10. ESRD Providers

10
esrd
providers
She taught me what her uncle once taught her:
How easily the biggest coal block split
If you got the grain and hammer right.
The sound of that relaxed alluring blow
Its co-opted and obliterated echo,
Taught me to hit, taught me to loosen,
Taught me between the hammer and the block
To face the music. Teach me now to listen,
To strike it rich behind the linear black.
Seamus Heaney
“Clearances”
10
esrd providers
194 | provider growth dialysis
treatments || unit growth || unit
& patient counts || profit status ||
freestanding/hospital-based status
196 | patient characteristics, by
unit affiliation demographics &
clinical parameters of incident &
prevalent patients || unit & patient
counts, by affiliation
T
198 | provider compliance
with K/DOQI & preventive care
guidelines anemia management
|| URR || Kt/V || AV fistulas || serum
albumin || HbA1c tests || lipid tests ||
influenza vaccinations
200 | provider differences in
preventive care diabetic care ||
preventive care in patients age 65+
202 | provider differences
in Bayesian mortality &
hospitalization ratios
204 | summary
contents
Figure 10.2 Between 1996 and 2004,
the total number of in-center hemodialysis treatments rose 66 percent,
from 25.7 to 42.7 million. Figure 10.7
The number of dialysis units grew
52.9 percent between 1996 and
2004, while the number of patients
increased at a slightly lower rate of
49.6. Figure 10.25 Only six in ten dialysis patients received an influenza
vaccination in the autumn of 2004,
far from the HP2010 target of 90
percent. Figure 10.29 Across providers,
only one in five patients receives
comprehensive diabetic monitoring;
the rate is highest in units owned by
Gambro, yet still reaches only 6.4
percent.
highlights
he growing numbers of ESRD patients and dialysis units has been associated
with a rather dramatic expansion of free-standing, for-profit providers, and
71–73 percent of units are now for-profit. Growth in the patient population,
however, has not been uniform across the dialysis modalities. All ESRD networks
have seen growth in the number of hemodialysis treatments, but in only four has
there been a major increase in the number of peritoneal dialysis treatments; treatments in the remaining networks have declined. As noted in Chapter Four, some of
these changes may be associated with different ownership patterns. Given the initial premise of the composite rate payment system, designed in 1982, to promote
greater use of home dialysis, the current practices of providers and large dialysis organizations appear to be directed at in-center hemodialysis. Reasons for these observations need further investigation. − In the past two years, many dialysis units
have further consolidated into two large providers, both of them for-profit, publiclytraded corporations. Recently, however, some units have begun to merge outside
of the large chains; they may create new chains which will need to be addressed in
future analyses. − In this year’s spread on provider compliance with K/DOQI and
preventive care guidelines, we present new analyses of provider-level adjustments
to epoetin dosing when hemoglobin levels exceed the recommended range of 11–
12 g/dl. We evaluate consecutive months of anemia treatment, with reported hemoglobins from the first month matched to changes in epoetin dosing in the following
month. We then assess the percent of managed months that appear to comply with
recommended epoetin dose reductions in the second month. Frequency distribution plots illustrate the distribution of units, by ownership, associated with recommended dose reductions, and show clear differences in dose adjustment patterns,
particularly in the large dialysis organizations. When hemoglobins are 12–13 g/dl,
DaVita units appear to make the lowest adjustment in epoetin doses. Even for hemoglobins of 13 g/dl and above, DaVita and National Nephrology Associates units
still have the lowest number of recommended managed months with dose reduction. The effect of these practices is in part illustrated by data on patient distribution
by hemoglobin level, showing that DaVita has the smallest proportion of patients
who achieve the target hemoglobin range of 11–12 g/dl. The relationship between
Number of units
4,000
3,000
2,000
1,000
0
90
Freestanding for-profit
Freestanding non-profit
Hospital center
Hospital facility
Tx & dialysis ctr
s
Tx center
nit fit
f u pro
o
nt for
rce re
Pe at a
th
90
92
94
96
98
Counts of dialysis & transplant
10.1 units,
by CMS certification type
|| Figure 10.1 data
obtained from
the CMS annual End-Stage Renal
Disease Facility Survey, CMS
Independent Renal Facility Cost
Reports, & the CMS “Dialysis
Facility Compare” website. The
leveling out of the number of freestanding, for-profit units in 2002 is
due to changes in how CMS determines profit status, resulting in
some units not being classified.
00
80
70
60
02
04
50
Percent of units that are for-profit
2006 annual data report || chapter ten
epoetin dosing practices and the achievement of target hemoglobin levels needs further examination, but these observations may be important.
Units owned by DCI, for instance, appear to have the greatest percent of recommended managed months and also the highest percentage of patients achieving
the target hemoglobin of 11–12 g/dl. − Anemia management is only one element
of care assessed by the USRDS on a provider level. Data on hemodialysis therapy, for
example, show that delivery is fairly consistent across all providers, while delivery
of peritoneal dialysis therapy varies slightly. New guidelines on peritoneal dialysis
adequacy are being published in 2006, and we will address these in future analyses.
Vascular access use also varies, with Gambro units having the lowest percentage
of patients using a fistula as their first access, and Fresenius and Renal Care Group
units the highest. Influenza vaccination rates across providers vary by as much as
35 percent. − This year we also examine Bayesian mortality and hospitalization
ratios of the large dialysis provider groups, comparing them to one another and to
the national average. DCI units have the most consistently low BMRs and BHRs. Outcomes in hospital-based units are significantly worse than those seen with chainowned providers; this is consistent with results we have reported in previous ADRs,
and may reflect the transitional nature of some of their patients, the fact that these
units serve a greater proportion of disadvantaged populations, or less consistent
practices than those used by the large chains. These differences in outcome merit further analysis to determine any temporal relationships to other components
of care as well as to socioeconomic factors. − Overall, the quality of care given
to the dialysis population differs among providers, particularly the chain-affiliated
units and their non-chain and hospital-based counterparts. Although the Clinical
Performance Measures (CPM) program of the Centers for Medicare and Medicaid
Services has focused primarily on dialysis delivery, anemia treatment, and vascular access, other aspects of care are clearly of concern as well. The largest dialysis
provider groups show considerable room for improvement. These areas and others
will be explored further in subsequent Annual Data Reports to help us better assess
provider performance.
193
10
esrdprovider
providers
growth
treatments, by
10.2 ESRDDialysis
network & modality
In-center treatments (in millions)
5
B
etween 1996 and 2004, the total
number of in-center hemodialysis treatments rose 66 percent,
from 25.7 to 42.7 million (Figure 10.2).
Growth ranged from 43 percent in Network 4 to more than 88 percent in Network
9. Changes in the use of peritoneal dialysis have varied widely—it has fallen 73 percent, for example, in Network 1, but grown
nearly 340 percent in Network 12. Close to
one in four patients in Networks 6, 8, 9, and
12 are on peritoneal dialysis, considerably
more than in any other network.
Unit growth between 1996 and 2004 for
facilities with chain affiliation was greatest in the eastern and southeastern United
States, not surprising since the majority of
for-profit units are located in these areas
(Figure 10.3).
Hemodialysis
1996
2004
4
3
2
1
0
Treatments (in thousands)
30
Peritoneal dialysis
25
20
15
10
5
0
growth in the number of units &
10.5 %dialysis
pts, by state, 1996 to 2004
1
2
3
4
5
6
7
8
9 10 11
ESRD network
12
13
14
15
16
17
18
Units
chain-affiliated & non-chain units
10.3 Unit growth1996between
& 2004
Chain units
Non-chain units
36.7 + (56.8)
30.2 to <36.7
15.3 to <30.2
10.3 to <15.3
below 10.3 (-2.2)
Hemodialysis patients
10.4
Units dropped
Units unchanged
Units added
Unit distribution, by ESRD
network, 1996 & 2004
100
34.4 + (40.5)
29.8 to <34.4
23.5 to <29.8
Non-chain
Chain-affiliated
19.1 to <23.5
below 19.1 (13.2)
Peritoneal dialysis patients
80
60
40
20
All
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
0
96
04
Percent of units
194
Units dropped
Units unchanged
Units added
22.2 + (46.7)
7.2 to <22.2
0.0 to <7.2
-15.0 to <0.0
below -15.0 (-27.7)
2006 annual data report || chapter ten
Units per 100,000
10.6 population,
2004, by HSA
|| Figures 10.2–9 data obtained from the CMS annual
End-Stage Renal Disease Facility Survey, CMS Independent Renal Facility Cost Reports, & the CMS
“Dialysis Facility Compare” website. Figure 10.5
excludes patients residing in Puerto Rico & the Territories. − || Figure 10.2 Transient treatments, which
account for less than 1 percent of all treatments, are
not included. Hemodialysis includes outpatient hemodialysis & hemodialysis training treatments; peritoneal dialysis includes outpatient IPD treatments &
IPD, CAPD, & CCPD training treatments. || Figure
10.6 2004, by HSA, unadjusted. Excludes patients
residing in Puerto Rico & the Territories. Data also
obtained from estimates of the United States 2004
census, based on the 2000 census. − Figure 2.46, in
Chapter Two, contains a map of the ESRD networks;
a list of network contacts can be found on page 238
of Appendix A.
1.84 + (2.24)
1.71 to <1.84
1.58 to <1.71
1.38 to <1.58
below 1.38 (1.17)
change in the number of units &
10.7 Percent
patients, 1996 to 2004, by ESRD network
Percent change, 1996-2004
100
Units
Patients
80
60
40
20
0
All
1
2
3
4
5
6
7
8
9 10
ESRD network
11
12
13
14
15
16
17
18
11
12
13
14
15
16
17
18
of for-profit & non-profit
10.8 Distribution
units, by ESRD network, 1996 & 2004
100
Percent of units
80
Unknown
Non-profit
Profit
60
40
20
All
1
2
3
4
5
6
7
8
9
10
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
9
10
11
12
13
14
15
16
17
18
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
96
04
8
96
04
96
04
7
96
04
96
04
6
96
04
96
04
5
96
04
96
04
4
96
04
96
04
3
96
04
96
04
2
96
04
96
04
1
96
04
96
04
All
96
04
96
04
0
Distribution of freestanding & hospital10.9 based
units, by ESRD network, 1996 & 2004
100
80
Percent of units
In Network 16, the percent of units that
are chain-affiliated rose from 29.7 in 1996
to 50.4 in 2004, the greatest growth seen
among the networks (Figure 10.4). The
market share of non-chain units continues
to decline: in only two networks do these
units now account for more than half of
those providing dialysis, down from five
networks in 2003.
Between 1996 and 2004, Wisconsin,
Illinois, Ohio, Kentucky, Vermont, New
Hampshire, Nebraska, Nevada, and Alaska
showed an average growth of 56.8 percent
in the number of dialysis facilities (Figure 10.5). The highest growth in the number of hemodialysis patients has occurred
in the western and southwestern states, in
which the average reaches nearly 41 percent. States represented by the upper quintile show overall increases of nearly 50 percent in the number of facilities that offer
peritoneal dialysis. In states represented by
the lower quintile, the number of facilities
providing peritoneal dialysis decreased by
an average of nearly 28 percent.
Dialysis units located in areas along the
Gulf Coast have the highest unit to patient
ratios, averaging 2.24 per 100,000 population (Figure 10.6).
The number of dialysis units grew 52.9
percent between 1996 and 2004, while the
number of patients increased at a slightly
lower rate of 49.6 (Figure 10.7). Among
individual networks, however, growth was
rarely so consistent. In Networks 2, 3, 4, and
9, expansion in the number of units was 24–
28 percentage points higher than that seen
with the patient population. In the two California networks, in contrast, a 62–64 percent
increase in patient counts was accompanied
by only a 29–37 percent growth in the number of units available to treat them.
Seventy-four percent of units are run on
a for-profit basis (Figure 10.8). By network,
for-profit status accounts for as many as
87–88 percent of units in Networks 7, 13, and
14, to a low of 46 percent in Network 2—a
number consistent with New York’s high
percentage of independently owned units.
Eighty-two percent of units nationwide
are freestanding, up slightly from 79 percent in 1996 (Figure 10.9). In Networks 6, 7,
and 8, 92–94 percent of units are freestanding, while in Network 2, New York, 46 percent of units are hospital-based. −
60
40
Hospital-based
Freestanding
20
0
195
10
esrdpatient
providers
characteristics, by unit affiliation
of incident dialysis
10.10 Characteristics
patients, by unit affiliation, 2004
Age
50
46
44
56
Hispanic ethnicity
Other/unknown
Non-Hispanic
Hispanic-other
Hispanic-Mexican
60
40
40
0
Diabetic status: diabetics
100
44
42
40
0
38
0
10.4
Mean hemoglobin at initiation
40
Other/unknown
Cystic kidney
Glomerulonephritis
Hypertension
Diabetes
Percent receiving EPO at initiation
Percent of patients
10.2
60
Hemoglobin (g/dl)
10.0
40
20
Peritoneal dialysis
Hemodialysis
9.6
70 Percent with albumin < test’s lower limit
29
65
BMI (kg/m2)
60
55
All
1
2
3
4
5
6
NC HB
30
25
Mean BMI at initiation
11.0
28
10.5
27
10.0
26
50
35
9.8
25
All
1
2
3
4
5
6
NC HB
Unit affiliation (see table at right for codes)
eGFR (ml/min/1.73 m2)
0
45
Primary diagnosis
60
20
Modality
Other/unknown
Asian
N Am
Black
White
80
40
80
Percent of patients
20
20
100
Percent of patients
40
46
Percent diabetic
Percent of patients
80
60
42
48
Race
80
Percent of patients
Percent female
Mean age (in years)
60
58
196
100
48
62
100
Gender: female
Percent of patients
64
incident
dialysis patients
Mean eGFR at initiation
9.5
9.0
All
1
2
3
4
5
6
NC HB
2006 annual data report || chapter ten
10.11
1,200
Unit & patient counts,
by unit affiliation
December 31 point
prevalent dialysis patients
Number of units
100
1999
2004
1,000
Chain 1 · Fresenius · 1,118 units in 2004
Chain 2 · Gambro · 582
Chain 3 · DaVita · 626
Chain 4 · Renal Care Group · 417
Chain 5 · Dialysis Clinics, Inc. · 181
Chain 6· Nat’l Nephrology Assoc. · 27
NC · Non-chain units · 934
HB · Hospital-based units · 837
Number of patients (in thousands)
80
800
60
600
20
200
0
1
2
3
4
5
0
6 NC HB
1
2
3
Unit affiliation (see table at right for codes)
of prevalent dialysis
10.12 Characteristics
patients, by unit prevalent, 2004
Age
50
60
58
Race
Gender: female
46
44
48
Percent diabetic
Percent of patients
HB
Diabetic status: diabetics
46
60
40
Other/unknown
Asian
N Am
Black
White
20
44
42
40
0
38
Primary diagnosis
100
Modality
80
60
40
Other/unknown
Cystic kidney
GN
20
All
1
2
3
4
HTN
Diabetes
5
6
NC HB
Percent of patients
80
Percent of patients
NC
40
80
0
6
42
56
100
5
48
62
100
4
December 31 point
prevalent dialysis patients
Percent female
Mean age (in years)
64
F
40
400
60
40
|| Figures 10.10–12 incident (Figure 10.10) & December
20
0
igures 10.10 and 10.12 illustrate differences, by provider, in the incident and prevalent dialysis populations. Mean age, for instance, is 62.6 in
the incident population, and slightly lower
in prevalent patients, at 60.7; by provider,
age is greatest in NNA and non-chain units.
Patient distribution by race varies slightly
by provider; 34 percent of incident Gambro
patients, for instance, are black, compared
to 28 percent overall and 24 percent in nonchain units. And 12 percent of new patients
treated in DaVita units are of HispanicMexican ethnicity, compared to 2.6–3.5 percent in DCI and NNA units.
The mean hemoglobin of patients starting dialysis is 10.1 g/dl overall; the level is
slightly higher in units owned by RCG and
NNA and in non-chain units. Provider differences in this initial hemoglobin are not
echoed by pre-ESRD EPO use, which is 32
percent overall, and ranges from 29.8 percent in Gambro patients to 37.4 percent in
those treated at DCI units. The mean BMI
and mean GFR at initiation are both greatest in patients at RCG units.
Between 1999 and 2004 the number of
units owned by Fresenius grew 38 percent,
to more than 1,100; the number of patients
treated in these units rose 41 percent, to
more than 80,000 (Figure 10.11). With DaVita’s December 2004 acquisition of Gambro
Healthcare, and the May 2005 purchase of
Renal Care Group by Fresenius Medical
Care, care of ESRD patients in the U.S. is
now the responsibility of an ever-decreasing
number of corporate providers. −
Peritoneal dialysis
Hemodialysis
All
1
2
Unit affiliation (see table above for codes)
3
4
5
6
NC HB
31 point prevalent (Figures 10.11–12) dialysis patients,
2004. Facility data obtained from the CMS annual
End-Stage Renal Disease Facility Survey, the CMS
Independent Renal Facility Cost Reports, & the CMS
“Dialysis Facility Compare” website. The lower limit of
albumins measured by bromcresol purple is 3.2 g/dl, &
by bromcresol green is 3.5 g/dl.
197
10
esrdprovider
providers
compliance with K/DOQI & preventive care guidelines
P
rovider management of hemoglobin levels that exceed the
upper limit of the target are assessed in Figures 10.13–16.
EPO dose reductions of 25 percent are recommended (in
the epoetin package insert) for hemoglobin levels approaching and
exceeding 12 g/dl. Since dose reductions appear to be randomly
distributed throughout a month of treatment, one would expect
a 12.5 percent reduction on a month-to-month basis. We assessed
provider practice patterns on dosing changes and found that
DaVita tends to adjust the least and DCI the most when hemoglobin levels exceed 12–13 g/dl.
A urea reduction ratio of ≥65 percent or a Kt/V ≥1.2 are indications of acceptable hemodialysis therapy. With the exception of
those treated in hospital-based and NNA units, over 90 percent
of patients meet these requirements (Figures 10.17–19). For CAPD
patients, on the other hand, only 74 percent
of patients meet the target Kt/V of ≥2.0.
anemia management
In the incident population, AV fistuManaged months (≥12.5% month-to-month EPO dose
EPO-treated
las are most common in patients dialyzing
reduction), by unit affiliation: when hemoglobin 12–<12.5 g/dl
dialysis patients
in Renal Care Group and Fresenius units,
while Renal Care Group and hospitalOverall
By
unit
affiliation
40
based units have the greatest proportion
All chains
Fresenius
Hospital-based
Gambro
of prevalent patients using this access (FigNon-chain
DaVita
ures 10.19–20).
30
RCG
The proportion of patients with a hemoDCI
globin level of 11–<12 g/dl ranges from 27.5
NNA
percent in units owned by DaVita to 64.8
20
percent in units owned by Dialysis Clinics
Inc. (Figure 10.21).
Fewer than one in three incident dialy10
sis patients begins therapy with an albumin
greater than the test’s lower limit; the proportion ranges from 29 percent in hospital0
<10
20-<30
40-<50
60-<70
80-<90
<10
20-<30
40-<50
60-<70
80-<90
based units to 40 in those owned by NNA
10-<20
30-<40
50-<60
70-<80
90+
10-<20
30-<40
50-<60
70-<80
90+
(Figure 10.22).
Percent of managed months
Only 53 percent of diabetic dialysis
Managed months (≥12.5% month-to-month EPO dose
EPO-treated
patients received four or more glycosylated
reduction), by unit affiliation: when hemoglobin 12.5–<13 g/dl
dialysis patients
hemoglobin (HbA1c) tests in 2004, while
Overall
By
unit
affiliation
only 41 percent received two or more lipid
40
All chains
Fresenius
tests (Figures 10.23–24). Compliance with
Hospital-based
Gambro
recommended HbA1c testing ranges from
Non-chain
DaVita
a high of 60–62 percent in Gambro and
30
RCG
DaVita units to a low of 38–41 percent in
DCI
DCI and hospital-based units. Lipid testNNA
ing, in contrast, is most frequent in units
20
owned by NNA, at 64 percent, and in nonchain units, at 53 percent. At RCG and DCI
Percent of units
10.13
Percent of units
10.14
10
man. mos w/12.5%
10.16 Ave.EPO
dose reduction
20-<30
40-<50
60-<70
80-<90
10-<20
30-<40
50-<60
70-<80
90+
<10
20-<30
40-<50
60-<70
80-<90
10-<20
30-<40
50-<60
70-<80
90+
Percent of managed months
Managed months (≥12.5% month-to-month EPO dose
10.15 reduction),
by unit affiliation: when hemoglobin 13+ g/dl
Overall
50
EPO-treated
dialysis patients
By unit affiliation
All chains
Hospital-based
Non-chain
40
Percent of units
198
<10
Fresenius
Gambro
DaVita
RCG
DCI
NNA
30
20
10
0
<10
20-<30
40-<50
60-<70
80-<90
10-<20
30-<40
50-<60
70-<80
90+
<10
20-<30
40-<50
60-<70
80-<90
10-<20
30-<40
50-<60
70-<80
90+
Percent of managed months
70
Percent of managed months
0
EPO-tr.
dialysis pts
60
50
40
30
20
10
0
1
2
3
4
5
6 NC HB
Unit affiliation (see table at right for codes)
p-values
2 3
4
5
6
NC
HB
* * 0.0779 0.0011 0.0718
*
*
*
* 0.9991
*
*
*
*
* 0.0098
* 0.0017
* 0.9352 0.0013 0.0006
*
*
*
0.9636 0.8573
0.9955
*<0.0001 / red: p<0.05
1
2
3
4
5
6
NC
2006 annual data report || chapter ten
facilities, recommended testing is provided to fewer than one in
five diabetic patients receiving dialysis.
Only six in ten dialysis patients received an influenza vaccination in the autumn of 2004, still far from the HP2010 target of 90
percent (Figure 10.25). While a vaccine shortage did occur during
this period, the vaccine was available to high-risk patients such as
those with ESRD. In units owned by Fresenius, Gambro, and Renal
Care Group, 66–68 percent of patients received the vaccination; in
DaVita units, in contrast, the number was only 47 percent. −
patients; mean hemoglobin represents the average hemoglobin value for the year
across all patients. || Figure 10.22 incident dialysis patients, 2004. The lower limit of
albumins measured by bromcresol purple is 3.2 g/dl, & by bromcresol green is 3.5 g/
dl. || Figures 10.23–24 point prevalent dialysis patients, 2003, with 90-day rule, age
18–75 on December 31, 2004, & alive through that day, with diabetes as the primary
cause of ESRD or a comorbidity on the Medical Evidence form, or with diabetes diagnosed in 2003. Testing tracked in 2004; tests are at least 30 days apart. || Figure 10.25
dialysis patients initiating therapy at least 90 days before September 1, 2004, alive on
December 31, 2004, & with Medicare Parts A & B coverage during period; vaccinations tracked between September 1 & December 31.
All · All units
Chain 1 · Fresenius
Chain 2 · Gambro
Chain 3 · DaVita
Chain 4 · Renal Care Group
Figures 10.13–16 EPO-treated dialysis patients prevalent on January 1, 2004;
includes all EPO claims for the population in calendar year 2004. For a detailed definition of managed months, see Appendix A. || Figure 10.17 prevalent hemodialysis patients, 2004; from Medicare claims. || Figures 10.18–20 incident & prevalent
dialysis patients; from 2004 CPM report—patient data from 2003. || Figure 10.21
prevalent dialysis patients, 2004; from Medicare claims. Includes only EPO-treated
||
with URR
10.17 HD pts≥65%,
2004
incident & prev.
dialysis patients
Delivered
10.18 Kt/V,
2003
incident & prevalent
dialysis pts; CPM data
fistula
10.19 Newaspts1 w/AV
access, 2003
80
40
20
0
40
80
Percent of patients
20
10
All 1 2 3 4 5 6 NC HB
Unit affiliation (see table above for codes)
testing
10.23 inHbA1c
DM pts, 2004
point prevalent
dialysis pts, 2003
20
10
albumin ≥
10.22 Ptstest’sw/serum
lower limit, 2004
12+
11-<12
10-<11
9-<10
<9
40
20
30
25
20
15
10
5
0
All 1 2 3 4 5 6 NC HB
Unit affiliation (see table above for codes)
Lipid testing in
10.24 diabetic
pts, 2004
point prevalent
dialysis pts, 2003
70
60
60
Percent receiving 2+ tests
70
30
20
10
0
All 1 2 3 4 5 6 NC HB
Unit affiliation (see table above for codes)
50
40
30
20
10
0
All 1 2 3 4 5 6 NC HB
Unit affiliation (see table above for codes)
Influenza
10.25 vaccinations,
2004
60
40
incident
dial. pts
35
70
50
All 1 2 3 4 5 6 NC HB
Unit affiliation (see table above for codes)
40
60
0
prevalent
dialysis pts
30
0
All 1 2 3 4 5 6 NC HB
Unit affiliation (see table above for codes)
Percent vaccinated
Percent of patients
100
30
HD pts w/delivered Kt/V ≥1.2
CAPD pts w/delivered Kt/V ≥2.0
Pt distribution,
10.21 by hemoglobin,
2004
50
0
Percent receiving 4+ tests
inc. & prev.
dial. pts; CPM
20
0
All 1 2 3 4 5 6 NC HB
Unit affiliation (see table above for codes)
pts w/AV fist. as
10.20 Prev.
current access, 2003
40
Percent of patients
40
Percent of patients
80
Percent of patients
50
Percent of patients
100
60
inc. & prev.
dial. pts; CPM
st
100
60
Chain 5 · Dialysis Clinics, Inc.
Chain 6· National Nephrology Associates
NC · Non-chain units
HB · Hospital-based units
dialysis
patients
50
40
30
20
10
All 1 2 3 4 5 6 NC HB
Unit affiliation (see table above for codes)
0
All 1 2 3 4 5 6 NC HB
Unit affiliation (see table above for codes)
199
10
esrdprovider
providers
differences in preventive care
diabetic care
patients receiving 4+ HbA1c
10.26 Diabetic
tests per year, by unit affiliation
patients receiving 2+ lipid
10.27 Diabetic
tests per year, by unit affiliation
point prevalent
dialysis patients
70
70
2001
2004
50
40
30
20
10
50
40
30
20
10
All
1
2
3
4
5
6
NC
Unit affiliation (see table below for codes)
pts receiving a prescription for 2+
10.28 Diabetic
diabetic test strips/day, by unit affiliation
0
HB
point prevalent
dialysis patients
All
1
2
3
4
5
6
NC
Unit affiliation (see table below for codes)
patients receiving comprehensive
10.29 Diabetic
diabetic monitoring, by unit affiliation
20
HB
point prevalent
dialysis patients
7
2001
2004
15
2001
2004
6
Percent of patients
Percent of patients
2001
2004
60
Percent of patients
Percent of patients
60
0
point prevalent
dialysis patients
10
5
5
4
3
2
1
0
D
200
All
1
2
3
4
5
6
NC
Unit affiliation (see table below for codes)
HB
iabetic preventive care has improved since 2001 across
all dialysis providers, yet still remains far from optimal. Only 29 percent of diabetic dialysis patients in 2001
received the four glycosylated hemoglobin (HbA1c) tests recommended by the American Diabetes Association; by 2004 this number had improved to 53 percent, yet almost one in two patients is
still not receiving this recommended care (Figure 10.26). Improvements have been most dramatic in units owned by Gambro and
DaVita, with rates of 9–12 percent in 2001 rising to 60–62 percent
in 2004.
The provision of two or more lipid tests per year has also
improved, though not as quickly (Figure 10.27). Forty-one percent of diabetic patients now receive this testing, up from 31 percent in 2001. Units owned by National Nephrology Associates have
the highest testing rate, at 64 percent, though this is an increase of
only one percentage point since 2001. The greatest improvement
has occurred in facilities owned by Fresenius, with testing rates rising from 26 to 41 percent.
Prescriptions of diabetic testing strips, in contrast, have risen
most in Gambro units; 18 percent of diabetic patients in 2004 had
a prescription for two or more strips per day, up from 10 percent in
2001 (Figure 10.28). Across all other unit affiliations, only 12 percent of patients receive this prescription.
Levels of comprehensive diabetic monitoring—at least four
HbA1c tests per year, at least two lipid tests per year, and a prescription for at least two testing strips per day—are extraordinarily low
(Figure 10.29). Though rates have increased since 2001, only one in
25 diabetic patients on dialysis receives this preventive care. Test-
0
All
1
2
3
4
5
6
NC
Unit affiliation (see table below for codes)
All · All units
Chain 1 · Fresenius
Chain 2 · Gambro
Chain 3 · DaVita
Chain 4 · Renal Care Group
HB
Chain 5 · Dialysis Clinics, Inc.
Chain 6· National Nephrology Associates
NC · Non-chain units
HB · Hospital-based units
ing is most frequent in units owned by Gambro, yet is still provided
to only 6.4 percent of patients; in RCG and DCI units, respectively,
rates are only 2.1 and 1.4 percent.
Figures 10.30–34 illustrate the likelihood, by unit affiliation, of
different types of preventive care in dialysis patients age 65 and
older. The probability of a diabetic patient receiving his or her
fourth HbA1c test, for example, begins to rise at month five, and
takes a sharp turn upward in month ten (Figure 10.30).
The probability of a diabetic dialysis patient receiving a second
lipid test, in contrast, begins to rise earlier, at month two, and in
most providers increases steadily during the year (Figure 10.31).
Units owned by National Nephrology Associates seem to adhere
to a testing schedule, as the probability of testing spikes in month
3 and again in month 6.
In most providers the probability of receiving a vaccination
against influenza is small during September, jumps in October and
November, and levels out in December; in units owned by DaVita,
in contrast, the probability continues to increase during December, though patients in these units are the least likely to be vaccinated (Figure 10.32). By month 4, the probability ranges from a
low of 0.52 in units owned by DaVita to a high of 0.7 in Fresenius,
Gambro, and RCG facilities.
2006 annual data report || chapter ten
preventive care in patients age 65 & OLDER
Probability of receiving a fourth
10.30 HbA1c
test, by unit affiliation, 2004
point prevalent
dialysis patients, 2003
Probability of receiving a second
10.31 lipid
test, by unit affiliation, 2004
0.7
Fresenius
Gambro
DaVita
RCG
DCI
NNA
Non-chain
Hosp.-based
All
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0
1
2
3
4
5
6 7 8
Months
Cumulative probability
Cumulative probability
0.7
point prevalent
dialysis patients, 2004
0.5
0.4
0.3
0.2
0.1
0
1
2
3
4
5
6 7
Months
8
9 10 11 12
a pneumococcal pneumonia
10.33 Prob. of receiving
vaccination, by unit affiliation, 2004
point prevalent
dialysis pts, 2003
0.4
Fresenius
Gambro
DaVita
RCG
DCI
NNA
Non-chain
Hosp.-based
All
0.6
0.4
0.2
Oct
Months
Nov
Across all unit affiliations, the likelihood of receiving a pneumococcal pneumonia vaccination begins its first sharp increase
at month 10, is relatively flat from months 12 to 21, and then rises
again (Figure 10.33). By month 24, the probability is lowest in
units owned by Gambro and in hospital-based units, at 0.14–0.15,
and greatest in RCG and NNA units, at 0.38 and 0.36.
With the occurrence of hepatitis B not tied to any season, the
probability of a vaccination rises more steadily throughout the
year (Figure 10.34). By month 12, it reaches 0.3 overall, with a low
of 0.23 in hospital-based units and a high of 0.38 in units owned
by Gambro. −
|| All figures patients with Medicare Parts A & B primary payor coverage during
entire period. − || Figures 10.26–29 point prevalent dialysis patients, 2000 &
2003, with 90-day rule, age 18–75 on December 31 of the year & alive through the
end of the next year, with diabetes as the primary cause of ESRD or a comorbidity on the Medical Evidence form, or with diabetes diagnosed in 2000 or 2003.
Testing tracked in 2001 or 2004; HbA1c & lipid tests are at least 30 days apart.
“Comprehensive diabetic monitoring” includes at least four HbA1c tests & two
lipid tests per year, & a prescription for at least two diabetic test strips per day. ||
Figures 10.30–31 point prevalent dialysis patients, 2003, with 90-day rule, age 65
& older on January 1, 2003, & alive through the end of 2003, with diabetes listed
as the primary cause of ESRD or a comorbidity on the Medical Evidence form,
or with diabetes diagnosed during 2003. First testing tracked in 2004. || Figure
10.32 dialysis patients point prevalent on Sepember 1, 2004, with 90-day rule, age
65 & older on January 1, 2004. First vaccinations tracked between September 1
& December 31, 2004. || Figure 10.33 point prevalent dialysis patients, 2003, with
90-day rule, age 65 & older on January 1, 2003. First vaccinations tracked in 2003
& 2004. || Figure 10.34 point prevalent dialysis patients, 2004, with 90-day rule,
age 65 & older on January 1, 2004. First vaccinations tracked in 2004.
Fresenius
Gambro
DaVita
RCG
DCI
NNA
Non-chain
Hosp.-based
All
0.3
0.2
0.1
0.0
Dec
0
10.34
2
4
6
8 10 12 14 16 18 20 22 24
Months
Probability of receiving a hepatitis B
vaccination, by unit affiliation, 2004
point prevalent
dialysis patients, 2004
0.4
Cumulative probability
Sep
Cumulative probability
0.8
0.0
Sep 1
Fresenius
Gambro
DaVita
RCG
DCI
NNA
Non-chain
Hosp.-based
All
0.6
0.0
9 10 11 12
of receiving an influenza
10.32 Probability
vaccination, by unit affiliation, 2004
Cumulative probability
point prevalent
dialysis patients, 2003
Fresenius
Gambro
DaVita
RCG
DCI
NNA
Non-chain
Hosp.-based
All
0.3
0.2
0.1
0.0
0
1
2
3
4
5
6 7
Months
8
9 10 11 12
201
10
esrdprovider
providers
differences in Bayesian mortality & hospitalization ratios
I
n 2005, the USRDS introduced direct comparisons of
mortality and hospitalizations in the large provider
groups. This year we extend these comparisons, reporting BMRs and BHRs by provider groups based on their relation
to the national average (the numbers in the darker triangles of the
grids) and between pairs of providers (reported in the columns
and rows; see legend for help in reading the grids).
We focus here on results in 2004. For most outcomes, DCI had
the best performance, though DaVita showed similar results in
2004 for the first time. Hospitalizations for cardiovascular disease
were lowest, by 15–40 percent, for DCI. Infectious hospitalization
rates once again were lowest for DCI, with RCG a close second,
while rates for bacteremia/septicemia were lowest in RCG units
followed closely by those owned by NNA. Hospital-based units
had consistently higher event rates in all categories, a finding present at least since 2002.
Differences in outcomes by provider may be complex, and go
well beyond simple adjustments for age, gender, race, and primary
cause of ESRD. Other practice patterns may need to be addressed,
such as the use of dialysis catheters and simple fistulas, the percent
of patients with hemoglobin levels within the recommended target of 11–12 g/dl, the likelihood of overshooting a hemoglobin of 13
g/dl, and rates of influenza vaccinations. These complex analyses
may require the use of instrumental variables to determine if certain practice patterns are associated with different outcomes or are
similar to those in the general population within the regions of the
dialysis providers. −
|| Figures 10.35–40 period
prevalent dialysis patients, 2002 & 2004, in all dialysis
providers; adjusted for age, gender, race, primary diagnosis, & vintage.
All · All units
Chain 1 · Fresenius
Chain 2 · Gambro
Chain 3 · DaVita
Chain 4 · Renal Care Group
Chain 5 · Dialysis Clinics, Inc.
Chain 6 · National Neph. Assoc.
NC · Non-chain units
HB · Hospital-based units
Key to box plots
Line in box: median
Bottom & top of box:
25th & 75th percentiles
Bottom & top caps:
5th & 95th percentiles
To read grids
Ratios are of column to row.
For example, in Figure 10.36,
the number 1.165 in line 5 and
column 2 is the the SMR for
provider 2 (Gambro) divided by
the SMR of provider 5 (DCI).
Numbers on the diagonal show
each unit’s SMR or SHR for 2004,
as compared to the national
SMR or SHR.
bayesian mortality & hospitalization ratios: all-cause mortality & hospitalization
& BHRs:
10.35 BMRsall-cause
prevalent
dialysis patients
of median provider10.36 levelComparison
BMRs & BHRs: all-cause, 2004
prevalent
dialysis patients
7.4 2002
Hospitalization ratios: all-cause, 2004
BMR: all-cause
BHR: all-cause
1
2.7
1
2
3
4
5
1.027
0.992
0.957
0.909
0.966
0.932
0.965
6
NC
HB
1.002
0.993
1.454
1
0.885
0.975
0.967
1.416
2
0.917
1.010
1.001
1.466
3
0.950
1.047
1.038
1.520
4
1.102
1.092
1.600
5
0.992
1.452
6
1.464
NC
0.969
0.995
0.893
0.957
1.0
0.37
2004
7.4
2.7
3
0.961
1.027
1.151
0.831
4
0.927
1.000
1.121
0.974
0.854
5
0.881
1.040
1.165
1.013
1.040
0.821
6
0.970
0.889
0.996
0.866
0.889
0.855
0.960
NC
0.962
0.934
1.047
0.910
0.934
0.898
1.050
0.914
1.0
HB
1.409
0.396
0.444
0.386
0.396
0.381
0.446
0.424
2.154
1
0.37
2
3
4
5
6
Mortality ratios: all-cause, 2004
1
2
3
4 5
6 NC HB
Unit affiliation (see box above)
NC
HB
HB
Hospitalization ratios: all-cause, 2004
2
Mortality ratios: all-cause, 2004
202
Ratio (ln scale)
0.854
2006 annual data report || chapter ten
bayesian hospitalization ratios: cardiovascular disease & vascular access
10.37
prevalent
dialysis patients
Comparison of median provider-level BHRs:
10.38 cardiovascular
disease & vascular access, 2004
prevalent
dialysis patients
2002
BHR: cardiovascular disease
BHR: vascular access
Hospitalization ratios: vascular access, 2004
1
1
2
3
4
5
1.045
1.035
0.883
0.846
0.991
0.845
0.854
6
NC
HB
0.973
0.989
1.301
1
0.810
0.932
0.947
1.246
2
0.818
0.941
0.956
1.258
3
0.958
1.102
1.120
1.473
4
1.150
1.169
1.538
5
1.016
1.337
6
1.316
NC
0.984
1.0
0.37
2.7
2004
1.0
2
1.028
0.999
1.001
3
1.018
1.057
1.058
0.946
4
0.869
1.032
1.034
0.977
0.968
5
0.833
1.218
1.219
1.152
1.180
0.821
6
0.958
1.030
1.032
0.975
0.998
0.846
0.970
NC
0.973
1.052
1.053
0.995
1.019
0.864
1.021
Hospitalization ratios: vascular access, 2004
1.000
Hospitalization ratios: cardiovascular disease, 2004
Hospitalization ratio (ln scale)
2.7
BHRs: CVD &
vascular access
0.950
HB
1.280
0.747
0.748
0.707
0.724
0.613
0.725
0.710
HB
1.338
1
0.37
2
3
4
5
6
NC
HB
Hospitalization ratios: cardiovascular disease, 2004
1
2
3
4 5
6 NC HB
Unit affiliation (see box at left)
bayesian hospitalization ratios: infection & bacteremia/septicemia
7.4
BHRs: infection &
bacteremia/septicemia
prevalent
dial. pts
10.40
Comparison of median provider-level BHRs:
infection & bacteremia/septicemia, 2004
prevalent
dialysis patients
2002
BHR: infection
BHR: bacteremia/septicemia
Hospitalization ratios: bacteremia/septicemia, 2004
1
2.7
1
2
3
4
5
1.035
0.950
0.810
0.902
0.918
0.783
0.853
6
NC
HB
0.837
1.110
2.109
1
0.872
0.808
1.073
2.037
2
0.950
0.881
1.168
2.219
3
1.114
1.033
1.370
2.603
4
0.927
1.230
2.337
5
1.327
2.520
6
1.899
NC
0.914
1.0
2
0.37
0.14
7.4
2004
2.7
1.003
3
0.869
1.029
1.086
0.923
4
0.741
1.075
1.136
1.046
0.883
5
0.825
1.100
1.161
1.069
1.023
0.864
6
0.765
1.007
1.063
0.979
0.936
0.916
0.943
NC
1.0
0.947
0.947
1.015
0.986
1.041
0.959
0.917
0.897
0.980
0.963
HB
1.928
0.604
0.637
0.587
0.561
0.549
0.599
0.612
0.37
1.574
1
0.14
2
3
4
5
6
Hospitalization ratios: infection, 2004
1
2
3
4 5
6 NC HB
Unit affiliation (see box at left)
NC
HB
HB
Hospitalization ratios: bacteremia/septicemia, 2004
0.950
Hospitalization ratios: infection, 2004
Hospitalization ratio (ln scale)
10.39
203
10
esrdchapter
providers
summary
Figure 10.2 Between 1996
and 2004, the total number of
in-center hemodialysis treatments rose 66 percent, from
25.7 to 42.7 million. The use of peritoneal dialysis
has varied widely—falling 73 percent, for example,
in Network 1, but increasing nearly 340 percent in
Network 12. Figure 10.4 In Network 16, the percent of units that are chain-affiliated rose from 29.7
in 1996 to 50.4 in 2004, the greatest growth seen
among the networks. The market share of nonchain units continues to decline: in only two networks do these units now account for more than
half of those providing dialysis, down from five
networks in 2003. Figure 10.7 The number of dialysis units grew 52.9 percent between 1996 and 2004,
while the number of patients increased at a slightly
lower rate of 49.6.
provider
growth
Figure 10.10 Patient distribu-
tion by race varies slightly by
provider; 34 percent of incident Gambro patients, for
instance, are black, compared
to 28 percent overall and 24
percent in non-chain units. And 12 percent of new
patients treated in DaVita units are of HispanicMexican ethnicity, compared to 2.6–3.5 percent in
DCI and NNA units. Figure 10.11 Between 1999
and 2004 the number of units owned by Fresenius
grew 38 percent, to more than 1,100; the number of
patients treated in these units rose 41 percent, to
more than 80,000. With DaVita’s December 2004
acquisition of Gambro Healthcare, and the May
2005 purchase of Renal Care Group by Fresenius
Medical Care, care of ESRD patients in the United
States is now the responsibility of an ever-decreasing number of corporate providers.
provider
characteristics
& unit
affiliation
204
Figures 10.13–15 When hemo-
globin levels exceed 12–13 g/dl,
DaVita tends to adjust EPO
doses the least, and DCI the
most. Figures 10.23–24 Only
53 percent of diabetic dialysis
patients received four or more glycosylated hemoglobin tests in 2004, while only 41 percent received
two or more lipid tests. Figure 10.25 Only six in ten
dialysis patients received an influenza vaccination in
the autumn of 2004, far from the HP2010 target of
90 percent.
provider
compliance
with care
guidelines
Figure 10.26 Diabetic pre-
ventive care has improved
since 2001 across all dialysis
providers, yet still remains
far from optimal. The provision of four or more glycosylated hemoglobin tests
has improved most dramatically in units owned by
Gambro and DaVita, with rates of 9–12 percent in
2001 rising to 60–62 percent in 2004. Figure 10.34
The cumulative one-year probability of a hepatitis
B vaccination ranges from a low of 0.23 in hospital-based units to a high of 0.38 in units owned by
Gambro.
provider
differences in
preventive care
Figures 10.35–40 In analyses
of BMRs and BHRs, for most
outcomes, DCI had the best
performance, though DaVita
showed similar results in
2004 for the first time. These
complex analyses may require the use of instrumental variables to determine if certain practice
patterns are associated with different outcomes or
are patterns similar to those in the general population within the regions of the dialysis providers.
differences in
mortality &
hospitalization
ratios