Chartbook on Effective Treatment

Chronic Kidney Disease

Measures of Effective Treatment of Chronic Kidney Disease

  • Process:
    • Nephrology care before kidney failure.
    • Registration for transplantation.
  • Outcome:
    • Hemodialysis death rate.

Nephrology Care Before Kidney Failure

Patients who saw a nephrologist at least 12 months prior to initiation of renal replacement therapy, by race and ethnicity, 2005-2012

Charts show patients who saw a nephrologist at least 12 months prior to initiation of renal replacement therapy, by sex and age. Go to tables below for details.

Left Chart:

Race 2005 2006 2007 2008 2009 2010 2011 2012
White 27.3 28.0 28.8 30.4 30.2 31.3 32.7 34.7
Black 22.2 23.1 24.1 24.7 25.0 25.5 27.2 29.7
Asian 25.8 24.0 26.7 27.7 29.3 29.9 31.6 32.1
AI/AN 25.4 27.0 26 27.9 27.2 24.2 28.3 30.1
NHOPI 23.2 25.4 24 22.0 23.8 25.3 27.1 27.4

Right Chart:

Ethnicity 2005 2006 2007 2008 2009 2010 2011 2012
Total 25.7 26.4 27.3 28.6 28.6 29.6 31 33.1
Hispanic 20 21.3 21.4 22.3 22.6 23.7 25.1 25.9
Non-Hispanic Black 22.2 23.2 24.1 24.7 25.0 25.6 27.3 29.8
Non-Hispanic White 28.8 29.4 30.5 32.3 32.0 33.2 34.7 37

Key: NHOPI = Native Hawaiian or Other Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: U.S. Renal Data System, 2005-2012. http://www.usrds.org/2014/view/v2_02.aspx.
Note: Hispanic includes all races. These charts use data from the newest version of the  ESRD Medical Evidence CMS 2278  form. The cohorts include incident hemodialysis patients. Includes only patients for whom it is known whether they saw a nephrologist prior to initiation.

  • Importance:
    • 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).
  • Groups With Disparities:
    • In all years, the percentage of new end stage renal disease (ESRD) patients who began nephrology care at least 12 months prior to initiation of renal replacement therapy was higher for non-Hispanic Whites than for Hispanics.
    • From 2009 to 2012, the percentage of ESRD patients who began nephrology care at least 12 months prior to initiation of renal replacement therapy was higher for White and Asian patients than for Black, AI/AN, and NHOPI patients.

Nephrology Care Before Kidney Failure

Patients who saw a nephrologist at least 12 months prior to initiation of renal replacement therapy, by sex and age, 2005-2012

Charts show patients who saw a nephrologist at least 12 months prior to initiation of renal replacement therapy, by sex and age. Go to tables below for details.

Left Chart:

Sex 2005 2006 2007 2008 2009 2010 2011 2012
Total 25.7 26.4 27.3 28.6 28.6 29.6 31 33.1
Male 26.1 26.5 27.3 28.4 28.3 29.6 30.8 33.2
Female 25.3 26.3 27.3 28.8 28.9 29.5 31.4 33.1

Right Chart:

Age 2005 2006 2007 2008 2009 2010 2011 2012
<18 39.7 36.1 35.1 40.1 39.1 37.7 44.7 40.7
18-44 23.3 23 23.7 24.4 23.9 24.3 25.8 27.8
45-64 25.7 26.1 26.7 27.3 27.4 27.9 29.5 31.2
65+ 26.1 27.5 28.6 30.5 30.5 32 33.4 35.9

Source: U.S. Renal Data System, 2005-2012. http://www.usrds.org/2014/view/v2_02.aspx.
Note: These charts use data from the newest version of the ESRD Medical Evidence CMS 2278 form. The cohorts include incident hemodialysis patients. Includes only patients for whom it is known whether they saw a nephrologist prior to initiation.

  • Groups With Disparities:
    • In 2012, at least 33% of both males and females began nephrology care at least 12 months prior to initiation of renal replacement therapy.
    • 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 under age 18, ages 45-64, and age 65 and over than for patients ages 18-44.

Nephrology Care Before Kidney Failure

Patients age 18 and over who saw a nephrologist at least 12 months prior to initiation of renal replacement therapy, by State, United States, 2011

Chart shows patients age 18 and over who saw a nephrologist at least 12 months prior to initiation of renal replacement therapy, by State: District of Columbia, 12.1; California, 15.0; Kentucky, 16.1; Maryland, 16.7; Illinois, 18.4; Indiana, 20.2; Tennessee, 21.2; Nevada, 22.5; Oklahoma, 22.8; Mississippi, 23.6; Pennsylvania, 23.6; New Mexico, 25.7; Florida, 25.8; Missouri, 26.4; Ohio, 27.0; Texas, 27.7; Louisiana, 27.9; New York, 28.2; Arizona, 28.6; New Jersey, 28.6; West Virginia, 28.6; Georgia, 28.9; Virginia, 28.9; Arkansas, 29.1; Alabama, 29.8; Kansas, 30.1; Connecticut, 30.2; Nebraska, 31.2; Michigan, 31.7; Wyoming, 32.2; North Dakota, 33.6; Rhode Island, 34.0; North Carolina, 34.8; South Carolina, 36.5; Minnesota, 37.1; Idaho, 37.6; Colorado, 37.7; Delaware, 38.4; South Dakota, 38.7; Utah, 39.6; Massachusetts, 40.1; Vermont, 40.7; Iowa, 41.2; Wisconsin, 42.9; Washington, 43.0; Oregon, 44.3; Hawaii, 45.3; New Hampshire, 45.3; Maine, 45.7; Alaska, 46.2;Montana, 50.0; Puerto Rico, DNA.

Source: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, United States Renal Data System, 2011.

  • Geographic Variation:
    • 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.
    • 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, Kentucky, Maryland, and Illinois.

Registration for Transplantation

Dialysis patients under age 70 who were registered for transplantation within a year of ESRD initiation, by race and ethnicity, 2000-2011

Charts show dialysis patients under age 70 who were registered for transplantation within a year of ESRD initiation, by race and ethnicity. Go to tables below for details.

Left Chart:

Race 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
White 17.1 16.3 16.1 16.4 16.8 17.6 18.5 18.6 18.2 18.3 17.9 18.7
Black 11.2 10.5 10.7 10.6 11.6 12.1 13.1 13.3 13.3 13.9 13.9 14.5
Asian 27 29.1 28 28.3 32.1 28.2 31.3 30.8 31.3 32.3 32.1 33.1
AI/AN 12.8 9.7 10.1 9.6 10.2 11.3 10.4 11.3 10.7 11.5 11.5 11.3
NHOPI 17.4 17.5 18.8 19.5 18.1 16.0 15.2 14.9 14.1 15.2 15.2 14.8

2011 Achievable Benchmark: 20.6%.

Right Chart:

Ethnicity 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Total 15.4 14.6 14.6 14.7 15.4 15.9 17 17.1 16.8 17.3 17 17.7
Hispanic 13 12.7 13.3 14.1 14.6 15.8 17.6 17.7 17.4 18.2 17.6 18.6
Non-Hispanic Black 11.2 10.5 10.7 10.6 11.6 12 13 13.2 13.2 13.9 13.9 14.5
Non-Hispanic White 18.1 17.1 16.8 16.8 17.2 18.1 18.8 18.9 18.4 18.3 18 18.5

2011 Achievable Benchmark: 20.6%.

Key: NHOPI = Native Hawaiian or Other Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: U.S. Renal Data System, 2000-2011. http://www.usrds.org/2014/view/v2_02.aspx.

Note: Hispanic includes all races. The cohort includes patients from 2000-2011 who were younger than 70 at the initiation of ESRD. Percentages are calculated as the number of patients placed on the deceased donor organ waiting list or receiving a deceased donor transplant within 1 year of initiation, divided by the number of patients without a living donor available (i.e., patients receiving a living donor transplant are excluded), and are estimated using the Kaplan-Meier methodology.

  • Importance: 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, 2013b).
  • Trends: From 2000 to 2011, the total percentage of dialysis patients under age 70 who were registered for transplantation within 1 year of progressing to ESRD increased from 15.4% to 17.7%.
  • Groups With Disparities:
    • From 2006 to 2011, Blacks, NHOPIs, and AI/ANs were less likely than Whites to be registered for transplantation within 1 year of progressing to ESRD. However, Asians were more likely than Whites to be registered.
    • From 2000 to 2011, the percentage of dialysis patients registered for transplantation within 1 year of progressing to ESRD was lower for non-Hispanic Blacks than for non-Hispanic Whites and Hispanics.
  • Achievable Benchmark:
    • The 2011 top 5 State achievable benchmark for registration for transplantation within 1 year of progressing to ESRD was 20.6%. The top 5 States that contributed to the achievable benchmark are Colorado, Delaware, Minnesota, South Dakota, and Vermont.
    • Asians have already surpassed the 2011 achievable benchmark.

Registration for Transplantation

Dialysis patients under age 70 who were registered for transplantation within a year of ESRD initiation, by sex and age, 2000-2011

Charts show dialysis patients under age 70 who were registered for transplantation within a year of ESRD initiation, by sex and age. Go to tables below for details.

Left Chart:

Sex 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Male 16.5 15.3 15.7 15.6 16.5 16.9 18.0 17.8 17.5 18.1 17.8 18.4
Female 13.4 13.4 12.7 13.1 13.7 14.3 15.3 15.8 15.7 15.8 15.8 16.5
Total 15.4 14.6 14.6 14.7 15.4 15.9 17.0 17.1 16.8 17.3 17 17.7

2011 Achievable Benchmark: 20.6%.

Right Chart:

Age 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
<18 42.9 40.7 43 50.1 46.3 53.3 57.5 56.2 58.2 57.9 56.5 54.9
18-44 29.5 27.6 27.7 26.1 27.8 26.9 28.9 27.8 27.6 27.9 27.1 28.9
45-64 18 17 16.3 16.5 17 17.5 18.3 18.6 17.7 18.4 18.3 19.1
65-69 7.4 7.3 7.9 8.4 9.2 10 11.1 11.4 11.9 12.3 12.3 12.6

2011 Achievable Benchmark: 20.6%.

Source: U.S. Renal Data System, 2000-2011. http://www.usrds.org/2014/view/v2_02.aspx
Denominator: Patients younger than 70 at ESRD initiation.
Note: Percentages are calculated as the number of patients placed on the deceased donor organ waiting list or receiving a deceased donor transplant within one year of initiation, divided by the number of patients without a living donor available (i.e., patients receiving a living donor transplant are excluded), and are estimated using the Kaplan-Meier methodology.

  • Groups With Disparities:
    • In all years, females were less likely than males to be registered for transplantation within 1 year of progressing to ESRD.
    • In all years, patients under age 18 years and ages 18-44 years were more likely than patients ages 45-64 and 65 and over to be registered for transplantation within 1 year of progressing to ESRD.
  • Achievable Benchmark:
    • The 2011 top 5 State achievable benchmark for registration for transplantation within 1 year of progressing to ESRD was 20.6%. The top 5 States that contributed to the achievable benchmark are Colorado, Delaware, Minnesota, South Dakota, and Vermont.
    •  Patients ages 18 and under and 18-44 have already surpassed the 2011 achievable benchmark.

Hemodialysis Death Rate

Standardized mortality ratios on hemodialysis, by State or territory, 2012

Chart shows mortality ratios on hemodialysis, by State or territory: Montana, 0.75; Colorado, 0.78; Maine, 0.78; South Dakota, 0.81; Rhode Island, 0.83; Massachusetts, 0.85; District of Columbia 0.86; Alaska, 0.86; Delaware, 0.87; Hawaii, 0.89; Idaho, 0.90; New Hampshire, 0.90; Oregon, 0.91; Virgin Islands 0.91; New Mexico, 0.92; Connecticut, 0.94; Wisconsin, 0.94; Indiana, 0.94; Northern Marianas 0.95; Nebraska, 0.95; Washington, 0.95; Iowa, 0.95; Vermont, 0.96; California, 0.97; New Jersey, 0.98; Minnesota, 0.98; Illinois, 0.98; New York, 0.98; Pennsylvania, 0.98; Utah, 0.98; Oklahoma, 0.99; Michigan, 1.01; Tennessee, 1.01; Wyoming, 1.01; Ohio, 1.02; North Dakota, 1.02; North Carolina, 1.02; Alabama, 1.03; Georgia, 1.03; Kansas, 1.03; Texas, 1.04; Arizona, 1.05; Missouri, 1.05; Mississippi, 1.06; Florida, 1.07; South Carolina, 1.07; Maryland, 1.07; Virginia, 1.09; Nevada, 1.09; West Virginia, 1.12; Arkansas, 1.13; Louisiana, 1.15; Kentucky, 1.16; Guam, 1.34; Puerto Rico, 1.44.

Source: University of Michigan Kidney Epidemiology and Cost Center (UM-KECC), Dialysis Facility Reports.

  • Importance:
    • 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.
  • Geographic Variation:
    • SMRs vary across U.S. States and territories, from a low in Montana to a high in Puerto Rico.
    • Montana’s SMR of 0.75 indicates facility death rates that are typically 25% below the national death rate.
    • Puerto Rico’s SMR of 1.44 indicates facility death rates that are 44% above the national death rate.

References

U.S. Renal Data System. USRDS 2013 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013a. Available at: http://www.usrds.org/atlas.aspx. Accessed July 8, 2015.

U.S. Renal Data System. USRDS 2013 annual data report reference tables. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013b. Available at http://www.usrds.org/atlas13.aspx. Accessed July 8, 2015.

Return to Contents

Page last reviewed July 2015
Page originally created September 2015
Internet Citation: Chronic Kidney Disease. Content last reviewed July 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/effectivetx/eff-kidney.html