Précisback

ground

on

the

u.s. esrd

pro

gram

20 Hopita

lizati

on D mort

ality {a

dmissions &

morta

lity,

overa

ll &

for c

ardio

vasc

ular d

iseas

e & in

fect

ion} {

five-

year

surv

ival

, by

first

mod

alit

y}

22 Trends in cl

inic

al care

{tren

ds & ge

ographic

varia

tions i

n URR &

vasc

ular a

cces

s use

} {tr

ends

in h

emog

lobi

n le

vels

, by

EPO

use

}

16 Introductio

N 1

8 Tren

ds in th

e U.S

. ESRD

pro

gram

{sum

mary

stat

istic

s} {t

rend

s in

spen

ding

} {pa

tient

coun

ts} {

pati

ent l

osse

s}

24 Economics of ESRD ca

re {per m

ember per

month allo

wable ex

penditu

res}

{phys

ician vi

sits}

{tre

nds in

Med

icar

e exp

endi

ture

s, ov

eral

l & p

er p

atie

nt y

ear}

26 Treatable risk factors fo

r CKD {o

dds ratio

s of e

GFR <60} {

demogra

phics, s

elf-re

porte

d dise

ases,

& ri

sk fa

ctor

s}

2

8 S

umm

ary

There are very few human beings who receivethe truth, complete and staggering, by instantillumination. Most of them acquire itfragment by fragment, on a small scale, bysuccessive developments, cellularly, like alaborious mosaic.

The diary of Anaïs Nin

AnaïsNinh

Introducion16 Précish

his ADR reports data from 2002—the twentieth year of coverage for the

ESRD program by the composite rate payment system. More than 1.5

million people have now been treated through this program, and in 2002

it reached the milestone of entering 100,359 individuals for therapy. In that year the adjusted

incident rate was 333 new cases per million population, and 431,284 patients were under

active care on December 31: 308,910 on dialysis (another milestone), and 122,374 with a

functioning transplant. The number of transplants continues to grow as well, with 15,106

performed in 2002: 9,429 from deceased donors, and 6,225 from living donors. Transplants

from living donors now constitute 41 percent of all transplants performed.

The program consumed 6.7 percent of the Medicare budget in 2002—up from 4.9 percent

a decade earlier (see Figure 12.1). Total program expenditures reached $25.2 billion in 2002, an

11.5 percent increase over the previous year, and Medicare spending accounted for $17 billion

of this total. As noted in the 2003 Annual Data Report, this continued growth is related

primarily to increases in the use of dialysis injectables such as IV vitamin D, IV iron, and

epoetin.

The incident population grew 4.1 percent in 2002, and the prevalent population, based

on reconciliation of the data by the USRDS, increased 4.6 percent. The decline in the use of

peritoneal dialysis seen in the late 1990s has slowed, with the population remaining steady

in 2001 and 2002.

Trends in hospital admission rates fell slightly from rates in 2001 for patients who have

been on dialysis less than three years, and for those of older vintage as well. And regardless

of patient vintage, admission rates for cardiovascular disease and, particularly, for infection

in hemodialysis patients have increased since 1993. Peritoneal dialysis patients continue to

have the highest hospitalization rates for infection.

Mortality rates by treatment modality and vintage have changed considerably over the

past twenty years. Rates for hemodialysis patients on the therapy less than three years, for

example, have fallen since the mid-1980s, though this decline has slowed in the past several

years. Rates in hemodialysis patients of older vintage, in contrast, continue to grow, indi-

cating that death is delayed longer after the start of therapy. In the peritoneal dialysis

population of younger vintage, mortality rates have consistently been higher than in hemo-

dialysis patients, but they have been improving steadily, and in 2001 and 2002 fell below

those seen in the hemodialysis population.

Chapt

er h

ighl

ight

s

Chapt

er h

ighl

ight

s

17H2004 USRDS Annual Data Report

78 80 82 84 86 88 90 92 94 96 98 00 02

)sd

nas

uo

ht ni( st

neit

ap f

o re

bm

uN

0

100

200

300

400

500

Incident ESRD(2002: 100,359)

Prevalent ESRD(2002: 431,284)

Prevalent dialysis(2002: 308,910)

Prevalent transplant(2002: 122,374)

92 93 94 95 96 97 98 99 00 01 02

)sd

nas

uo

ht ni( st

neit

ap f

o re

bm

uN

0

10

20

30

40

50

Medicare 65+ (2002: 45,846)

<65 Disabled & Medicare (2002: 5,965)

Employed/EGHP (2002: 12,207)

Five-year survival rates for patients beginning ESRD therapy

in 1993–1997 improved compared to those of patients start-

ing in the previous five years—6.8 percent for hemodialysis

patients, 14.9 percent for those on peritoneal dialysis, and 8.7

percent for those with a transplant. Almost three-fourths of

transplant patients are now alive five years after beginning

therapy, compared to one-third of those on either type of

dialysis.

As shown by data from CMS’s Clinical Performance Mea-

sures (CPM) Project, the quality of delivered dialysis in the

hemodialysis population has improved dramatically over

the last nine years. Eighty-six percent of patients now have

urea reduction ratios of 65 percent or greater—the level rec-

ommended by the National Kidney Foundation’s K/DOQI

guidelines. The use of a fistula as the primary access has

improved slowly, although catheter use also continues to

grow. And hemoglobin levels have improved as well,

with three in four dialysis patients now reaching the target

level of 11 g/dl and above.

Our understanding of the costs associated with the ESRD

program continues to evolve as we develop new information

on the transition to ESRD. Patient expenditures increase ex-

ponentially, for example, in the three months prior to initia-

tion of ESRD therapy, and in the month of initiation costs

are $15,000–25,000; employer group health plans (EGHPs)

pay the most for care in this period. During this month in-

patient care accounts for 70 percent of expenditures, sug-

gesting that there may be opportunities to deliver care in

alternative settings.

At initiation, there is a substantial shift in providers. Neph-

rologists, as expected, assume a more prominent role, while

internists, cardiologists, and general practitioners also be-

come more involved. A significantly higher proportion of

Medicare patients, who are older, receive care from neph-

rologists, internists, and cardiologists, while younger EGHP

patients are more likely to see general practitioners.

Annual Medicare expenditures continue to show a wid-

ening of the gap between outpatient and inpatient costs for

dialysis, with the growth in outpatient costs reflecting in-

creased use of alternative IV iron and IV vitamin D medica-

tions to treat mineral metabolism disorders and the iron

deficiency associated with EPO treatment.

Based on the projections we reported in the 2000

Annual Data Report, the growth of the ESRD pro-

gram is slightly behind for incident patients and

ahead for prevalent patients, particularly for

those with functioning grafts; expenditures

are half a billion dollars ahead of pro-

jections. Continued monitoring of

the program is needed to deter-

mine if projections to 2010

need to be revised based

on improved sur-

vival and grow-

ing costs.

{p.7} Since

1993, hospital

admission rates

have fallen approxi-

mately 3 percent for both

hemodialysis and peritoneal

dialysis patients who have been

on the therapy less than three years,

and are down 8 percent for transplant

patients of similar vintage. {p.10} For

prevalent hemodialysis, peritoneal dialysis,

and transplant patients on their modality less than

three years, adjusted mortality rates have fallen. For

hemodialysis patients of older vintage, however, rates have

increased since 1994. {p.21} Transitional costs from pre- to

post-ESRD are considerable, with costs in the month of initiation

averaging almost $15,000 for Medicare patients, and almost $25,000 for

patients in employer group health plans. The greatest portion of costs is

associated with hospitalizations.

{p.1} Incident & prevalent ESRD patient counts, by modalityincident ESRD patients & December 31 point prevalent patients.

{p.2} Counts of chronic kidney disease patients, by insurance typeMedicare: general Medicare CKD patients, continuously enrolled inMedicare Parts A & B for an entire calendar year; patients enrolledin an HMO during the year are excluded. EGHP: CKD patientsyounger than 65, & continuously enrolled in a fee-for-service-planfor an entire calendar year.

18 Précish

n 2002, 100,359 dialysis and trans-

plant patients initiated ESRD

therapy; diabetes was the primary

cause of ESRD in 44 percent of these pa-

tients (Table p.a). The overall incident rate

in 2002, adjusted for age, gender, and race,

was 333 patients per million population.

The number of patients receiving ESRD

therapy on December 31, 2002 was 431,284,

a 4.6 percent increase over the previous year.

The adjusted prevalent rate was 1,435 per

million population. Among these prevalent

patients, 308,910—72 percent—were un-

dergoing dialysis, while 122,374 had a func-

tioning transplant. More than 15,000

transplants were performed during 2002,

and nearly 80,000 patients died.

In the hemodialysis population, the av-

erage annual percent change in prevalent

rates fell from 6.3 during 1994–1998 to 3.2

during 1998–2002; the annual increase in

transplant rates fell from 5.6 to 4.3. Preva-

lent rates for the peritoneal dialysis popula-

tion continue to decline, though at a slightly

slower pace—3.5 percent annually in the

most recent period, compared to 4.2 per-

cent in 1994–1998.

Between 2001 and 2002, Medicare

spending per patient year rose 8 percent;

after adjustments for inflation, however, this

change drops to 3.6–4.5 percent.USRDS data show that the number of

new ESRD patients rose 4.1 percent in

2002; data from the CMS Facility Survey

indicate a growth of 2.1 percent (Figure p.3).

The two sources show a growth of 4.3–4.4

percent in the overall prevalent population,

and an increase of 4.6–4.7 percent in the

number of prevalent patients receiving he-

modialysis. The prevalent peritoneal dialy-

sis population, which declined in the late

1990s, seems to have stabilized.

The number of new patients beginning

dialysis has increased 139 percent since 1988

(Figure p.4). There has been less growth—

95 percent—for patients returning to di-

alysis after a transplant. For those who

restart dialysis after recovering function or

discontinuing therapy, in contrast, the popu-

lation has increased 170 percent since 1988.

In 2002, dialysis therapy was stopped for

4,450 patients who recovered kidney func-

tion, and for 1,565 patients who discon-

tinued dialysis (Figure p.5).

In 2002, total Medicare costs for the

ESRD program were $17 billion, an increase

{p.a} Summary statistics on reported ESRD in the United States, 2002

Trends in the U.S. ESRD program

IncidenceA December 31 Point Prevalence Kidney transplantsPatient Adj. Adj. Living ESRDcharacteristics Count RateB CountC RateB DialysisC TxC Cadaver donor deathsD

AgeE

0-19 1,299 1 5 6,982 8 0 2,347 4,635 374 527 141

20-44 13,178 115 92,080 822 48,862 43,218 3,342 2,544 5,250

45-64 35,500 598 180,284 2,945 120,535 59,749 4,695 2,631 23,125

65-74 24,661 1,440 85,306 5,107 72,526 12,780 921 489 22,326

75+ 25,718 1,671 66,571 4,383 64,598 1,973 9 7 3 3 28,970

Unknown * 6 1 4 2 1 9 *

White 64,676 256 266,263 1,060 172,502 93,761 6,195 4,995 53,028

Black 28,500 982 135,135 4,467 113,632 21,503 2,651 923 22,538

Native American 1,088 514 5,797 2,569 4,490 1,307 103 4 5 920

Asian/Pacific Islander 3,414 344 17,234 1,571 12,300 4,934 437 219 2,224

Other/unknown 2,681 6,855 5,986 869 4 3 4 3 1,102

Male 54,489 409 238,140 1,729 165,573 72,567 5,632 3,651 41,972

Female 45,855 276 193,069 1,193 143,292 49,777 3,797 2,574 37,839

Unknown gender 1 5 7 5 4 5 3 0 *

Primary diagnosis

Diabetes 44,514 147 154,197 511 127,731 26,466 2,844 1,397 35,741

Hypertension 27,227 9 2 102,385 343 85,324 17,061 1,767 872 22,190

Glomerulonephritis 8,243 2 7 67,207 224 35,799 31,408 2,081 1,624 6,002

Cystic kidney disease 2,231 7 18,560 6 2 8,304 10,256 722 558 1,368

Urologic disease 1,695 6 8,935 3 0 5,713 3,222 182 182 1,293

Other known cause 11,709 3 9 52,551 177 32,549 20,002 1,248 1,085 9,047

Unknown cause 4,122 1 4 21,237 7 0 12,925 8,312 415 338 3,418

Missing cause 618 2 6,212 1 7 565 5,647 170 169 753

All 100,359 333 431,284 1,435 308,910F 122,374 9,429 6,225 79,812

Unadjusted rateG 336 1,446 Total TransplantsH 15,106

* Values for cells with ten or fewer patients are suppressed.

A Incident counts: include all known ESRD patients, regardless of any incomplete data on patient characteristics and ofU.S. residency status.

B Includes only residents of the 50 states and Washington D.C. Rates are adjusted for age, race, and/or gender using theestimated July 1, 2001 U.S. resident population as the standard population. All rates are per million population. Rates byage are adjusted for race and gender. Rates by gender are adjusted for race and age. Rates by race are adjusted for ageand gender. Rates by disease group and total adjusted rates are adjusted for age, gender, and race. Adjusted rates donot include patients with other or unknown race.

C Patients are classified as receiving dialysis or having a functioning transplant. Those whose treatment modality onDecember 31 is unknown are assumed to be receiving dialysis. Includes all Medicare and non-Medicare ESRD patients,and patients in the U.S. Territories and foreign countries.

D Deaths are not counted for patients whose age is unknown.

E Age is computed at the start of therapy for incidence, on December 31 for point prevalence, at the time of transplantfor transplants, and on the date of death for death.

F Includes patients whose modality is unknown.

G Unadjusted total rates include all ESRD patients in the 50 states and Washington D.C.

H From the 2002 CMS Facility Survey. Claims were found for 7,360 transplants for which Medicare appeared to be theprimary payor.

I Adjustments using the CMS inflation adjustment for the medical component, and the Bureau of Labor Statisticsinflationary adjustment.

Average annual percent change in rates per million HD PD Transplant

94-98 98-02 94-98 98-02 94-98 98-02Incident patientsWhite 5.88 3.00 -2.29 -4.37 5.64 6.52

Black 4.57 0.87 -6.16 -4.49 -2.52 10.72

N Am 4.06 -6.83 -8.20 -13.25 38.74 -20.86

Asian 4.93 -3.02 -1.27 -4.66 -2.82 7.60

DM 9.51 2.31 -0.75 -4.74 1.89 7.39

HTN 2.40 2.61 -5.92 -2.48 0.88 17.35

GN 3.18 -2.94 -1.90 -8.32 9.00 5.74

CK 5.12 -1.33 -2.37 -2.62 21.70 6.35

All 5.28 1.93 -3.29 -4.54 4.75 6.76Prevalent patientsWhite 6.75 4.20 -4.33 -3.05 5.44 4.28

Black 5.81 2.27 -4.96 -4.51 5.99 4.69

N Am 5.05 -1.63 -6.45 -5.40 4.92 2.30

Asian 6.51 1.29 2.25 -2.93 6.74 4.84

DM 11.19 4.97 -1.56 -2.84 7.52 5.36

HTN 4.32 2.74 -6.33 -2.88 5.56 3.96

GN 4.61 0.62 -2.77 -5.00 5.14 4.07

CK 2.99 1.04 -4.06 -4.50 6.96 5.43

All 6.26 3.19 -4.24 -3.46 5.56 4.33

Medicare spendingMedicare spending for ESRD in 2002

(billions of dollars)

SAF paid claims (Parts A & B) 15.64

2% incurred but not reported 0.31

HMO-Medicare risk 0.83

Organ acquisition 0.22

Total Medicare costs 17.00

Non-Medicare spending for ESRD

(billions of dollars)

EGHP (MSP) 1.71

Patient obligations 3.92

Non-Medicare patients 2.61

Total non-Medicare costs 8.24

Change in Medicare spending

from 2001 to 2002

Total 10.1

Per patient year 8.0

Adjusted for inflationI 4.5% to 3.6%

Medicare spending per patient year

from 1998 to 2002

ESRD 46,490

Hemodialysis 54,006

Peritoneal dialysis 41,353

Transplant 18,394

19H2004 USRDS Annual Data Report

88 89 90 91 92 93 94 95 96 97 98 99 00 01 02

)sd

nas

uo

ht ni( st

neit

ap f

o re

bm

uN

0

2

440

60

80

100

120

New dialysis patients(2002: n=96,698)

Patients returning from transplant(2002: n=4,812)

Total patients starting or restarting dialysis(2002: n=103,318)

Patients restarting dialysis(2002: n=1,808)

USRDS

CMS Facility Survey

89 90 91 92 93 94 95 96 97 98 99 00 01 02 0

5

10

15

89 90 91 92 93 94 95 96 97 98 99 00 01 02 -10

-5

0

5

10

15

20

Incident: All Prevalent: All

Prevalent hemodialysis Prevalent peritoneal dialysis

ra

ey su

oiv

erp

morf

eg

na

hc tn

ecre

P

0

5

10

15

88 89 90 91 92 93 94 95 96 97 98 99 00 01 02

)sd

nas

uo

ht ni( st

ne it

ap f

o re

bm

uN

0

1

2

3

4

20

40

60

80

Death (2002: n=71,006)

Recovered function(2002: n=4,450)

Discontinued dialysis (2002: n=1,565)

91 92 93 94 95 96 97 98 99 00 01 02

)sn

oillib

ni ( s rall

oD

0

5

10

15

20

25

30

Medicare (2002: $17 billion)

Non-Medicare (2002: $8.2 billion)

Total (2002: $25.2 billion)

{p.3} Annual percent change in patient counts

{p.6} Medicare vs. non-Medicare ESRD spending

{p.4} Counts of new & returning dialysis patients {p.5} Patients ceasing dialysis

of 11 percent over costs in 2001, while non-Medicare spending

grew 12.3 percent, to $8.2 billion (Table p.a and Figure p.6). Costs

for the entire program reached $25.2 billion, 11.5 percent higher

than in 2001.

{Figure p.3} incident patients: USRDS data contain all ESRD patients, whileCMS Facility Survey data (FSD) contain dialysis patients only. Prevalent patients:USRDS data contain patients with the indicated modality on December 31, FSDdata for “all” include dialysis patients only, & FSD data for dialysis include patientswith the indicated modality at the time of the survey. {Figures p.3–5} data ob-tained from CMS’s annual End-Stage Renal Disease Facility Survey, CMS Inde-pendent Renal Facility Cost Reports, & the CMS “Dialysis Facility Compare”website. {Figure p.6} Medicare spending includes paid claims, estimatedMedicare+Choice costs, & estimated organ acquisition costs. Non-Medicarespending includes estimates of costs for EGHP patients & for non-Medicare ESRDpatients, & estimates of patient obligations. See Appendix A for further details.

20 Précish

ksir ta r

aey t

ne it

ap r

ep s

noiss i

md

A

0.0

0.2

0.4

0.6

0.8 Hemodialysis: vintage <3 years

Peritoneal dialysis

0.0

0.2

0.4

0.6

94 96 98 00 02 0.0

0.1

0.2

0.3Transplant

94 96 98 00 02

3+ years

All cardiovascular

CHF

ISHD

Other cardiovascular

93 94 95 96 97 98 99 00 01 02

ksir ta r

ae

y tn

eita

p re

p sn

oissim

dA

1.8

2.0

2.2

2.4

<3 years

3+ years

Hemodialysis Peritoneal dialysis

93 94 95 96 97 98 99 00 01 02 93 94 95 96 97 98 99 00 01 02 0.8

0.9

1.0

1.1 Transplant

ksir ta r

aey t

neit

ap r

ep s

noissi

md

A

0.0

0.2

0.4

0.6

All infections

Bacteremia/septicemia

UTI

Infection/internal device (dialysis only)

Hemodialysis: vintage <3 years

Peritoneal dialysis

0.0

0.2

0.4

0.6

0.8

94 96 98 00 02 0.0

0.1

0.2

0.3Transplant

94 96 98 00 02

3+ years

ifferences by vintage in adjusted hospital admission rates

per patient year at risk have declined over time for hemo-

dialysis patients, while growing for patients on peritoneal

dialysis (Figure p.7). Admission rates are consistently greater for the

newest hemodialysis patients, while the opposite is true for perito-

neal dialysis patients, among whom the highest rates occur in those

on the modality for three or more years. Transplant patients have

the lowest admission rates by modality, with rates slightly higher for

patients of older vintage.

Unlike the overall admission rates, most rates for cardiovascular

disease and infection show little difference by patient vintage (Fig-

ures p.8–9). Compared to those of hemodialysis patients, 2002 ad-

mission rates for infection were 24 percent higher in younger vintage

peritoneal dialysis patients, and 61 percent higher in those on the

modality for three or more years.

Adjusted mortality rates and their patterns of change vary widely

by vintage and modality (Figure p.10). The most dramatic changes

{p.9} Adjusted admissions for infection: prevalent patients

Hopitalization D mortality

{p.8} Adjusted admissions for cardiovascular disease: prevalent patients

{p.7} Adjusted hospital admissions, by modality & patient vintage: prevalent patients

have occurred in peritoneal dialysis and transplant populations of

younger vintage, with rates decreasing, respectively, 35 percent since

1986 and 62 percent since 1983. In 2002, rates in hemodialysis

patients of older vintage were 18 percent higher than those of newer

patients on the same modality; in peritoneal dialysis patients, in

contrast, the difference was 67 percent. Older vintage patients on

peritoneal dialysis continue to have the highest rates—in 2002, 32

percent higher than those seen in their hemodialysis counterparts.

Across most modality and vintage groups, rates of mortality due

to cardiovascular disease have generally decreased since 1993 (Figure

p.11). Again, the greatest differences are seen in peritoneal patients

who have been on the modality three or more years. For younger

vintage patients of either dialysis modality, overall cardiovascular

mortality rates were almost identical in 2002; for patients of older

vintage, however, rates in peritoneal dialysis patients were 29 per-

cent higher than in those on hemodialysis.

A similar pattern is seen for mortality due to infection, with

21H2004 USRDS Annual Data Report

0 12 24 36 48 60

ytilib

ab

orp l

avi

vru

S

0.2

0.4

0.6

0.8

1.0

Hemodialysis

Peritoneal dialysis

Transplant

1988-1992 1993-1997

Months after initiation

0 12 24 36 48 60

0.32

0.29

0.66

0.34

0.33

0.72

80 82 84 86 88 90 92 94 96 98 00 02

ksir ta sr

aey t

p 0

00,

1 re

p sht

ae

D 190

200

210

220

230

240

250

<3 years

3+ years

Hemodialysis Peritoneal dialysis

86 88 90 92 94 96 98 00 02 150

200

250

300

350

84 86 88 90 92 94 96 98 00 02 20

30

40

50

60

70Transplant

ksir ta sr

ae

y tn

eita

p 0

00,

1 re

p sht

ae

D

0

25

50

75

100

125Hemodialysis: vintage <3 years

Peritoneal dialysis

0

50

100

150

200

94 96 98 00 02 0

5

10

15

20Transplant

All CVD

CHF

ISHD

Other CVD

94 96 98 00 02

3+ years

ksir ta sr

ae

y tn

eita

p 0

00,

1 re

p sht

ae

D

0

10

20

30

40 Hemodialysis: vintage <3 years

Peritoneal dialysis

0

25

50

75

94 96 98 00 02 0

2

4

6

8Transplant

94 96 98 00 02

3+ years

Pneumonia

Infection due tointernal device (HD only)

All infections

Bacteremia/septicemia

{p.12} Adjusted mortality rates for infection: prevalent patients{p.11} Adjusted mortality rates for cardiovascular disease: prevalent patients

{p.10} Adjusted mortality rates, by modality & patient vintage: prevalent patients

{p.13} Adjusted five-year survival, by first modalityoverall rates equivalent in dialysis patients of younger vintage, but

twice as high in older vintage peritoneal dialysis patients compared

to those on hemodialysis (Figure p.12). While rates have decreased

consistently across vintages for transplant patients, in peritoneal

dialysis patients of older vintage they have increased for overall in-

fections, bacteremia/septicemia, and pneumonia.

Five-year survival probabilities for patients beginning therapy in

1993–1997 improved over those of the previous period—7 percent

for hemodialysis patients, 15 percent for those on peritoneal dialy-

sis, and 9 percent for those with a transplant (Figure p.13). Seventy-

two percent of transplant patients survive at least five years, compared

to 33–34 percent of those on dialysis.

{Figures p.7–9} period prevalent ESRD patients; adjusted for age, gender, race, &primary diagnosis. All ESRD patients, 2002, used as reference cohort. At the end of1998 a new ICD-9-CM code was added for infections due to internal devices inperitoneal dialysis patients; data prior to this date are omitted. {Figures p.10–12}period prevalent ESRD patients; adjusted for age, gender, race, & primary diagnosis.

ESRD patients, 2001, used as reference cohort. {Figure p.13} incident dialysis pa-tients & patients receiving a first transplant in the incident year; adjusted for age,gender, race, & primary diagnosis. Incident ESRD patients, 1996, used as referencecohort. Modality determined on first ESRD service date; excludes patients trans-planted or dying during the first 90 days.

22 Précish

93 94 95 96 97 98 99 00 01

stn

eita

p fo t

necr

eP

0

20

40

60

80

10075+

70-<75

65-<7060-<65

<60

93 94 95 96 97 98 99 00 01 93 94 95 96 97 98 99 00 01

All White Black

1998 1999 2000 2001

stn

eita

p fo t

nec r

eP

0

10

20

30

40

50

60

AV fistulas

Catheters

Grafts

1998 1999 2000 2001 1998 1999 2000 2001

All White Black

89.4+ (93.3)87.5 to <89.484.7 to <87.582.8 to <84.7below 82.8 (81.8)

89.4+ (98.1)87.5 to <89.484.7 to <87.5

82.8 to <84.7below 82.8 (74.7)insuff. data

89.4+ (92.5)87.5 to <89.484.7 to <87.582.8 to <84.7below 82.8 (69.3)

44.8+ (51.7)35.0 to <44.829.9 to <35.026.9 to <29.9below 26.9 (23.3)

44.8+ (53.0)35.0 to <44.829.9 to <35.026.9 to <29.9below 26.9 (19.3)

44.8+ (51.4)35.0 to <44.829.9 to <35.0

26.9 to <29.9below 26.9 (16.3)Insuff. data

Dialysis adequacy

{p.14} Hemodialysis patient distribution, by URR (%) range & race: prevalent patients

Trends in clinical care

{p.15} Geographic variations in the percent of hemodialysis patients with URR ≥65 percent, by race: prevalent patients

Vascular access in hemodialysis patients

{p.16} Patient distribution, by access use & race: prevalent patients

{p.17} Geographic variations in the percent of patients with a current fistula, by race

All White Black

All White Black

23H2004 USRDS Annual Data Report

10-<11

12+

91 92 93 94 95 96 97 98 99 00 01 02

)stin

u fo s

dn

asu

oht

ni ( e s

od

OP

E n

ae

M

5

7

9

11

13

15

17

19

)ld/

g( ni

bol

go

me

H

9

10

11

12

EPO

Hemoglobin

Mean monthly hemoglobin & mean EPO dose per week

91 92 93 94 95 96 97 98 99 00 01 02 03

stn

eita

p fo t

nec r

eP

0

20

40

60

80

100

<9

11-<12

9-<10

Patient distribution, by mean monthly hemoglobin (g/dl)

stn

eita

p fo t

necr

eP

0

20

40

60

80

10012+

11-<12

10-<119-<10

<9

12+

11-<12

10-<119-<10

<9

0

20

40

60

80

100

93 94 95 96 97 98 99 00 01 0

20

40

60

80

100

All patients

Patients receiving EPO

Patients not receiving EPO

stn

eita

p fo t

necr

eP

0

20

40

60

80

100

0

20

40

60

80

100

94 95 96 97 98 99 00 01 0

20

40

60

80

100

All patients

Patients receiving EPO

Patients not receiving EPO

EPO use & hemoglobin (g/dl) in prevalent patients

{p.18} in hemodialysis patients {p.19} in peritoneal dialysis patients

{p.20} Anemia & anemia treatment in prevalent patients

ighty-five percent of hemodialysis patients in 2002 met

the target urea reduction ratio (URR) of ≥65 percent set

by the Kidney Disease Outcomes Quality Initiative

(K/DOQI)—almost double the 1993 rate (Figure p.14).

The highest percentage of hemodialysis patients meeting this

target occurs in the Plains states, Texas, and the Southwest (Figure

p.15). There is an 11.5 percent difference when comparing the

upper and lower quintiles.

The use of grafts in prevalent hemodialysis patients has been

declining since 1998, from 52 to 42 percent overall, while use of

arteriovenous fistulas has increased slightly, from 28 to 32 percent

(Figure p.16). Black patients remain more

likely than whites to have a graft, and less

likely to have a fistula or catheter.

Fistula use varies widely across the coun-

try and, despite K/DOQI guidelines recom-

mending the increased use of this access, a

use rate greater than 50 percent is evident in

relatively few states (Figure p.17). There is a

28.4 percent difference in mean values of

the upper and lower quintiles.

In 2001, 76 percent of prevalent hemo-

dialysis and peritoneal dialysis patients had a

hemoglobin of 11 g/dl or above, meeting

the K/DOQI target (Figures p.18–19).

Among patients not receiving EPO, how-

ever, 82 percent of those on hemodialysis,

and 92 percent of peritoneal dialysis patients,

had hemoglobins in this higher range.Changes in the mean monthly hemoglo-

bin continue to parallel those in the mean

weekly EPO dose (Figure p.20). In June of

2002, the mean monthly hemoglobin for all

dialysis patients was 11.7 g/dl; the mean EPO

dose per week was 16,700 units.

{Figures p.14–19} year represents the prevalent year.x {Figures p.14–15 } prevalent hemodialysis pa-tients; CPM data. Map data from 2002. Each patienthas 1–3 URR measurements (one for each of three con-secutive one-month intervals), which are transformed

into categories, & the median category is calculated. If the median falls between twocategories, 0.5 patients are added to each. {Figures p.16–17} prevalent hemodialy-sis patients; CPM data. Map data from 2002. No vascular access information col-lected prior to the 1999 survey. Includes only patients whose access is known.{Figures p.18–19} prevalent hemodialysis (Figure p.18) & peritoneal dialysis (Fig-ure p.19) patients; CPM data. Each patient has 1–3 hematocrit measurements, eachof which is converted to a hemoglobin by dividing it by three. A mean hemoglobin iscalculated for each patient, then an overall mean across patients is calculated. Fordata collected in 1997–1998, an individual hemoglobin value is substituted if thecorresponding hematocrit value is missing. For data collected in 1999 & after, he-moglobin values are used instead of hematocrit values. {Figure p.20} period preva-lent dialysis patients with EPO claims. Monthly hemoglobin includes all claims witha hematocrit value between 10 & 50; weekly EPO dose includes all claims for patientswith an average number of administrations per month of ≤20; EPO doses adjustedfor inpatient days.

24 Précish

PM

PM

exp

en

dit

ure

s (i

n t

ho

usa

nd

s o

f d

olla

rs)

0

5

10

15

20

<45 (Medstat/EGHP)

45-64 (Medstat/EGHP)

65-74 (Medicare)

75+ (Medicare)

Inpatient

Months before and after first service date

-6 -5 -4 -3 -2 -1 0 1 2 3 4 50

5

10

15

20

25

30 Total

stn

eita

p fo t

necr

eP 0

20

40

60

80

100

Medicare

EGHP

Nephrologist Internist

Months before and after first service date

-6 -5 -4 -3 -2 -1 0 1 2 3 4 50

20

40

60

80

100Cardiologist General practitioner

-6 -5 -4 -3 -2 -1 0 1 2 3 4 5

er member per month expenditures for both Medicare

patients and those with private insurance begin to rise

markedly in the month prior to the first ESRD service date

(Figure p.21). It appears that patients are initiating therapy in the

hospital, a conclusion borne out by the fact that inpatient hospital

costs at the time of the first service date in those with private insur-

ance account for nearly 70 percent of total monthly expenditures,

and close to 80 percent in those insured by Medicare.

A greater percentage (19–34 percent at month “0”) of Medicare

patients, compared to those with private insurance, see specialty

physicians prior to and after their first ESRD service date (Figure

p.22). This trend is reversed, however, for general practitioners; this

may be related to coding issues in the Medstat data that make it

difficult to identify physician specialties.

In 2002, overall Medicare expenditures (derived from paid claims)

and Medicare expenditures per patient year for outpatient services

were 10–11 percent higher than those for inpatient services (Figures

p.23–24 and Table p.b), a difference that has grown since the late

1990s. Overall expenditures for inpatient care increased 4–6 per-

cent between 2001 and 2002 for patients with a transplant event, a

functioning graft, or a graft failure within the year, and 8 percent for

those on dialysis. Costs for outpatient care, in contrast, increased at

least 11–12 percent, and 16 percent for patients with a functioning

graft.

{p.21} Per member per month expenditures for pts initiating in 2001, by age

Economics of ESRD care

{p.22} Percent of patients who saw a physician, by physician specialty

Overall inpatient costs for transplants continue to increase—46

percent since 1992, and 4 percent between 2001 and 2002. Inpa-

tient costs per patient year for those receiving a transplant, however,

have decreased slightly since the mid-1990s, and have been relatively

stable over the past five years.

As the number of transplants continues to rise, overall costs for

patients with a functioning graft have, as expected, increased as

well; since 1992, inpatient costs for these patients have more than

doubled, and Part B costs have more than quadrupled. Part B costs

per patient year have also grown—137 percent since 1992—but

over the same period inpatient costs increased only 17 percent.

Since 1992, the greatest increase in both total Medicare expen-

ditures and costs per patient year has been for patients with a func-

tioning graft, at 168 and 47 percent, while costs for transplant

events have grown the least, at 53 and 15 percent.

{Figures p.21–22} Medicare: incident ESRD patients age 67 & older, 2001, withMedicare as primary payor for the six months before & the six months after the firstESRD service date. Medstat (EGHP): incident EGHP patients younger than 65, 2001,enrolled for the six months before & the six months after the first ESRD service date.{Figures p.23–24 & Table p.b} period prevalent ESRD patients; modalities deter-mined using methods from the HCFA Research Report on End-Stage Renal Disease(publication number 03393); see Appendix A for further details. Totals are paidclaims for all ESRD patients starting at first ESRD service date & continuing untildeath or the end of the study period. Patients with Medicare as secondary payor areexcluded in Figure p.24.

25H2004 USRDS Annual Data Report

91 92 93 94 95 96 97 98 99 00 01 02

To

tal e

xpe

nd

itu

res

(in

mill

ion

s o

f d

olla

rs)

0

100

200

300

400

0

50

100400

500

600

700

0

200

400

2,000

4,000

6,000Dialysis only

Functioning graft only

Transplant event within year

Graft failure within year

91 92 93 94 95 96 97 98 99 00 01 02 0

1

2

20

40

60

80

100

Home health

Skilled nursing

Hospice

Inpatient

Outpatient

Part B

0

5

10

15

20

25

0

5

10

15

55

60

65

70Dialysis only

Functioning graft only

Transplant event within year

Graft failure within year

91 92 93 94 95 96 97 98 99 00 01 02

Exp

en

dit

ure

s p

er

pa

tie

nt

yea

r (i

n t

ho

usa

nd

s o

f d

olla

rs)

0

3

6

9

91 92 93 94 95 96 97 98 99 00 01 02 0

10

20

30

40

Home health

Skilled nursing

Hospice

Inpatient

Outpatient

Part B

{p.23} Growth in annual Medicare expenditures, by modality & type of service: prevalent patients

{p.24} Growth in Medicare expenditures per patient year, by modality & type of service: prevalent patients

{p.b} Total Medicare expenditures & expenditures per patient year ($), by modality

Total Medicare expenditures Medicare expenditures per patient year Dialysis Transplant event Functioning Graft failure Dialysis Transplant event Functioning Graft failure

only within year graft only within year only within year graft only within year1991 4,785,027,256 561,464,596 256,574,092 66,581,904 35,895 79,177 10,085 45,639

1992 5,506,924,605 570,323,176 295,831,440 93,937,922 42,222 83,191 10,686 49,372

1993 6,019,165,609 628,777,539 312,915,698 94,726,864 43,013 87,301 10,730 46,281

1994 7,037,407,382 657,336,389 378,171,927 109,439,966 45,869 90,372 11,699 52,517

1995 7,888,956,231 708,671,105 420,612,771 111,625,927 48,185 93,332 12,374 53,717

1996 8,916,945,971 726,889,609 478,007,850 121,668,752 51,521 94,225 13,060 58,324

1997 9,559,036,832 748,761,829 531,681,285 127,784,123 52,517 95,069 13,468 59,801

1998 9,762,410,720 741,798,600 541,220,060 133,939,466 51,768 93,370 13,025 57,892

1999 10,178,722,982 733,243,392 545,346,574 142,448,430 51,841 93,262 12,569 60,590

2000 10,905,861,487 771,838,688 621,906,888 151,757,001 53,264 92,635 13,601 59,938

2001 12,195,136,176 826,717,737 713,948,717 171,034,545 57,280 94,977 14,884 64,942

2002 13,376,723,614 870,439,555 793,779,608 184,123,362 59,975 95,508 15,735 67,245

26 Précish

20-39 40-59 60-69 70+

Pe

rce

nt

of

pa

tie

nts

Pe

rce

nt

of

pa

tie

nts

Pe

rce

nt

of

pa

tie

nts

Pe

rce

nt

of

pa

tie

nts

0

20

40

60

80

NHANES III

NHANES 1999-2000

NH-W NH-B MA Other

Age Race/ethnicity

1 2 3 4-5

CKD stage

20-390

20

40

60

80

100

NHANES III

NHANES 1999-2000

Age Race/ethnicityGender

1 2 3 4-5

CKD stage

0

10

20

30

40

NHANES III

NHANES 1999-2000

Age Race/ethnicityGender CKD stage

0

10

20

30

40

50

60

70

NHANES III

NHANES 1999-2000

Age Race/ethnicityGender CKD stage

60-6940-59 70+

NH-W MANH-B Other

MaleFemale

20-39 1 2 3 4-560-6940-59 70+

NH-W MANH-B Other

MaleFemale

20-39 1 2 3 4-560-6940-59 70+

NH-W MANH-B Other

MaleFemale

Treatable risk facors for CKD (NHANES data)

{p.25} Participant distribution, by age, race/ethnicity, & CKD stage

{p.c} Adjusted OR of eGFR <60 ml/min/1.73 m2

for demographics & self-reported diseases

{p.26} Distribution of participants with self-reported HTN, by age, gender, race/ethnicity, & CKD stage

{p.27} Distribution of participants with self-reported diabetes, by age, gender, race/ethnicity, & CKD stage

{p.28} Distribution of participants with anemia (WHO definition), by age, gender, race/ethnicity, & CKD stage

he CDC’s National Health and Nu-

trition Examination Survey col-

lects information on health, illness,

and diet in the United States. We look here

at data on participants age 20 and older in

NHANES III, conducted during 1988–1994,

and in NHANES 1999–2000.

In both cohorts, more than 40 percent

of participants are age 20–39; one in five is

age 60 or older (Figure p.25). By race/

ethnicity, non-Hispanic whites account for

more than 70 percent, though this number

fell slightly between the two periods. Thirty-

one percent of NHANES III participants

have an eGFR of 60–<90 ml/min/1.73 m2,

indicating Stage 2 CKD; this number rises

to 36 percent in the later cohort.

The distribution of participants with self-

reported hypertension or diabetes is quite

different by CKD stage (Figures p.26–27).

In the 1999–2000 cohort, for example, Stage

3 CKD is found in 57 percent of those with

self-reported hypertension and in nearly 17

percent of those with self-reported diabetes.

Almost three times more women than

men in the surveys are anemic—defined by

the World Health Organization as a hemo-

globin <12 g/dl for women and <13 g/dl for

men (Figure p.28). The prevalence of ane-mia fell between the two surveys.

Table p.d lists odds ratios for the pres-

ence of an adjusted eGFR less than 60 ml/

min/1.73 m2, indicating CKD of Stage 3 or

higher. A high BMI, a C-reactive protein

NH-W · Non-Hispanic white

NH-B · Non-Hispanic black

MA · Mexican-American

% pts OR 95% CI p-valueAge 84.9 <0.001

20-39 1.0

40-59 6.9 3.5-13.6

60-69 20.7 9.6-44.4

≥70 79.7 39.5-160.6

Female 84.9 1.4 1.0-1.8 0.03

Race/ethnicity 84.9 <0.001

Non-Hispanic white 1.0

Non-Hispanic black 0.8 0.6-1.0

Mexican-American 0.5 0.3-0.6

Other 0.9 0.4-1.9

Self-reported HTN 84.9 2.5 2.0-3.1 <0.001

Self-rep CVD 84.9 1.4 1.1-1.7 <0.001

Self-rep DM 84.9 1.5 1.2-2.0 <0.001

Stage 1 · eGFR ≥90Stage 2 · eGFR 60–<90Stage 3 · eGFR 30–<60Stages 4–5 · eGFR <30

eGFR: ml/min/1.73 m2

27H2004 USRDS Annual Data Report

0

10

20

30

40

50

60

70

0

10

20

30

40

50

60

70

NHANES 1999-2000

0

20

40

60

80

100

0

20

40

60

80

100

0

20

40

60

80

100

0

5

10

15

20

25

30

35

40

Pe

rce

nt

of

pa

tie

nts

0

20

40

60

80

100Smoking status C-reactive protein 1 mg/dl

BMI 30 kg/m2 Homocysteine level (µmol/l)

Blood pressure 140/90 mm/Hg

Total cholesterol (mg/dl) Urinary albumin/creatinine (mg/g)

Stage 1 Stage 2 Stage 3 Stages 4-5 Stage 1 Stage 2 Stage 3 Stages 4-5

Percent with measured anemia (WHO definition)

0

5

10

15

20

25

30

35

NHANES 1999-2000

Number of treatable risk factors

0 1 2+

Od

ds

rati

o o

f e

GF

R <

60

ml/

min

0

5

10

15

stn

eita

p fo t

necr

eP

0

20

40

60

80

100

Stage 1 Stage 2 Stage 3 Stages 4-5

0

1

2+ risk factors

NHANES III

Never smoked

Current smoker

Ex-smoker

NHANES III

NHANES 1999-2000

NHANES III

NHANES 1999-2000

<200

200-239

240+

III 99-00 III 99-00 III 99-00 III 99-00 III 99-00 III 99-00 III 99-00 III 99-00

<30

30-300

300+

NHANES III

2.0-6.9

7.0-8.7

8.8-11.0

>11.0

III 99-00 III 99-00 III 99-00 III 99-00

>_

>_

>_

{p.31} Participant distribution, by CKD stage & treatable risk factors for cardiovascular disease

{p.29} Adjusted OR of eGFR <60 ml/min/1.73 m2

by number of treatable CV risk factors

{p.30} Participant distribution

by CKD stage & treatable CV risk factors

% pts OR 95% CI p-valueSmoking status 84.9 0.1

Non-smoker 1.0

Ex-smoker 1.3 1.0-1.6

Current smoker 1.1 0.9-1.4

BMI ≥30 kg/m2 84.9 1.3 1.0-1.7 0.05

Blood pressure 84.6 0.8

<120/80 mmHg 1.0

120-139/80-89 0.9 0.6-1.4

≥140/90 1.0 0.7-1.5

Total cholesterol 84.7 0.3

<200 mg/dL 1.0

200-239 1.2 0.9-1.5

≥240 1.5 1.1-2.0

Glyco. hgb 84.5 0.8

<7% 1.0

7-8% 1.1 0.6-2.0

>8% 1.2 0.7-2.1

CRP ≥1 mg/dl 84.8 1.7 1.2-2.5 <0.002

Homocysteine 40.8

2.0-6.9 µmol/l 1.0

7.0-8.7 3.7 1.0-14.3

8.8-11.0 9.4 2.4-37.5

>11.0 40.2 11.1-145.1 <0.001

Anemia 83.9 3.5 2.8-4.4 <0.001

Urinary alb./crt 81.5

<30 mg/g 1.0 <0.001

30-300 2.0 1.5-2.6

≥300 6.9 4.4-10.9

# CV risk factors 16.9

Zero 1.0 <0.001

One 3.9 1.3-12.1

Two+ 11.9 4.5-31.4

greater than or equal to one, a high homocys-

teine level, a low hemoglobin level, and a

high urinary albumin-to-creatinine level are

each associated with the presence of an eGFR

less than 60 ml/min/1.73 m2. The number

of treatable cardiovascular risk factors is also

highly associated with low eGFR; participants

with one risk factor are 3.9 times more likely

to have a low eGFR, while in those with two

or more the likelihood increases to 11.9.

{Table p.c} NHANESIII (1988–1994) par-ticipants, age 20 &older. All results ad-justed for years of edu-cation, income, &insurance coverage;rates by age, gender,race/ethnicity, & self-reported diseases adjusted forother covariates in the table. {Figures p.25–28}NHANES participants, age 20 & older. Anemia de-fined by WHO criteria: hemoglobin <12 g/dl for women,& <13 g/dl for men. {Table p.d} NHANES III (1988–1994) participants, age 20 & older. Adjusted for age;gender; race/ethnicity; self-reported hypertension, car-diovascular disease, & diabetes mellitus; years of edu-cation; income; & insurance coverage. {Figuresp.29–31} NHANES III (1991–1994) & NHANES1999–2000 participants, age 20 & older. In Figure p.30,risk factors do not include glycosylated hemoglobin.

{p.d} Adjusted ORs of eGFR <60 ml/min/1.73 m2

for treatable cardiovascular risk factors

Stage 1 · eGFR ≥90Stage 2 · eGFR 60–<90Stage 3 · eGFR 30–<60Stages 4–5 · eGFR <30

eGFR: ml/min/1.73 m2

Chap

terJ

o

sum

mary

Chapter summary28 Précish

Trends in clinical care{Figure p.14 Delivered dialysis therapy, as indicated by the urea reduction ratio, appears to have stabilized; 85 percent of patients have aURR of 65 percent or greater.} {Figure p.16 There has been a slight increase in the percent of prevalent hemodialysis patients using simplefistulas, though synthetic grafts are still the most common vascular access. A greater proportion of black patients, compared to whites, havesynthetic grafts.} {Figure p.20 The mean hemoglobin level in prevalent dialysis patients reached 11.7 g/dl in June, 2002, and the meanerythropoietin dose per week at this time was 16,700 units.}

Economics of ESRD care{Figure p.21 Transitional costs from pre- to post-ESRD are considerable, with costs in the month of initiation averaging almost $15,000 for Medicarepatients, and almost $25,000 for patients in employer group health plans. The greatest portion of costs is associated with hospitalizations.} {Figure p.22The cumulative percent of patients seeing specialists versus primary care physicians changes dramatically after the initiation of ESRD treatment. In theMedicare population, approximately 80–85 percent of patients are seen by nephrologists. In the elderly population, nearly 80 percent are also seen by acardiologist. There are some concerns about possible coding problems in the EGHP data and the indication of general practitioner versus nephrologistvisits.} {Figure p.24 Outpatient Medicare expenditures per patient year for dialysis patients continue to exceed inpatient costs, as they have since 1998.Costs for Part B physician services continue to increase, particularly in patients with functioning grafts.}

Treatable risk factors for CKD (NHANES data){Figure p.26 The proportion of NHANES participants reporting a diagnosis of hypertension increases in the higher stages ofCKD.} {Figure p.27 The proportion of NHANES participants with self-reported diabetes also increases in the higher stagesof CKD. Almost 40 percent of patients with CKD of Stages 4–5 report having diabetes.} {Figure p.28 The prevalence ofanemia increases with advancing chronic kidney disease.} {Table p.d The likelihood of having an eGFR less than 60 ml/min isalmost 12 times higher in NHANES participants with two or more treatable cardiovascular risk factors than in those withnone.} {Figure p.31 The percent of patients with an elevated C-reactive protein greater than 1 mg/dl increases steadily withincreasing evidence of kidney damage. Insulin resistance, obesity, and evidence of inflammation each increase with decreasingkidney function.}

Maps: National means & patient populationsFigure number p.15 p.15 p.15 p.17 p.17 p.17

All White Black All White BlackOverall value for all pts 85.4 86.8 82.5 32.4 34.8 27.6Total patients 8,342 4,446 3,110 8,110 4,341 3,001Overall value for pts mapped 85.4 86.8 82.4 32.4 34.8 27.7Missing HSA/state: pts dropped 52 13 22 51 13 21

Hospitalization & mortality{Figure p.7 Since 1993, hospital admission rates have fallen approximately 3 percent for both hemodialysis and peritoneal dialysis patients who have beenon the therapy less than three years, and are down 8 percent for transplant patients of similar vintage. } {Figure p.10 For prevalent hemodialysis, peritonealdialysis, and transplant patients on their modality less than three years, adjusted mortality rates have fallen. For hemodialysis patients of older vintage,however, rates have increased since 1994.} {Figure p.12 Rates of mortality secondary to infection have increased for older vintage hemodialysis andperitoneal dialysis patients, but have declined in the transplant population.} {Figure p.13 Between the 1988–1992 and 1993–1997 periods, five-yearsurvival improved 7 percent for hemodialysis patients, 15 percent for peritoneal dialysis patients, and 9 percent for patients with a transplant.}

Trends in the U.S. ESRD program{Table p.a The adjusted incident rate in 2002 was 333 per million population, and the adjusted prevalent rate was 1,435. Theincident population grew 4.1 percent in 2002, and the prevalent population 4.6 percent. Diabetes was the primary cause ofESRD in nearly 45 percent of incident Spatients. More than 15,000 transplants were performed during the year. Total programexpenditures reached $25.2 billion: $17 billion in Medicare spending and $8.2 billion from non-Medicare sources.} {Figurep.4 The population of patients starting dialysis in 2002 included 1,808 who had recovered kidney function after previousdialysis therapy, and 4,812 returning after a failed kidney transplant.}

Introduction{Figure p.1 In 2002 there were 431,284 prevalent ESRD patients, 308,910prevalent dialysis patients, and 122,374 prevalent transplant patients; 100,359new patients began ESRD therapy.}