Progress Toward Healthy People 2010 Targets

The following discussion highlights objectives that met or exceeded their 2010 targets; moved toward the targets, demonstrated no change, or moved away from the targets; and those that lacked data to assess progress. Progress is illustrated in the Progress Quotient bar chart (see Figure 4-1), which displays the percent of targeted change achieved for objectives and subobjectives with sufficient data to assess progress.

Objectives that met or exceeded their targets. No objective in this focus area attained its target at midcourse.

Objectives that moved toward their targets. Progress was observed in the use of arteriovenous fistulas in hemodialysis patients aged 20 years and older (4-4). Both the NKF's Dialysis Outcomes Quality Initiative and the Centers for Medicare and Medicaid Services' Fistula First program promote the arteriovenous fistula as the preferred access for hemodialysis patients. Fistula use results in lower complication rates, better flow, and lower associated illness.^{13, 14, 15} However, some segments of the health care community lag behind in integrating the concept into practice. More education of both health care providers and patients is thus required for improvement.

Objectives that moved away from their targets. Five objectives moved away from their targets: new cases of ESRD (4-1), cardiovascular disease deaths in persons with chronic kidney failure (4-2), registration for kidney transplantation (4-5), waiting time for kidney transplantation (4-6), and kidney failure due to diabetes (4-7).

After rising steadily during the 1980s and early 1990s, the rate of new ESRD cases became more stable, averaging less than a 1 percent increase per year since 2000.^{16, 17} Between 1997 and 2002, deaths of ESRD patients due to cardiovascular disease (4-2) increased slightly, moving away from the target of 62.1 deaths per 1,000 patient years.

ESRD due to diabetes was the primary factor in the increased death rate, rising 50 percent between 1993 and 2003 but beginning to plateau in the past several years. This persistent rise may be attributable to the increasing overall cases of diagnosed diabetes (5-3) in the United States.

The rate for ESRD due to high blood pressure rose 19 percent in the same period. For patients with glomerulonephritis, the rate of new cases fell nearly 10 percent. NKF, ADA, NDEP, NKDEP, and NIDDK have developed guidelines and initiatives to better educate health care providers and patients.

The proportion of dialysis patients who either are wait-listed for a transplant or receive a deceased-donor transplant within a year of starting ESRD therapy (4-5) fell between 1998 and 2001 from 21.9 percent to 14.9 percent. In 2002, the proportion increased to 15.9 percent. However, the proportion of wait-listed patients remained far from the target of 30 percent of the dialysis patients.¹⁸

The major reason for the low rate of registration on the wait list is the severe shortage of available organs for transplantation. The National Institutes of Health (NIH) and the Health Resources and Services Administration (HRSA) are developing initiatives to educate prospective donors, especially in select racial and ethnic populations, about the need to participate in organ donation programs.^{19, 20}

The proportion of patients with treated chronic kidney failure who receive a transplant within 3 years of ESRD (4-6) moved away from the 2010 target of 30.5 percent falling to 19 percent in 1999. The major obstacle is a lack of organs for transplantation. Organ donation from select racial and ethnic populations increased, but greater efforts are required to reduce disparities.

Although the rate for diabetic ESRD (4-7) rose between 1997 and 2000, it has since slowed. In 2002, the rate was 147 diabetic ESRD persons per million, a rate almost two-thirds higher than the target of 90. The driving force is the persistent increasing rate for type 2 diabetes in the U.S. population. The slight decrease in the diabetic ESRD rate, particularly in the American Indian or Alaska Native population, may be due to the aggressive campaign to use ACE inhibitors and ARBs over the past 10 to 15 years. Further attention to blood pressure control and diabetic monitoring in the general population may help lower the rates.²¹

Objectives that could not be assessed. Sufficient data did not exist to draw conclusions on progress for counseling of chronic kidney failure patients (4-3) on nutrition, treatment choices, and cardiovascular care 12 months before the start of renal replacement therapy. Investigators of the Special Studies Centers of the U.S. Renal Data System are collecting data that are anticipated by the end of the decade to assess objective 4-3.

Baselines have been established for medical evaluation and treatment of persons with type 1 or type 2 diabetes and chronic kidney disease (4-8a and b), and this objective became measurable. Progress in this area will be assessed as trend data become available.

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