Racial differences in trends of end-stage renal disease, by primary diagnosis--United States, 1994-2004

The leading cause of end-stage renal disease (ESRD) (i.e., kidney failure requiring dialysis or transplantation) in the United States is diabetes, followed by hypertension and glomerulonephritis. These three conditions accounted for approximately 80% of new cases of ESRD treated during 2004. This report presents an analysis of data from the United States Renal Data System (USRDS) to examine trends in the primary diagnosis of ESRD in the United States. The findings of that analysis indicated that, during 1994-2004, ESRD incidence attributed to glomerulonephritis decreased among all races analyzed. During 1999-2004, ESRD incidence attributed to diabetes or hypertension also decreased for American Indians/Alaska Natives (AI/ANs) and Asians/Pacific Islanders (A/PIs) but not for whites or blacks. Continued interventions, such as those addressing blood-glucose and blood-pressure control, are needed to reduce the prevalence of these risk factors for kidney failure and to improve care among persons with these conditions.     

Outcomes Associated with a Disease Management Program for End-Stage Renal Disease

Disease-state management is gaining in use for the management of chronically ill individuals including those with diabetes mellitus, congestive heart failure, asthma, and some forms of cancer. Recently, disease management (DM) has been applied to patients with chronic kidney disease (CKD), a growing population of patients with high annual costs. CKD is ideally suited to DM since the definition of the condition is unambiguous and current care is highly fragmented. There are currently over 240 000 patients receiving dialysis for end-stage renal disease (ESRD), with projected numbers of nearly 600 000 by 2010, and nearly 9 million individuals with CKD not yet on dialysis. The total cost of care for patients with ESRD alone exceeded $US17 billion in 2000. Over 40% of costs for patients with ESRD result from hospitalizations, many of which can be avoided. In addition, much of the clinical morbidity and cost relates to associated comorbidities rather than ESRD per se, with little management presently provided for these conditions in the dialysis facility setting.DM for CKD uses field-based nurse care managers who can risk-assess patients and provide coordination of care so that the renal issues as well as comorbidities are identified and appropriately managed. Although few results from such efforts have been published, those that have, from RMS Disease Mnagement Inc., show remarkable improvements in a variety of clinical outcomes including mortality and hospitalization.Challenges to expanding DM for CKD include up-front funding to provide the needed DM, the availability of robust information systems to manage and analyze clinical and financial data, and the interest and participation of nephrologists, primary care providers and dialysis facilities, as well as other key providers to ensure that the DM approach is effective. With continuing increases in the number of patients with CKD in managed health plans, DM for this population will be even more important in the future to optimize clinical outcomes while constraining the costs of care.     

Kidney disease mortality--Michigan, 1989-2005

Kidney disease was the ninth leading cause of death in Michigan in 2005 and in the United States in 2004. In 2004, the incidence rate for kidney failure (i.e., end-stage renal disease) was higher in Michigan than in the United States (365 versus 353 per 1 million population). A total of 3,695 Michigan residents started treatment (i.e., dialysis or transplant) for kidney failure in 2004; by the end of that year, 11,002 Michigan residents were receiving dialysis, and 614 had received a transplant. Many of these persons had a diagnosis of diabetes (40%) or hypertension (30%) as the primary cause of kidney failure. To examine recent trends in kidney disease mortality, the Michigan Department of Community Health (MDCH) analyzed vital statistics data from the period 1989--2005. This report describes the results of that analysis, which indicated that kidney disease mortality is a growing public health problem in Michigan and that blacks were more likely than whites to die from kidney disease. Continued disease-prevention and health-promotion activities, including targeted interventions among populations at greatest risk, are needed by MDCH and other organizations to reduce the burden of kidney disease in Michigan.     

Detailed diagnoses and procedures, National Hospital Discharge Survey, 1997

OBJECTIVES: This report presents national estimates of the use of non-Federal short-stay hospitals in the United States during 1997. Estimates of first-listed diagnoses, all-listed diagnoses, days of care for first-listed diagnoses, and all-listed procedures are shown by sex and age of patient and geographic region of hospital. METHODS: The estimates are based on data collected through the National Hospital Discharge Survey for 1997. The survey has been conducted annually by the National Center for Health Statistics since 1965. In 1997 data were collected for approximately 300,000 discharges from 474 non-Federal short-stay hospitals. Diagnoses and procedures are presented according to their code number in the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM).     

Incidence of end-stage renal disease among persons with diabetes--United States, 1990-2002

Diabetes mellitus is the leading cause of end-stage renal disease (ESRD) (i.e., kidney failure requiring dialysis or transplantation) in the United States, accounting for 44% of new cases of treated ESRD in 2002. To examine trends in ESRD attributed to diabetes mellitus (ESRD-DM) in the United States, CDC analyzed 1990-2002 data from the United States Renal Data System (USRDS) and the National Health Interview Survey (NHIS). This report summarizes the findings of that analysis, which indicated that, although the number of new cases of ESRD-DM increased overall, the incidence of ESRD-DM among persons with diabetes is not increasing among blacks, Hispanics, men, and persons aged 65-74 years, and is declining among persons aged <65 years, women, and whites. Continued interventions to reduce the prevalence of risk factors for kidney disease and improve diabetes care are needed to sustain and improve these trends.     

Characteristics of patients referred for treatment of end-stage renal disease in a defined population.

We studied the incidence of referral for treatment of end-stage renal disease (ESRD) in the Kaiser Foundation Health Plan (KFHP) in northern California from 1972 through 1977. In this population of over 1 million persons, we found an age-adjusted annual incidence of 44.9 per million after 1973, when the Federal ESRD Program went into effect. Age-specific incidence was highest in in men greater than 70 years of age and in women in the 50- to 59-year age group; the male/female ratio was 1.4:1. The most common diagnoses of patients referred with ESRD were glomerulonephritis (11.4 per million per year), diabetic nephropathy (5.0 per million per year), primary hypertensive disease (3.1 per million per year), and polycystic kidney disease (2.4 per million per year). Estimated rates of referral for ESRD were highest for Blacks, lowest for Whites, and intermediate for Asians. Incidence varied by geographic area within the health plan service area and was highest where the percentage of the Black population was highest.     

Prevalence of chronic kidney disease and associated risk factors--United States, 1999-2004

Chronic kidney disease (CKD) is a serious condition associated with premature mortality, decreased quality of life, and increased health-care expenditures. Untreated CKD can result in end-stage renal disease and necessitate dialysis or kidney transplantation. Risk factors for CKD include cardiovascular disease, diabetes, hypertension, and obesity. To estimate the prevalence of CKD in the United States (overall and by health risk factors and other characteristics), CDC analyzed the most recent data from the National Health and Nutrition Examination Survey (NHANES). This report summarizes the results of that analysis, which determined that 16.8% of the U.S. population aged >/=20 years had CKD, according to 1999-2004 NHANES data, compared with 14.5% from the 1988-1994 NHANES (i.e., NHANES III), an increase of 15.9% based on crude estimates of prevalence. Persons with diabetes or cardiovascular disease had a greater prevalence of CKD than persons without those conditions. The results underscore the need to continue surveillance for CKD and its risk factors in the United States and to implement new strategies to reduce the number of persons with this condition.     

National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary

OBJECTIVE: This report presents the most current (2005) nationally representative data on visits to hospital emergency departments (ED) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. Selected trends in ED utilization from 1995 through 2005 are also presented. METHODS: Data are from the 2005 National Hospital Ambulatory Medical Care Survey (NHAMCS), the longest continuously running nationally representative survey of hospital ED and outpatient department (OPD) utilization. The NHAMCS collects data on visits to emergency and outpatient departments of nonfederal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. RESULTS: During 2005, an estimated 115.3 million visits were made to hospital EDs, about 39.6 visits per 100 persons. This represents on average roughly 30,000 visits per ED in 2005, a 31 percent increase over 1995 (23,000). Visit rates have shown an increasing trend since 1995 for persons 22-49 years of age, 50-64 years of age, and 65 years of age and over. In 2005, about 0.5 million (0.4 percent) of visits were made by homeless individuals. Nearly 18 million patients arrived by ambulance (15.5 percent). At 1.9 percent of visits, the patient had been discharged from the hospital within the previous 7 days. Abdominal pain, chest pain, fever, and cough were the leading patient complaints, accounting for nearly one-fifth of all visits. Abdominal pain was the leading illness-related diagnosis at ED visits. There were an estimated 41.9 million injury-related visits or 14.4 visits per 100 persons. Diagnostic and screening services were provided at 71.1 percent of visits, and procedures were performed at 47.3 percent of visits. Medications were either given in the ED or prescribed at discharge at 76.7 percent of visits, resulting in 204.9 million drug mentions. On average, patients spent 56.3 minutes waiting to see a physician, and 3.3 hours for the full duration of their ED visit. About 12 percent of ED visits resulted in hospital admission. The average total length of stay for those admitted was 5.2 days, and the leading principal hospital discharge diagnosis was nonischemic heart disease.     

Epidemiology of salmonellosis in California, 1990-1999: morbidity,mortality, and hospitalization costs

Salmonella is a common cause of bacterial foodborne illness in the United States. The epidemiology and costs of nontyphoidal salmonellosis in California from 1990 through 1999 are described using surveillance, hospitalization, and death data. Trends in Salmonella rates and factors associated with prolonged hospitalization were evaluated using Poisson and linear regression models, respectively. There were 56,660 reported cases, 11,102 hospitalizations, and 74 deaths attributed to Samonella. Reported case and hospital discharge rates have decreased since 1996. Among reported cases, infants had the highest rate (121 cases per 10(5) person-years), followed by children 1-4 years of age (40 cases per 10(5) person-years). The highest hospitalization rates were among the elderly and young children. Most deaths occurred among persons aged 65 or more years (59%). Among hospitalizations, gastroenteritis (61%) and septicemia (23%) were the most common Salmonella diagnoses. Salmonella pneumonia patients were the oldest (median age, 55 years) and Salmonella meningitis patients the youngest (median age, 0.3 years). These two diagnoses were the costliest, approaching 30,000 dollars (median) per hospitalization. Having an acquired immunodeficiency syndrome diagnosis or multiple Salmonella diagnoses was independently associated with prolonged hospitalization. The estimated 10-year hospitalization costs for Salmonella were $200 million. Salmonellosis is a costly disease that disproportionately affects the young and elderly.     

A comparison of three approaches for attributing hospitalizations to specific diseases in cost analyses

OBJECTIVES: Calculations of healthcare costs rarely disclose the specific approach used to allocate the cost of hospitalizations by diagnosis. However, the type of approach used can have a major impact on the findings in the case of significant comorbidities. The present analyses compared three approaches for attributing Medicare DRG reimbursements (which were used as surrogates for average costs) for hospitalization by diagnosis. METHODS: Medical resource utilization data from the National Hospital Discharge Survey were analyzed using each of three allocation approaches: a) attributing 100% of the cost of hospitalization to the disease when it was the first-listed diagnosis; b) attributing a portion of the cost of hospitalization to the disease, depending on its position in the list of diagnoses and the relevance of any comorbidities; and c) an incremental analysis of cost based upon the hospitalization experiences of an age and gender matched cohort. These three approaches were applied to the cost of hospitalization for chronic obstructive pulmonary disease (COPD). RESULTS: The first approach projected 206,098 hospitalizations at $3,449 per hospitalization for a projected U.S. annual total of $711 million. The second approach projected 681,547 hospitalizations at $3,205 per hospitalization for a projected U.S. annual total of $2.2 billion. The third approach also projected 681,547 hospitalizations, but at $2,361 per hospitalization, for a projected U.S. annual total of $1.6 billion. CONCLUSIONS: Expanding from the example on COPD, the limitations of each approach are described and their applications to other conditions are presented.     

End state renal disease among Native Americans, 1983-86.

We used data reported to Medicare from 1983 through 1986 to determine the incidence of end-stage renal disease (ESRD) among Native Americans and Whites in the United States. The 1,075 Native American cases represented an annual incidence, age-adjusted to the White population, of 269 per million, 2.8 times the rate for Whites. Fifty-six percent of Native American cases and 27 percent of the White cases were attributed to diabetes, indicating that ESRD is a major problem. Diabetes control provides the greatest opportunity for prevention.     

Cost of hospitalizations associated with sickle cell disease in the United States.

OBJECTIVE: This study estimated the number and cost of hospitalizations associated with sickle cell disease in the United States. METHODS: To estimate the number of hospitalizations per year in the United States of people with sickle cell disease, the authors used data for the years 1989 through 1993 from national hospital discharge surveys conducted by the National Center for Health Statistics. The authors derived cost estimates using data from a 1992 national hospital discharge survey conducted by the Agency for Health Care Policy and Research and a 1992 survey of physicians conducted by the American Medical Association. RESULTS: During the years 1989 through 1993, there were on average an estimated 75,000 hospitalizations per year of children and adults with sickle cell disease. The average direct cost per hospitalization (in 1996 dollars) was estimated at $6300, for a total direct cost of $475 million per year. In 66% of hospital discharge records, government programs were listed as the expected principal source of payment. CONCLUSIONS: The cost of hospitalizations associated with sickle cell disease is substantial. Because government programs pay most of this cost, further government-funded research to develop interventions that prevent complications of the disease has great potential for cost savings as well as for reducing the suffering of those afflicted with this painful genetic disorder. These national cost estimates contribute to an understanding of the impact of sickle cell disease and should be useful in establishing research priorities.     

Leptospirosis-Associated Hospitalizations,United States, 1998–2009

A small percentage of persons with leptospirosis, a reemerging zoonosis, experience severe complications that require hospitalization. The number of leptospirosis cases in the United States is unknown. Thus, to estimate the hospitalization rate for this disease, we analyzed US hospital discharge records for 1998–2009 for the total US population by using the Nationwide Inpatient Sample. During that time, the average annual rate of leptospirosis-associated hospitalizations was 0.6 hospitalizations/1,000,000 population. Leptospirosis-associated hospitalization rates were higher for persons >20 years of age and for male patients. For leptospirosis-associated hospitalizations, the average age of patients at admission was lower, the average length of stay for patients was longer, and hospital charges were higher than those for nonleptospirosis infectious disease–associated hospitalizations. Educating clinicians on the signs and symptoms of leptospirosis may result in earlier diagnosis and treatment and, thereby, reduced disease severity and hospitalization costs.     

Food-related illness and death in the United States.

To better quantify the impact of foodborne diseases on health in the United States, we compiled and analyzed information from multiple surveillance systems and other sources. We estimate that foodborne diseases cause approximately 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths in the United States each year. Known pathogens account for an estimated 14 million illnesses, 60, 000 hospitalizations, and 1,800 deaths. Three pathogens, Salmonella, Listeria, and Toxoplasma, are responsible for 1,500 deaths each year, more than 75% of those caused by known pathogens, while unknown agents account for the remaining 62 million illnesses, 265,000 hospitalizations, and 3,200 deaths. Overall, foodborne diseases appear to cause more illnesses but fewer deaths than previously estimated.     

State-specific trends in chronic kidney failure--United States, 1990-2001

Kidney disease is the ninth leading cause of death in the United States. Approximately 19 million U.S. adults have chronic kidney disease, and an estimated 80,000 persons have chronic kidney failure diagnosed annually. Major causes of chronic kidney failure are diabetes mellitus and hypertension, which account for approximately 60% of new cases. To assess national and state-specific trends in the prevalence of chronic kidney failure during 1990-2001, CDC analyzed data from the United States Renal Data System (USRDS). This report summarizes the results of that analysis, which indicated that the prevalence of chronic kidney failure in the United States increased 104% during 1990-2001. Treating and controlling risk factors and screening persons at high risk for chronic kidney failure are key steps that health-care providers and public health practitioners can take to reverse the upward trend in this disease.     

Blood pressure and the risk of chronic kidney disease progression using multistate marginal structural models in the CRIC Study

In patients with chronic kidney disease (CKD), clinical interest often centers on determining treatments and exposures that are causally related to renal progression. Analyses of longitudinal clinical data in this population are often complicated by clinical competing events, such as end‐stage renal disease (ESRD) and death, and time‐dependent confounding, where patient factors that are predictive of later exposures and outcomes are affected by past exposures. We developed multistate marginal structural models (MS‐MSMs) to assess the effect of time‐varying systolic blood pressure on disease progression in subjects with CKD. The multistate nature of the model allows us to jointly model disease progression characterized by changes in the estimated glomerular filtration rate (eGFR), the onset of ESRD, and death, and thereby avoid unnatural assumptions of death and ESRD as noninformative censoring events for subsequent changes in eGFR. We model the causal effect of systolic blood pressure on the probability of transitioning into 1 of 6 disease states given the current state. We use inverse probability weights with stabilization to account for potential time‐varying confounders, including past eGFR, total protein, serum creatinine, and hemoglobin. We apply the model to data from the Chronic Renal Insufficiency Cohort Study, a multisite observational study of patients with CKD.     

Delayed supply of influenza vaccine and adjunct ACIP influenza vaccine recommendations for the 2000-01 influenza season. Advisory Committee on Immunization Practices

Annual vaccination against influenza is the primary means for minimizing serious adverse outcomes from influenza virus infections. These infections result in approximately 20,000 deaths and 110,000 hospitalizations per year in the United States (1). The amount of trivalent inactivated influenza vaccine produced for distribution in the United States has increased substantially; in 1999, four manufacturers produced a combined total of 80 to 85 million doses.     

Incidence of end-stage renal disease attributed to diabetes among persons with diagnosed diabetes --- United States and Puerto Rico, 1996-2007

During 2007, approximately 110,000 persons in the United States and Puerto Rico began treatment for end-stage renal disease (ESRD) (i.e., kidney failure requiring dialysis or transplantation). Diabetes is the leading cause of ESRD in the United States, accounting for 44% of new cases in 2007. Although the number of persons initiating treatment for kidney failure each year who have diabetes listed as a primary cause (ESRD-D) has increased since 1996, ESRD-D incidence among persons with diagnosed diabetes has declined since 1996. To determine whether this decline occurred in every U.S. region and in every state, CDC analyzed 1996-2007 data from the U.S. Renal Data System (USRDS) and the Behavioral Risk Factor Surveillance System (BRFSS). During the period, the age-adjusted rate of ESRD-D among persons with diagnosed diabetes declined 35% overall, from 304.5 to 199.1 per 100,000 persons with diagnosed diabetes, and declined in all U.S. regions and in most states. No state showed a significant increase in the age-adjusted ESRD-D rate. Continued awareness of risk factors for kidney failure and interventions to improve diabetes care are needed to sustain and improve these trends.     

Hospitalizations for fractures after renal transplantation in the United States

PURPOSE: To investigate the incidence, risk factors, and associated mortality of fractures in renal transplant recipients. METHODS: Retrospective registry study of 33,479 patients in the United States Renal Data System (USRDS) who received kidney transplants between 1 July 1994 and 30 June 1997. Associations with hospitalizations for a primary discharge diagnosis of fractures (all causes) were assessed. RESULTS: Renal transplant recipients had an adjusted incidence ratio for fractures of 4.59 (95% confidence interval 3.29 to 6.31). In multivariate analysis, recipients with prevalent fractures, as well as recipients who were Caucasian, women, in the lower quartiles of recipient weight (<95.9 kg), had end stage renal disease caused by diabetes, and had prolonged pretransplant dialysis were at increased risk for hospitalization because of fractures after transplantation. Recipients hospitalized for hip fractures had decreased all-cause survival (hazard ratio for mortality 1.60, 95% CI 1.13 to 2.26) in Cox Regression analysis. CONCLUSIONS: In the early post-transplant course (<3 years), renal transplant recipients had a greater incidence of fractures than the general population, which were associated with decreased patient survival. Preventive efforts should focus on recipients with the risk factors identified in this analysis, most of which can be easily obtained through history and physical examination.