Latest US Renal Data System report examines Medicare Advantage, post-COVID-19 care
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The latest edition of the United States Renal Data System Annual Data Report offers a look at outcomes from the second year of the COVID-19 pandemic, as well as outcomes in the Medicare Advantage and Medicaid programs among patients with kidney disease.
The United States Renal Data System (USRDS) Annual Data Report (ADR) includes two volumes, one about chronic kidney disease and another about end-stage kidney disease. Some key analyses include the following:
- The picture of CKD continues to develop gradually, in both the burden and the treatment of the disease. Among the more than 20 million older patients with traditional Medicare coverage, the prevalence of CKD reached a new high of 14.2%, according to the ADR.
- Among Black patients with traditional Medicare coverage, the prevalence of CKD exceeded 20% for the first time.
- Among adults younger than 65 years with CKD who were enrolled in Medicaid programs, comorbidity was common in 2021: 42% had diabetes, 38% had cardiovascular disease and 20% had heart failure. Yet 22% of Medicaid enrollees with CKD stage 4 saw a nephrologist in 2021.
- The sudden increase in mortality that defined the first year of the COVID-19 pandemic abated only slightly in 2021. Among older people with traditional Medicare coverage, the adjusted rate of death decreased only 2% between 2020 and 2021, after having increased 10% between 2019 and 2020.
- For people younger than 65 years with Medicaid coverage, the adjusted rate of death from COVID-19 remained 22% higher in 2021 than in 2019, essentially the same as in 2020.
Hospitalizations
In contrast with elevated rates of death, rates of hospitalization in patients with CKD remained depressed in 2021, still well below pre-pandemic levels. As part of the presentation about morbidity, the USRDS debuted a comparison of hospitalization rates among patients with advanced CKD in the traditional Medicare vs. Medicare Advantage programs, albeit during calendar year 2020. Notably, in patients with CKD stage 4, the adjusted hospitalization rate in the traditional Medicare program was 741 admissions per 1,000 person-years, while the corresponding rate in the Medicare Advantage program was only 599 admissions per 1,000 patient-years. Among all hospital admissions in older patients with traditional Medicare coverage in 2021, 27% included a diagnosis of AKI. Among patients without preexisting CKD, the corresponding share was 21%. Both were new highs.
As in patients with CKD, the rate of hospitalization in patients with ESKD in 2021 remained below pre-pandemic levels. As for patients on dialysis with Medicare coverage in 2020, the adjusted rate of hospitalization with hemodialysis was 12% lower in Medicare Advantage vs. traditional Medicare, while the adjusted rate with patients on peritoneal dialysis was 13% lower.
Medications
Among older patients with CKD enrolled in a Part D prescription drug plan, the most used classes of medication were statins (67%), renin-angiotensin inhibitors (55%), beta blockers (54%), antibiotics (53%) and calcium channel blockers (35%). Meanwhile, 29% used opioids and 20% used gabapentinoids.
Sodium-glucose cotransporter-2 inhibitor utilization was modest in 2021. Overall utilization of SGLT2 inhibitors in patients with CKD was 4.6%. Utilization was slightly higher in the subgroup of CKD patients with diabetes, but in those without diabetes, utilization was less than 2%.
In patients with CKD and diabetes, metformin use continued to increase in 2021, reaching nearly 36%, while sulfonylurea use continued to decrease, reaching 24%. Use of GLP1 receptor agonists increased to almost 11%, thanks to the largest year-over-year increase to date.
Dialysis care
Source: U.S. Renal Data System Annual Data Report.
The state of ESKD continued to reflect the direct and indirect effects of COVID-19. As has been widely reported, calendar year 2020 featured a precipitous decline in ESKD incidence during the second quarter of the year and an unprecedented decrease in the overall census of patients undergoing maintenance dialysis.
The story in 2021 was more complicated. The number of newly registered cases of ESKD once again increased between 2020 and 2021, reaching an all-time high of 135,972. However, the unadjusted rate of ESKD incidence increased only from 393 cases per million people in 2020 to 399 cases per million people in 2021, a level still below the unadjusted rates in 2018 and 2019. Furthermore, the adjusted rate of ESRD incidence, controlling for age, sex and race, was just 363 cases per million people in 2021, a level not even 1% higher than the generational low observed in 2020. The percentage of older patients with previously diagnosed CKD stage 4 or 5 who initiated maintenance dialysis outside the hospital reached a new high in 2021, at 66.9%.
The prevalence of ESKD in the United States reached an all-time high of 808,536 patients at the end of 2021, but the adjusted rate of ESKD prevalence fell for the second consecutive year, reaching 2,219 cases per million people. The modest increase in the prevalence of ESKD was wholly attributable to continued expansion of the home dialysis and kidney transplant subpopulations.
Home dialysis
Home dialysis either grew a bit in 2021 or stalled, depending on the choice of statistic. The sheer number of patients undergoing either home hemodialysis or peritoneal dialysis reached almost 79,000 by the end of 2021, a new high. This achievement resulted in overall utilization increasing from 13.7% in 2020 to 14.1% in 2021, a level not observed since 1997.
On the other hand, growth in the percentage of incident ESKD patients undergoing home dialysis slowed, increasing from 13.2% to 13.4% between 2020 and 2021. The gap in home dialysis utilization between white and Asian patients on one hand and Black and Hispanic patients on the other hand exhibited no sign of closing.
Vascular access, mortality rate
The share of patients who initiated hemodialysis with a central venous catheter without a maturing arteriovenous access increased to 74% in 2021, contributing to overall catheter dependence of more than 85% among patients initiating hemodialysis.
Mortality remained elevated in 2021. The adjusted rate of death among patients undergoing dialysis increased slightly between 2020 and 2021, from 186.4 to 187.7 deaths per 100 patient-years. Troublingly, the adjusted date of death among patients with a functioning transplant increased from 63.9 to 74.3 deaths per 100 patient-years, an increase only slightly smaller than that observed between 2020 and 2021.
Kidney transplants, cost of care
The percentage of prevalent dialysis patients who were placed on a waitlist for a kidney transplant decreased to 12.3% in 2021, continuing a decline that began in 2013. However, the rate of kidney transplantation among dialysis patients reached another high, at four grafts per 100 patient-years, despite lagging volume of living-donor kidney transplants.
Inflation-adjusted cost of care for patients with traditional Medicare coverage in 2021 was $99,325 with hemodialysis, $86,976 with peritoneal dialysis and $43,913 with a functioning transplant. The cost associated with peritoneal dialysis was the highest since 2015, while the cost associated with a functioning transplant was the highest in at least a decade.
One additional detail regarding ESKD incidence is concerning. Figure 1.4 in the ADR shows rates of ESKD stratified by age, sex and race/ethnicity. With respect to race/ethnicity, the adjusted rate of ESKD incidence in white patients continues to show new lows, at roughly 250 cases per million people in both 2020 and 2021. The adjusted rate in Hispanic patients has exhibited similar behavior in the long run, while the rate in Asian patients has been essentially static. In contrast, the adjusted rate of ESRD incidence in Black patients seems to have reversed course. Between 2001 and 2018, that rate fell impressively, from 1,173 to 909 cases per million people. However, the rate has iteratively increased since 2018, reaching 964 cases per million people in 2021.
Realistically, the hope of reducing the incidence of ESKD in the United States will evaporate if the country loses control of ESKD incidence among Black patients.
As is always the case, the picture of kidney disease in the United States as painted by the USRDS is complex, with contrasting strokes of success and frustration. Newer medications aimed at slowing the progression of CKD are clearly infiltrating clinical practice, but the pace of that infiltration is not rapid, especially outside of diabetic nephropathy. The adjusted rate of ESKD incidence seems to signal progress, but the sheer number of annual cases of kidney failure ratchets upward, largely due to steady aging of the population. Home dialysis continues to grow, but the rate of growth falls short of what many would classify as transformational.
In hindsight, COVID-19 struck transplant patients hard. Ultimately, the fight to improve kidney health is at hand. The pharmacologic tools to fight are within reach, but the disease is formidable.
- Reference:
- United States Renal Data System. 2023 USRDS annual data report: Epidemiology of kidney disease in the United States. NIH, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md. 2023. https://www.niddk.nih.gov/about-niddk/strategic-plans-reports/usrds. Published Oct. 31, 2023. Accessed Dec. 10, 2023.
- For more information:
- Eric Weinhandl, PhD, MS, is vice president of epidemiology at DaVita Clinical Research, and a member of the Editorial Advisory Board for Healio | Nephrology News & Issues. He can be reached at wein0205@umn.edu.
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