over had higher rates of ESRD due to diabetes than adults ages 20-44. In addition, males had higher rates than females.
  • The 2010 top 5 State achievable benchmark was 71 per million population.xvii Females are moving slightly toward the benchmark but will not achieve it for 31 years.

Also, in the NHDR:

  • In all years, AI/ANs, APIs, and Blacks had higher rates than Whites, and Hispanics had higher rates than non-Hispanics.

 


xii The top 5 States that contributed to the achievable benchmark are Hawaii, Maine, Montana, North Dakota, and Vermont.
xiii The top 5 States that contributed to the achievable benchmark are Delaware, Iowa, Minnesota, Montana, and Vermont.
xiv The total number of people with diabetes is the sum of the estimated number of those age 20 years and over with diagnosed or undiagnosed diabetes and the number of those younger than 20 years with diagnosed diabetes. The estimated number of adults age 20 years and over with diabetes (diagnosed or undiagnosed) was obtained using the fasting subsample from the 2005-2008 National Health and Nutrition Examination Survey (NHANES) data. The diabetes estimates from NHANES were applied to the 2010 U.S. resident population estimates to derive the estimated number of adults with diabetes. People who self-reported having been told by a doctor or health professional that they had diabetes were classified as having diagnosed diabetes. Those without a history of diabetes but with a fasting plasma glucose greater than or equal to 126 mg/dL or an HbA1c level greater than or equal to 6.5% were classified as having undiagnosed diabetes. Estimates of undiagnosed diabetes for people younger than 20 years are not available.
xv The laboratory test for HbA1c, also known as "glycosylated hemoglobin," shows a patient's average blood glucose (in percent) over the previous 2 to 3 months.
xvi The top 4 States that contributed to the achievable benchmark are Colorado, Hawaii, Utah, and Vermont.
xvii The top 5 States that contributed to the achievable benchmark are District of Columbia, Montana, New Hampshire, Vermont, and Wyoming.


Return to Contents

Page last reviewed May 2014
Page originally created May 2014

 

The information on this page is archived and provided for reference purposes only.

 

AHRQ Advancing Excellence in Health Care