2009 ADR v2 Atlas of ESRD - United States Renal Data System

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C1) Prevalence: Total number of ESRD patients (all treatment categories) at the end of the year (December 31) 0–19 20–44 45–64 65–74 75+ Total 2005 __________ __________ __________ __________ __________ __________ 2006 __________ __________ __________ __________ __________ __________ 2007 __________ __________ __________ __________ __________ __________ 2008 __________ __________ __________ __________ __________ __________ C2) Prevalence: Total number of ESRD patients with a functioning graft at the end of the year (December 31) 0–19 20–44 45–64 65–74 75+ Total 2005 __________ __________ __________ __________ __________ __________ 2006 __________ __________ __________ __________ __________ __________ 2007 __________ __________ __________ __________ __________ __________ 2008 __________ __________ __________ __________ __________ __________ C3) Prevalence: Total number of ESRD patients on dialysis at the end of the year (December 31) 0–19 20–44 45–64 65–74 75+ Total 2005 __________ __________ __________ __________ __________ __________ 2006 __________ __________ __________ __________ __________ __________ 2007 __________ __________ __________ __________ __________ __________ 2008 __________ __________ __________ __________ __________ __________ C4) Prevalence: Total number of ESRD patients on in-center hemodialysis at the end of the year (December 31) 0–19 20–44 45–64 65–74 75+ Total 2005 __________ __________ __________ __________ __________ __________ 2006 __________ __________ __________ __________ __________ __________ 2007 __________ __________ __________ __________ __________ __________ 2008 __________ __________ __________ __________ __________ __________ C5) Prevalence: Total number of ESRD patients on CAPD/CCPD at the end of the year (December 31) 0–19 20–44 45–64 65–74 75+ Total 2005 __________ __________ __________ __________ __________ __________ 2006 __________ __________ __________ __________ __________ __________ 2007 __________ __________ __________ __________ __________ __________ 2008 __________ __________ __________ __________ __________ __________ C6) Prevalence: Total number of ESRD patients on home hemodialysis at the end of the year (December 31) 0–19 20–44 45–64 65–74 75+ Total 2005 __________ __________ __________ __________ __________ __________ 2006 __________ __________ __________ __________ __________ __________ 2007 __________ __________ __________ __________ __________ __________ 2008 __________ __________ __________ __________ __________ __________ D1) Transplant: Total number of cadaveric transplants during the year 0–19 20–44 45–64 65–74 75+ Total 2005 __________ __________ __________ __________ __________ __________ 2006 __________ __________ __________ __________ __________ __________ 2007 __________ __________ __________ __________ __________ __________ 2008 __________ __________ __________ __________ __________ __________ D2) Transplant: Total number of living donor transplants during the year 0–19 20–44 45–64 65–74 75+ Total 2005 __________ __________ __________ __________ __________ __________ 2006 __________ __________ __________ __________ __________ __________ 2007 __________ __________ __________ __________ __________ __________ 2008 __________ __________ __________ __________ __________ __________
DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0046 END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION A. COMPLETE FOR ALL ESRD PATIENTS Check one: Initial Re-entitlement Supplemental 1. Name (Last, First, Middle Initial) 2. Medicare Claim Number 3. Social Security Number 4. Date of Birth 5. Patient Mailing Address (Include City, State and Zip) 6. Phone Number ( ) t Prior Curren MM DD YYYY 7. Sex 8. Ethnicity 9. Country/Area of Origin or Ancestry Male Female Not Hispanic or Latino Hispanic or Latino (Complete Item 9) 10. Race (Check all that apply) 11. Is patient applying for ESRD White Asian Medicare coverage? Black or African American American Indian/Alaska Native Native Hawaiian or Other Pacific Islander* Yes No Print Name of Enrolled/Principal Tribe _________________ *complete Item 9 12. Current Medical Coverage (Check all that apply) 13. Height 14. Dry Weight 15. Primary Cause of Renal Medicaid Medicare Employer Group Health Insurance INCHES _______ OR POUNDS _______ OR Failure (Use code from back of form) DVA Medicare Advantage Other None CENTIMETERS _______ KILOGRAMS _______ 16. Employment Status (6 mos prior and 17. Co-Morbid Conditions (Check all that apply currently and/or during last 10 years) *See instructions current status) a. Congestive heart failure n. Malignant neoplasm, Cancer b. Atherosclerotic heart disease ASHD o. Toxic nephropathy c. Other cardiac disease p. Alcohol dependence Unemployed Employed Full Time Employed Part Time d. e. f. g. Cerebrovascular disease, CVA, TIA* Peripheral vascular disease* History of hypertension Amputation q. r. s. t. Drug dependence* Inability to ambulate Inability to transfer Needs assistance with daily activities Homemaker h. Diabetes, currently on insulin u. Institutionalized Retired due to Age/Preference Retired (Disability) Medical Leave of Absence i. j. k. l. Diabetes, on oral medications Diabetes, without medications Diabetic retinopathy Chronic obstructive pulmonary disease v. 1. Assisted Living 2. Nursing Home 3. Other Institution Non-renal congenital abnormality Student 18. Prior to ESRD therapy: m. Tobacco use (current smoker) w. None a. Did patient receive exogenous erythropoetin or equivalent? Yes No Unknown If Yes, answer: 6-12 months >12 months b. Was patient under care of a nephrologist? Yes No Unknown If Yes, answer: 6-12 months >12 months c. Was patient under care of kidney dietitian? Yes No Unknown If Yes, answer: 6-12 months >12 months d. What access was used on first outpatient dialysis: AVF Graft Catheter Other If not AVF, then: Is maturing AVF present? Yes No Is maturing graft present? Yes No 19. Laboratory Values Within 45 Days Prior to the Most Recent ESRD Episode. (Lipid Profile within 1 Year of Most Recent ESRD Episode). LABORATORY TEST VALUE DATE LABORATORY TEST VALUE DATE a.1. Serum Albumin (g/dl) ___ . ___ d. HbA1c ___ ___ . ___% a.2. Serum Albumin Lower Limit ___ . ___ e. Lipid Profile TC ___ ___ ___ a.3. Lab Method Used (BCG or BCP) LDL ___ ___ ___ b. Serum Creatinine (mg/dl) ___ ___ . ___ HDL ___ ___ c. Hemoglobin (g/dl) ___ ___ . ___ TG ___ ___ ___ ___ B. COMPLETE FOR ALL ESRD PATIENTS IN DIALYSIS TREATMENT 20. Name of Dialysis Facility 21. Medicare Provider Number (for item 20) 22. Primary Dialysis Setting Home Dialysis Facility/Center SNF/Long Term Care Facility 24. Date Regular Chronic Dialysis Began 26. Has patient been informed of kidney transplant options? Yes No FORM CMS-2728-U3 (06/04) EF(03/2005) MM DD YYYY Medical Evidence form (2728), 2005 version 23. Primary Type of Dialysis Hemodialysis (Sessions per week____/hours per session____) CAPD CCPD Other 25. Date Patient Started Chronic Dialysis at Current Facility MM DD YYYY 27. If patient NOT informed of transplant options, please check all that apply: Medically unfit Patient declines information Unsuitable due to age Patient has not been assessed Psychologically unfit Other
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Page 5 and 6: the sample for four years, with app
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Page 11 and 12: ence Section G; here, however, inci
Page 13 and 14: dialysis patients in 2007, each pat
Page 15 and 16: therapy on January 1, with a first
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Page 19 and 20: 6. Alaska, Hawaii, Idaho, Montana,
Page 21 and 22: the given year, regardless of when
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Page 25 and 26: survive, continue dialysis, and car
Page 27 and 28: a dii Medicare categories of paymen
Page 29 and 30: 4 the Philippines Renal Disease Reg
Page 31 and 32: each table. The marginal rates are
Page 33 and 34: Levey AS, Berg RL, Gassman JJ, Hall
Page 35 and 36: Dialyzers Th e Case Mix Severity, C
Page 37 and 38: quality of life and nutrition issue
Page 39 and 40: Medicare enrollment for the periods
Page 41 and 42: ESRD Facility Survey Data for this
Page 43 and 44: United States Renal Data System (US
Page 45: United States Renal Data System (US
Page 49 and 50: LIST OF PRIMARY CAUSES OF END STAGE
Page 51 and 52: C. COMPLETE FOR ALL KIDNEY TRANSPLA
Page 53 and 54: Medical Evidence form (2728), 1987
Page 55 and 56: CARDIAC 23 Myocardial infarction, a
Page 57 and 58: ESRD DEATH NOTIFICATION FORM LIST O
Page 59 and 60: DEPARTMENT OF HEALTH AND HUMAN SERV
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Page 63 and 64: during transition to ESRD 135, 341
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2009 ADR v2 Atlas of ESRD - United States Renal Data System

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