Chapter Five - Peer Kidney€¦ · · 2016-11-16awareness and understanding of the determinants of health, ... Chapter 5: Benchmarks . Morality in the first 3 months of dialysis

Chapter Five

BENCHMARKS

PEER REPORT DIALYSIS CARE & OUTCOMES IN THE US, 2016 124

Chapter 5: BENCHMARKS Introduction

INTRODUCTION Since the turn of the millennium, major gains have occurred in the health of

patients receiving maintenance dialysis in freestanding facilities. The rate of growth in numbers of incident patients has decreased markedly since approximately 2008-2009 (Chapter 1, Figure 1.2), while mortality rates have also declined (Chapter 3, Figures 3.1-3.4).

These are, of course, welcome achievements. However, they should be evaluated within the broader context of established nationwide public health objectives, and scrutinized to determine whether all patient groups and all areas of the country have shared in them. The US public health objectives are codified by the Healthy People (HP) 2020 project, the nation’s foremost “health promotion and disease prevention initiative.” The HP initiative originated with the landmark Surgeon General’s HP report of 1979, which enshrined the concept that the health of the US population should be a societal priority. The stated missions of the current version of the initiative (HP 2020) are to (1) identify nationwide health improvement priorities; (2) increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress; (3) provide measurable objectives and goals that are applicable at the national, state, and local levels; (4) engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge; and (5) identify critical research, evaluation, and data collection needs.

While the HP 2010 initiative was the first to enumerate kidney-disease-specific goals, the HP 2020 initiative advanced this effort by explicitly listing a series of chronic kidney disease (CKD) public health targets (https://www.healthypeople.gov/2020/topics-objectives/topic/chronic-kidney-disease). In this chapter, we examine how the kidney care community has fared with regard to achieving specific HP 2020 goals, or benchmarks. Additionally, we examine how factors such as demographic characteristics and geographic location have been associated with the gains of the previous decade, and consider how these findings might inform future goal-development efforts. We present unadjusted data relevant to some specific HP 2020 goals, as described more fully on the following pages.

• Incidence rates

• Prevalent patient mortality rates

• Mortality in the first 3 months of dialysis

• Cardiovascular mortality

• Vascular access

https://www.healthypeople.gov/2020/topics-objectives/topic/chronic-kidney-disease

https://www.healthypeople.gov/2020/topics-objectives/topic/chronic-kidney-disease

Chapter 5: Benchmarks Incidence rates


5.1 Incidence rates, overall & by US census divisionPatients aged 18 years or older.

INCIDENT HP 2020 goal CKD-8 is to reduce the number of new cases of end-stage renal disease (ESRD) by 10%. Incidence rates of new dialysis initiates in freestanding facilities, overall and by US census division, are shown in Figure 5.1. Overall unadjusted rates grew steadily from approximately 35 per 100,000 persons in 2000 to 42 in 2009. However, the rate has remained relatively stable since then, and was approximately 43 per 100,000 persons in 2013. Incidence rates varied considerably geographically, however, with a 2.0-fold difference between the regions with the highest and lowest rates.

Rates differed notably by race, as shown in Figure 5.2. Since 2009, rates of new white dialysis patients increased slightly, from 34.5 to 35.5 per 100,000 persons. However, the rate of new African American dialysis patients, nearly triple that of white patients, declined from 101.9 to 97.3; the rate also declined for Asians (41.8 to 40.4).

5.2 Incidence rates, by racePatients aged 18 years or older.

INCIDENT

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5.3 Incidence rates, overall & by US census division Patients aged 18 years or older.

INCIDENT

White African American

Other

As would be expected based on Figures 5.1 and 5.2, geographic variation in incidence rates was present across all races (Figure 5.3).

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Chapter 5: Benchmarks Prevalent patient mortality rates


5.4 One-year mortality rates in prevalent dialysis patients,

overall & by US census division Patients aged 18 years or older.

PREVALENT The HP 2020 mortality goal for incident patients is a 10% improvement (decrease) from 2007 to 2020, which would require an improvement of about 0.8% annually. From 2003 to 2013, the average annual improvement was approximately 2.5%, more than double that anticipated (Figure 5.4). All regions demonstrated improvement, despite substantial geographic variation. Patients of every racial group have benefitted, in unadjusted terms: from 2000 to 2013, mortality rates declined from 26.9 to 20.1 per 100 patient-years for white patients, from 17.4 to 13.0 for African American patients, from 16.8 to 13.0 for Asian patients, and from 22.05 to 13.2 for patients of other races (Figure 5.5).

5.5 One-year mortality rates in prevalent dialysis patients,

by race Patients aged 18 years or older.

PREVALENT

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5.6 One-year mortality rates in prevalent dialysis patients, by race, overall & by US

census division Patients aged 18 years or older.

PREVALENT


Other

Mortality rates by race are shown across census divisions in Figure 5.6.

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Chapter 5: Benchmarks Mortality in the first 3 months of dialysis


5.7 Mortality in the first 3 months of dialysis, by incident year & quarter Patients aged 18 years or older.

INCIDENT

Mortality is strikingly high in the first 90 days after dialysis initiation. This likely reflects numerous factors, including use of tunneled dialysis catheters and the resulting risk of infection, under-adaptation to rapid swings in hemodynamics and electrolytes, presence of late-stage CKD disorders such as anemia and secondary hyperparathyroidism, and perhaps lingering effects of other clinical events that may have prompted dialysis initiation.

Mortality rates in the first 3 months increased slowly but steadily from 1996, when the rate was 37.0 per 100 person-years, to a peak of 43.4 in 2003. Since then, the increase has been reversed; rates gradually declined such that the 2013 rate was 34.7, lower than in 1996 (Figure 5.7).

Geovariability was substantial, as shown in Figure 5.8. For example, the Pacific and Mountain census divisions experienced declines of more than 8 deaths per 100 person-years, and rates in 2013 were below 30; the West South Central division also experienced a substantial decline of nearly 5 deaths per 100 person-years. The West North Central and South Atlantic divisions experienced more modest declines. However, the New England and East South Central divisions experienced slight increases, while rates in the Middle Atlantic and East North Central divisions increased by about 3 and 4 deaths per 100 person-years, respectively.

5.8 Mortality in the first 3 months of dialysis, overall & by US census division Patients aged 18 years or older.

INCIDENT

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Three-month mortality among all incident patients in the quarter

Three-month mortality among all incident patients in the year

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5.9 Mortality in the first 3 months of dialysis, by race Patients aged 18 years or older.

INCIDENT

The findings regarding race are somewhat complex. A consistent finding is that the death rates for white patients are over 50% higher than for African American patients in the first 3 months (Figure 5.9). Since peaking in 2003, however, rates declined over 20% for both races, from 50.4 to 39.9 for white patients and 31.9 to 25.2 for African American patients.

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Chapter 5: Benchmarks Morality in the first 3 months of dialysis


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5.10 Mortality in the first 3 months of dialysis, by race, overall & by US census

division Patients aged 18 years or older.

INCIDENT


Other

Mortality in the first 3 months of dialysis by race across the geographic regions is shown in Figure 5.10.

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Chapter 5: Benchmarks Cardiovascular mortality


Cardiovascular diseases are the most common cause of death in dialysis patients. As such, cardiovascular mortality in prevalent patients was targeted for a 10% improvement (goal CKD-143). From 2001 to 2013, mortality decreased by approximately 5% annually, far exceeding the goal of approximately 0.8% per year. In terms of unadjusted rates, cardiovascular deaths decreased from approximately 12 deaths per 100 person-years in 1996 to less than 7 in 2013 (Figure 5.11).

All regions experienced the same general magnitude of decline (Figure 5.12), although an approximately 20% difference in unadjusted rates remained across regions (7.7 deaths per 100 patient-years in the Middle Atlantic division versus 6.4 in the Pacific).

5.11 One-year cardiovascular mortality rates in prevalent dialysis patients, by

calendar year & quarter Patients aged 18 years or older.

PREVALENT

5.12 One-year cardiovascular mortality rates in prevalent dialysis patients, overall &

by US census division Patients aged 18 years or older.

PREVALENT

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CV mortality among patients prevalent on the first day of the quarter

CV mortality among patients prevalent on the first day of the year

Chapter 5: Benchmarks Cardiovascular mortality


All races shared in this cardiovascular death improvement (declining rates); however, in unadjusted terms, the decrease was relatively more for white patients, who have the highest rates of cardiovascular mortality of any race, than for African American patients (Figure 5.13).

That the decrease in cardiovascular-related mortality has been greater than in all-cause mortality is noteworthy, and invites speculation (Figure 5.11 and Chapter 3, Figure 3.3). One factor that may partially account for this finding is increased use of drugs such as β-adrenergic blockers and renin-angiotensin-aldosterone-system inhibitors in the dialysis population. For example, use of β-blockers, whose potentially beneficial effects were posited nearly 2 decades ago (Zuanetti et al, Nephrol Dial Transplant 1997;12:2497-2500), increased in US dialysis patients from approximately 43% in the DOPPS II data from 2002-2004 (Lopes et al, Nephrol Dial Transplant 2009;24:2809-2816) to approximately 59% in 2011 (USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease & End-Stage Renal Disease in the United States). Whether this increase was due to deliberate actions by nephrologists or to a more general “carryover” phenomenon originating in the general population is uncertain. Indeed, whether increasing use of such agents might help prevent heart failure-related, arrhythmia-related, and/or other cardiac deaths is speculative.

5.13 One-year cardiovascular mortality rates in prevalent dialysis patients, by race Patients aged 18 years or older.

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5.14 One-year cardiovascular mortality rates in prevalent dialysis patients, by race,

overall & by US census division Patients aged 18 years or older.

PREVALENT


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Figure 5.14 demonstrates cardiovascular mortality decreases, by race, across geographic regions.

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Chapter 5: Benchmarks Vascular access


5.15 Vascular access at dialysis initiation, hemodialysis patients According to the Medical Evidence Report; patients aged 18 years or older.

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Vascular access, specifically the percentage of patients with a functioning or maturing arteriovenous fistula at dialysis initiation, is also an HP 2020 goal (CKD-11.3), which aims for a 10% improvement from 2007 to 2020.

Vascular access data present a complex story and require careful analysis. In unadjusted data, use of fistulas at dialysis initiation increased only marginally in absolute terms, from 17.1% in 2006 to 19.1% in 2013 (Figure 5.15). This does not take into account patients with a maturing permanent access in place at the time of initiation. In relative terms, this is an improvement of approximately 12%, which, were it the result of a pharmacological intervention in a randomized controlled trial, would likely be considered non-trivial. Overall use of catheters did not appear to vary much geographically: use of fistulas or grafts ranged from 15.2% in the West South Central division to 24.0% in New England in 2006 and from 16.7% to 26.5%, respectively, in 2013 (Figure 5.16).

5.16 Vascular access at dialysis initiation, hemodialysis patients, overall & by US

census division According to the Medical Evidence Report; patients aged 18 years or older.

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5.17 Vascular access at dialysis initiation & during first year of dialysis, hemodialysis

patients incident July 2011-December 2012, overall & by US census division According to the Medical Evidence Report & Medicare claims; patients aged 18 years

or older.

INCIDENT

Catheters Fistulas/Grafts

5.18 Vascular access at initiation & during first year of dialysis, hemodialysis patients

incident July 2011-December 2012, by race According to the Medical Evidence Report & Medicare claims; patients aged 18 years

or older.

INCIDENT


The structure of billing claims changed in July 2010, permitting ascertainment of the type of access actually in use. This had the effect of allowing examination of the transition off catheters within the first year after initiation. A consistent pattern is apparent (Figure 5.17), and can be broadly summed up as follows: Upon initiation, roughly 80% of patients use catheters. Little progress is made in the first 3 months, such that the rate decreases only to approximately 73%. At 6 months, more than half of patients (52%) are still using catheters. Roughly a third are using catheters at 9 months, and a quarter at 1 year. Importantly, these findings, as unfortunate as they are, are likely more sobering than they appear: as catheter use is associated with early mortality on dialysis, catheter users are likely culled out disproportionately as the year progresses. Thus, survivors are likely enriched in users of permanent accesses.

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Chapter 5: Benchmarks Vascular access



patients incident July 2011-December 2012, by age According to the Medical Evidence Report & Medicare claims; patients aged 18 years

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INCIDENT



Use of catheters over the course of the first year appears to differ little by race (Figure 5.18), by age (Figure 5.19), or by cause of ESRD (Figure 5.20), with the exception of consistently greater penetrance of permanent accesses at all time points in patients with cystic kidney disease, such as autosomal dominant polycystic kidney disease, who likely have consistent interactions with nephrologists for years or decades before dialysis initiation.

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Chapter 5: Benchmarks Vascular access, by US census division & state


Ra ra

Overall, no consistent trend up or down occurred in the East North Central division, although the percentage of patients initiating with a catheter declined modestly in recent years, from 82.3% in 2010 to 77.8% in 2013.

The decline was most pronounced in Wisconsin, at 1.4% per year. In Indiana and Ohio, the percentage was actually higher in 2013 than in 2006.

5.a Percentage of hemodialysis patients by vascular access at dialysis initiation,

by US census division & state, divisions 1-3 According to the Medical Evidence Report; patients aged 18 years or older. APC, annual percent change. Maps show 2013 results.

INCIDENT

Division 1 ● New England

Percentages of patients using a catheter declined modestly in New England, at an annual percent change of 0.9 from 2006 to 2013.

Rates declined most sharply in New Hampshire, at an average of 1.4% per year, resulting in an 8% decline from 2006 to 2013.

There was no consistent year to year trend in Maine, resulting in an annual percent change of0.0%.

* Denotes “not applicable” because the APC could not be calculated due to a zero value in 2006.

Division 2 ● Mid Atlantic

Division 3 ● East North Central

2006 2007 2008 2009 2010 2011 2012 2013 APC sparklines

ALL 75.6 75.8 75.8 73.8 74.4 71.3 72.6 72.0 -0.9

CT 77.8 73.9 73.0 72.8 76.1 74.5 72.3 73.6 -0.5

ME 62.7 67.1 71.3 70.5 73.4 63.6 65.1 66.7 0.0

MA 77.7 77.7 77.4 75.1 73.6 70.7 74.1 72.3 -1.2

NH 68.8 69.5 71.4 67.3 69.0 61.3 67.3 63.3 -1.4

RI 76.2 83.1 81.8 80.4 79.7 78.2 75.1 79.1 -0.5

VT 0.0 66.7 100.0 42.9 92.9 85.7 75.0 66.7 *

2006 2007 2008 2009 2010 2011 2012 2013 APC sparklines

ALL 78.8 80.9 81.2 81.0 79.5 78.5 78.1 77.8 -0.5

NJ 79.6 81.1 82.7 81.0 78.8 80.2 81.2 80.3 -0.1

NY 74.4 78.3 78.9 78.9 76.5 76.0 76.4 77.4 0.0

PA 82.1 83.3 82.9 83.0 82.9 80.1 77.9 76.4 -1.1

2006 2007 2008 2009 2010 2011 2012 2013 APC sparklines

ALL 80.1 79.8 79.6 80.2 82.3 81.7 78.5 77.8 -0.2

IL 81.6 79.8 78.8 81.1 83.2 81.9 79.0 77.8 -0.3

IN 78.3 78.1 81.2 80.4 82.7 84.1 78.4 79.7 0.3

MI 82.6 83.0 84.3 82.0 83.1 81.9 79.0 77.0 -1.0

OH 76.7 77.7 75.1 77.8 80.9 80.5 78.7 78.3 0.5

WI 82.7 81.9 81.1 79.6 80.6 79.5 75.4 74.8 -1.4

Overall, the percentage of patients using a catheter declined slightly in the Mid Atlantic division, at 0.5% per year. Most of this decline occurred from 2009 to 2013, when the percentage ofpatients using a catheter dropped by 4.0%.

No consistent overall change occurred in New York, and most of the change in the divisionappeared to be driven by Pennsylvania.

Chapter 5: Benchmarks Vascular access, by US census division & state


percentage of patients using a catheter percentage of patients using a catheter

INCIDENT

Division 4 ● West North Central

The percentage of patients using a catheter decreased most markedly in the West North Central division, compared with other divisions, at 1.6% per year.

All states experienced a decline of at least 1% per year except North Dakota and South Dakota, where the pattern over time was not consistent.

The percentage of patients using a catheter declined by 0.9% annually in the South Atlantic division.

There was considerable variation across the region, however, with Delaware (1.9%) and Maryland (1.7%) demonstrating the largest annual decreases and DC showing no consistent change (0.0 annual percent change).

Division 5 ● South Atlantic

Division 6 ● East South Central

2006 2007 2008 2009 2010 2011 2012 2013 APC sparklines

ALL 82.6 82.1 82.0 81.9 81.0 80.2 78.1 77.3 -0.9

DE 77.6 72.9 70.9 75.0 70.2 66.8 71.0 65.2 -1.9

DC 77.4 76.2 77.8 77.7 81.4 76.1 79.1 75.2 0.0

FL 86.0 85.1 86.4 85.7 85.5 84.4 83.1 81.8 -0.6

GA 82.5 82.9 81.9 82.0 81.7 81.6 80.7 77.8 -0.7

MD 84.0 81.8 81.6 79.0 80.8 80.9 73.1 73.8 -1.7

NC 79.7 79.6 77.4 78.0 74.5 74.1 72.7 72.7 -1.5

SC 76.9 76.5 77.7 77.9 76.4 77.5 74.9 74.9 -0.4

VA 82.8 83.0 81.2 83.1 80.6 78.5 75.1 77.4 -1.3

WV 77.6 79.9 82.0 82.7 79.2 77.4 76.7 75.0 -0.8

2006 2007 2008 2009 2010 2011 2012 2013 APC sparklines

ALL 84.2 83.4 83.0 82.1 81.2 76.9 76.9 75.8 -1.6

IA 81.9 81.5 78.6 82.5 78.1 72.3 77.3 78.8 -1.0

KS 82.9 82.6 81.4 83.3 83.8 78.4 76.7 70.5 -1.9

MN 84.4 83.5 81.4 82.6 79.3 75.6 75.2 74.9 -1.9

MO 84.5 83.3 83.9 80.8 81.5 77.1 76.9 76.0 -1.6

NE 85.3 86.5 87.1 81.3 82.7 79.6 77.6 78.2 -1.7

ND 100.0 50.0 97.4 93.1 83.9 89.5 80.0 84.1 0.9

SD 95.5 90.6 90.0 91.7 81.0 82.6 84.6 92.1 -1.1

2006 2007 2008 2009 2010 2011 2012 2013 APC sparklines

ALL 79.5 80.4 80.4 79.1 80.0 80.3 78.7 77.9 -0.3

AL 78.4 77.7 76.4 76.4 76.0 76.5 73.8 75.1 -0.7

KY 74.4 78.4 77.6 75.2 79.4 81.8 78.5 76.6 0.5

MS 80.8 79.0 83.2 83.0 82.1 81.2 80.6 79.0 -0.2

TN 82.7 84.6 83.8 81.6 82.6 81.9 81.7 80.5 -0.5 The percentage of patients using a catheter decreased only 0.3% per year, overall, in the East

South Central division. Alabama led the region with an improvement of 0.7 annual percent change, while catheter use

in Kentucky was actually higher in 2013 than 2006.


by US census division & state, divisions 4-6 According to the Medical Evidence Report; patients aged 18 years or older. APC, annual percent

change. Maps show 2013 results.

Patients aged 18 years or older. APC, annual percent change. Maps show 2013 counts.



by US census division & state, divisions 7-9 According to the Medical Evidence Report; patients aged 18 years or older. APC, annual percent

change. Maps show 2013 results.

INCIDENT

Division 7 ● West South Central

The percentage of patients using a catheter improved robustly at 1.5% per year annually in the Mountain division.

Utah, Nevada, and Arizona all experienced substantial declines (2.3, 1.9, and 1.8 annual percent change, respectively).

Wyoming and Montana, however, actually experienced increases in catheter use from 2006 to 2013.

Division 8 ● Mountain

Division 9 ● Pacific

2006 2007 2008 2009 2010 2011 2012 2013 APC sparklines

ALL 83.1 82.2 83.2 81.7 80.4 79.4 75.7 75.5 -1.5

AZ 85.3 84.5 84.2 83.9 81.7 79.2 76.7 75.3 -1.8

CO 77.2 77.8 77.6 76.6 75.5 75.1 71.6 76.0 -0.8

ID 79.7 75.9 85.4 76.4 77.0 75.7 72.9 70.7 -1.6

MT 68.0 83.6 80.0 83.9 79.0 77.7 72.4 79.3 0.3

NV 90.1 86.1 87.3 84.7 86.1 84.2 78.5 77.2 -1.9

NM 79.1 78.9 82.6 83.2 76.6 80.8 77.2 78.8 -0.3

UT 81.9 80.2 81.4 76.7 76.7 78.6 72.1 67.5 -2.3

WY 65.7 89.2 64.9 75.0 82.9 79.1 81.5 73.5 1.2

2006 2007 2008 2009 2010 2011 2012 2013 APC sparklines

ALL 84.3 85.0 85.3 84.6 84.3 83.4 81.2 80.5 -0.7

AR 88.1 88.6 89.8 87.6 87.8 87.5 82.7 80.8 -1.2

LA 84.0 82.7 83.3 81.0 80.0 79.1 75.6 75.3 -1.6

OK 86.0 85.6 87.1 85.6 84.9 86.7 81.5 79.5 -1.0

TX 83.8 85.1 85.0 85.1 84.9 83.6 82.3 81.8 -0.5

2006 2007 2008 2009 2010 2011 2012 2013 APC sparklines

ALL 78.0 81.0 79.7 80.5 80.5 79.9 77.6 76.2 -0.4

AK 85.7 81.6 77.0 67.9 66.1 73.0 78.8 70.1 -2.1

CA 79.3 82.8 81.5 82.7 82.6 81.8 79.6 78.0 -0.4

HI 65.8 67.2 67.9 67.3 64.4 66.7 71.6 67.0 0.4

OR 76.6 76.0 76.4 73.2 74.0 73.4 67.0 67.2 -2.0

WA 72.5 74.5 70.1 72.7 73.1 71.3 67.4 69.9 -0.8

The percentage of patients using a catheter decreased by an annual percent change of 0.4 in the Pacific division.

Oregon, at 2.0 annual percent change, experienced a substantial improvement. While the pattern overtime was inconsistent, Hawaii experienced a slight overall increase of

1.7% from 2006 to 2013.

The percentage of patients using a catheter decreased, on average, by 0.7% per year. All states experienced an average annual decrease of at least 0.5% per year, with Louisiana

leading the division at 1.6%.


Chapter 5: BENCHMARKS Talking points

The HP 2020 CKD goals have helped to focus the nephrology community on

improving outcomes in patients receiving maintenance dialysis. A

dedicated discussion of these issues was recently published (Wetmore et

al , Clin J Am Soc Nephrol 2016 Aug 30, epub ahead of print). Fortunately,

improvements on many fronts have exceeded expectations established for

2007: the mortality rate has decreased for incident patients, deaths due to

cardiovascular disease have declined sharply, and modest gains have

occurred in patients initiating dialysis with a working or maturing

arteriovenous fistula . All races appear to have benefitted, as have all

geographic regions, although disparities by race and region remain

substantial. In retrospect, many of the gains described in this chapter

were well underway at the time the HP 2020 goals were established ;

however, given the lag in data availability, this would not have been

appreciated at the time. Two imp ortant cautions must be noted. First, i t is

uncertain why these gains have occurred, meaning that, until they are

better understood, leveraging them for future improvement may not be

possible. Second, it is quite likely that many of the improvements over t he

past decade, while substantial, may not be sustainable in the absence of an

understanding of why they occurred. Perhaps the truly hard work has yet

to be undertaken. The nephrology community should collectively discuss

what goals are appropriate for fut ure public health efforts, such as HP

2030.

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Chapter Five - Peer Kidney€¦ · · 2016-11-16awareness and understanding of the determinants of health, ... Chapter 5: Benchmarks . Morality in the first 3 months of dialysis