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

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ondary payor (MSP) with EGHP, MSP non-EGHP, Medicare Advantage
(Medicare + Choice), Medicaid, or a combination of payers. With
this approach, the USRDS is now able to apply payor status information
in all outcome analyses using the “as-treated” model (see the
discussion of Chapter Eleven).
PRIMARY CAUSE OF RENAL FAILURE
Information on the primary cause of renal failure is obtained
directly from the ME form. For the ADR we use eight categories,
with ICD-9-CM codes as follows:
4 diabetes: 250.00 and 250.01
4 hypertension: 403.9, 440.1, and 593.81
4 glomerulonephritis: 580.0, 580.4, 582.0, 582.1, 582.9, 583.1, 583.2,
583.4, and 583.81
4 cystic kidney: 753.13, 753.14, and 753.16
4 other urologic: 223.0, 223.9, 590.0, 592.0, 592.9, and 599.6
4 other cause: all other ICD-9-CM codes covered in the list of
primary causes on the ME form, with the exception of 799.9
4 unknown cause: 799.9 and ICD-9-CM codes not covered in
the list of primary causes on the ME form
4 missing cause: no ICD-9-CM code listed
RACE & ETHNICITY
Data on patient race and ethnicity are obtained from the ME form,
the CMS Medicare Enrollment Database, and the REMIS/REBUS identification
file. Because they are addressed in separate questions on
the ME form, racial and ethnic categories can overlap.
Patient ethnicity became a required field on the 1995 revised ME
form; because data for 1995 are incomplete, information on Hispanic
patients is presented starting in 1996. The non-Hispanic category
includes all non-Hispanics and patients with unknown ethnicity.
Because of the small number of ESRD patients of some races,
as well as the construction of the U.S. census data, we concentrate
on white, African American, Native American (includes Alaskan
Native), and Asian (includes Pacific Islander) populations. Data on
patients of other races will be presented as their numbers increase.
EGHP COHORT
As mentioned, EGHP data in this year’s ADR are derived from the
MarketScan and Ingenix I3 databases. To examine the demographic
segment not represented by Medicare, we use enrollment information
to construct yearly cohorts of enrollees younger than 65. To ensure
that we select enrollees with the potential to generate claims evidence
appropriate to the demands of analytical methods, rules for inclusion
also include 12 months of continuous coverage in a commercial
fee-for-service plan, and, for medication analyses, continuous prescription
drug coverage. Comorbidities are identified using claims.
Patients with at least one inpatient claim or at least two outpatient
claims during the period of interest and with a diagnosis code of a
particular comorbidity are identified as having that comorbidity.
ESRD COHORT IN THE EGHP POPULATION
As the MarketScan and I3 databases provide no identifiable data elements,
we cannot link them directly to the USRDS ESRD registry. To
identify ESRD patients we thus use a process similar to that of the
registry. Transplant patients are identified by evidence of a kidney
transplant procedure or an adverse graft event, and chronic dialysis
patients by evidence of continuous history of dialysis therapy, with at
least three consecutive months of dialysis service and with dialysis
service claims in at least 70 percent of treatment months. Treatment
months are defined from the first dialysis claim to the earliest of
kidney transplant, death, or end of enrollment. Both inpatient and
outpatient claims are evaluated for evidence of dialysis service history.
The first ESRD service date is set to the earliest of the first dialysis
service date or the transplant date. If neither is available, the start
of enrollment is used. Incidence is defined by a first ESRD service
date at least 60 days after the start of enrollment.
Précis
For Figure p.1 we identify chronic kidney disease (CKD), cardiovascular
disease (CVD), and diabetes in patients from the 5 percent
Medicare sample using methods described for Chapter Eleven; these
methods are also used to determine diabetic status and CVD in the
ESRD population. Costs for the “cost year” are determined for the
entire calendar year for patients who have fee-for-service coverage
and Medicare as primary payor. Because this analysis combines the
ESRD cohort with the 5 percent Medicare sample, ESRD patients in
the 5 percent sample are excluded.
Methods for the portion of Table p.a that addresses Medicare
spending are addressed in the discussion of Chapter Eleven. Total
transplant counts shown in Table p.a include all transplants performed
in 2007 as reported by the OPTN. Transplants of unknown
donor type are excluded from by-donor counts. New waiting list
counts include all patients added to the waiting list for a kidneyalone
or a kidney-pancreas transplant in 2007; patients added at
multiple centers are counted once. The total N on the waiting list
includes all patients listed for a kidney-alone or kidney-pancreas
transplant as of December 31, 2007, regardless of when they first
listed. If patients are added to the list in early 2007 and removed
from the list before the end of the year, it is possible for a group to
have more new patients than existing patients, as seen in patients
age 0–17. Median time on the list is shown for patients listed on
December 31, 2007.
Adjusted rates in Figures p.4–5 and p.8 are adjusted for age, gender,
and race.
Figure p.6 shows the point prevalent by-year wait list counts for
those listed for a kidney-alone transplant, and displays the median
time to transplant, as well as the 25 th and 75 th percentiles for time
to transplant, among patients transplanted during the given year.
Time to transplant is computed using Kaplan-Meier methodology.
QUALITY OF CARE
Figure p.12 presents the monthly distribution of patients by mean
hemoglobin group, with each month containing all patients with
at least one valid EPO claim during the month. The hemoglobin is
calculated as the reported hematocrit value divided by three. Figure
p.13 shows the mean hemoglobin, by month, for prevalent dialysis
patients with EPO claims, along with the monthly EPO dose per week
for patients with 20 or fewer administrations per month. The mean
EPO dose is adjusted in the same way used in Chapter Five, with a
patient’s time at risk including only those days in which he or she
is not in an inpatient hospital setting.
For Figure p.14, an archived PMMIS quarterly dialysis record is
used to track transfusions in ESRD patients before 1991. The percentage
of hemodialysis patients receiving transfusions is calculated
as the number receiving at least one transfusion in a given quarter
divided by the number with at least one dialysis record in that quarter.
Since the archived data are current only to the third quarter of
1995, we emulate this method, using Medicare claims generated by
ESRD facilities, to update the data.
Figure p.15 includes prevalent hemodialysis patients in the ESRD
CPM database who have at least one valid URR measurement. For