Large databases offer details on ESRD care

CHICAGO – Nephrology is a small specialty compared to areas like oncology and cardiology. Yet it has a set of databases that may be the envy of the health care community. Three major data sources––the U.S. Renal Data System (the oldest); the Dialysis Outcomes and Practice Patterns Study (DOPPS just celebrated its 20 anniversary this year), and the PEER Group, supported by major dialysis providers––all provide detailed understanding of how kidney disease is being treated, how clinicians are succeeding (or failing) at meeting quality goals, and how much it is all costing the Medicare-funded program. The three databases were featured in a session during the American Society of Nephrology’s Kidney Week.

Looking at practice patterns

DOPPS offers a global, real-time view of a slice of kidney care. Researchers review a sampling of patients in the U.S. and other countries so that practice patterns can be studied and reviewed––and compared. And indeed, one of the areas that the U.S. continues to fall behind is in the area of catheters.

“Our catheter use in the U.S. is still too high,” noted DOPPS researcher Francesca Tentori, MD. “Seventy-five percent of incident patients in the US still start with a catheter.”

While other countries do better at avoiding catheters, they can also get patients started sooner on the more optimum access choice. In Japan, for example, cannulation takes place within a month of a fistula placement. But that could be because average blood flow is 250 cc per treatment––much lower than in the U.S., noted Tentori.

One indicator that shows similarity across a number of countries is hemoglobin. Once set at higher levels in the U.S before clinical studies and payment changes pushed providers to lower them to below 10, Tentori said hgbs saw a slight increase in the past in Japan and now are about equal to U.S. levels. Still U.S. doses of anemia drugs are higher than in Japan, she said.

Following changes in mortality

For years, the mortality rate in the U.S. of patients with renal disease on dialysis was the worst in the developed world, going as high as 22% in the late 1980s. But that rate has shown a steady decline through 2013. Why remains unclear, Allan Collins noted in discussing PEER Initiative data. And it looks like that drop in mortality rate, close to 2.5% per year, will slow down to about 1% in 2014, Collins said.

Mortality can be tied to two major causes: sudden cardiac death and infections, which used to represent only about one-third of hospitalizations.

“Today, they (cases of infections) are now equal to cardiac-related admissions.”

The key, says Collins, is controlling the intake of salt and water.

Despite a slowdown in reducing mortality, Collins said the U.S. can expect between 649,000-750,000 patients with kidney disease by 2025.

Looking at CKD

The oldest renal database in the country, says Richard Hirth, PhD, has taken close examinations of the CKD population. The U.S. Renal Data System shows that mortality in the CKD population (66 and older) is down, but still over double of the general population. In fact, Medicare spending for CKD patients (age 66+) is up. -by Mark Neumann