Department of Health and Human

¶ … Department of Health and Human Services with respect to the issue of chronic kidney disease suggests that this condition has the potential to have considerable health ramifications for specific groups as well as overall public health. At a time when other chronic conditions such as cardiovascular disease are being reduced, the incidence of chronic kidney disease is increasing. Further, the data demonstrates the individuals over the age of 75 are more susceptible to this condition. Given that almost one-third of the American population is poised to turn 65 chronic kidney disease represents an emerging health threat that must be addressed.

In an effort to improve health outcomes in this area, Department of Health and Human Services has developed its Healthy People (HP) 2010 initiative. This initiative sets specific targets for improving health based on the unique needs of the condition. For instance, in the case of chronic kidney disease, research demonstrates that there is no effective cure and that current treatment options are both expensive and do not markedly improve overall quality of life. As such recommendations for prevention and aggressive treatment of kidney disease are the focus of intervention. By focusing on these specific areas DHHS believes that health improvements can be garnered.

In an effort to understand the impact of HP 2010 goals and objectives for chronic kidney disease, this investigation considers a review of the initial goals and the outcomes that have been measured during the Midcourse Review. Through a careful review of the data problems with operationalizing data and outcomes are discussed along with some of the challenges that remain for improving overall public health with respect to the treatment and prevention of chronic kidney disease.

Selection and Overview

Focus Area and Its Parameters

In order to begin this investigation, it is first necessary to delineate the specific focus area, its parameters and how it fits into the overall U.S. Prevention Agenda. For the purposes of this investigation, chronic kidney disease has been selected. According to the Department of Health and Human Services (DHHS) (2000) Healthy People 2010 report, chronic kidney disease represents one of the most challenging obstacles for modern health care. At a time when other chronic diseases such as heart disease are declining in total number, the occurrence of chronic kidney disease is increasing (DHHS, 2000). A review of statistical data indicates that the individuals of all ages are susceptible to this condition; however individuals over the age of 75 are the most frequently diagnosed group with this condition. Although dialysis and kidney transplantation provide notable alternatives for improving patient outcomes, the treatments are not a panacea. Both do not restore complete health and both are expensive to undertake. DDHS argues that the growing number of patients with chronic kidney appears to coincide with an increase in the number of patients with type II diabetes.

Considering chronic kidney disease in the context of the overall U.S. Prevention Agenda, it seems reasonable to argue that improving outcomes in this area would be directly linked to the desire to effectively prevent health care complications with the final goal of improving overall health for the individual (Midcourse Review, 2006). By preventing the condition, it is possible that health care providers can effectively improve quality of life for patients by ensuring that patients do not fall prey to the development of a chronic condition which could markedly impede their ability to function. This would have an overwhelming impact for both those at risk for developing the condition as well on improving overall public health.

Two Goals of HP2010

DHHS (2000) reports that there are two overarching goals of HP 2010. These include: increase quality and years of healthy life and eliminate health disparities. Although these goals are aimed at improving the overall health of the population, this appears to be a notable challenge in the context of chronic kidney disease. Considering the first goal of DHHS -- i.e. To increase quality and years of life -- DHHS (2000, Chronic Kidney Disease) notes that presently treatment for chronic kidney disease does not dramatically improve the quality of life for most patients with this condition. Dialysis and renal transplantation both represent notable challenges for health care providers. Further, this condition can have a devastating impact on the overall health of the individual. Thus, in order to effectively meet this objective, DHHS will have to consider more preventative measures as a central means to reduce the onset of kidney dysfunction. Only by addressing this area will it be possible to reduce the negative health consequences that are associated with this disease.

The second objective noted by DHHS is to reduce health disparities overall. The data provided by DHHS (2000, Chronic Kidney Disease) clearly indicates that there are notable disparities with regard to ethnicity in addressing this disease. Specifically, African-Americans are more likely to develop chronic renal failure than their white counterparts. Overall health initiatives have sought to improve minority access to health care in recent years. However, African-Americans continue to remain an underserved population. Given that renal failure often has no direct symptoms, increasing awareness and developing prevention campaigns for these vulnerable populations will be a significant challenge for reducing the health disparities that have been reported with respect to this condition. In total, chronic kidney disease appears to represent a clear challenge for improving public health in terms of these two objectives.

Why this is a Population of Significance

With a basic review of the current state of chronic kidney disease elucidated, it is now possible to consider the reasons why this population is of significance for efforts to improve public health. According to the original DHHS (2000) Health People 2010 report approximately 10 million individuals over the age of 12 have some form of kidney disease. Further, DHHS reports that most of the new cases of kidney failure are reported in individuals over the age of 75. Finally, DHHS notes that there are notable disparities in the diagnosis of this condition based on ethnicity. When these specific issues are examined in the context of population trends for the United States, the importance of addressing this condition becomes quite clear.

According to the U.S. Census Bureau (2006) "In 2006, the oldest of the baby boomers, the generation born between 1946 and 1964, will turn 60 years old (Oldest baby...). The Bureau goes on to report that this population includes more than 78 million Americans or almost one-third of the population. As approximately one-third of the population becomes poised to reach the 75 and over demographic, it is reasonable to assume that the number of individuals developing chronic kidney disease will increase dramatically. The growing number of ethnic minorities living in the U.S. is also a critical issue for concern. Specifically, Mather (2007) reports that in 2006 the United States Census Bureau reported that the total number of ethnic minorities living in the U.S. toped 100 million for the first time. Although these individuals are not equally dispersed across all age groups, again changes in the demographics of the general population warrant concern as more individuals will be susceptible to developing chronic kidney disease.

Objectives and Sub-Objectives of the Population Focus Area

The next issue that must be addressed in the context of this investigation is a description of all of the objectives and sub-objectives for this population focus area. A review of the HP2010 goals developed by DHHS (2000, Chronic Kidney Disease) indicates that the central goal for this condition is as follows: "Reduce new cases of chronic kidney disease and its complications, disability, death and economic costs" (p. 4-9). In order to achieve this goal, DHHS has developed eight sub-objectives that include the following:

4-1: Reduce the rate of new cases of end-stage renal disease: DHHS reports that current rate of increase in this condition is 6% per year, with the number of cases increasing 5 to 8% per year. Thus, if efforts are not made to reduce the total number of ESRD cases a significant number of deaths will result as a consequence of this condition.

4-2: Reduce deaths from cardiovascular disease in persons with chronic kidney failure: Cardiovascular disease is a leading cause of death for patients with chronic kidney disease. As such, reducing the number of patients with cardiovascular disease should improve outcomes for patients with chronic kidney disease.

4-3: Increase the proportion of treated chronic kidney failure patients who have received counseling on nutrition, treatment choices and cardiovascular care 12 months before the start of renal replacement therapy: This measure is intended to improve overall health outcomes for the patient by improving other areas of health that can impact outcomes of chronic kidney disease.

4-4: Increase the proportion of new hemodialysis patients who use arteriorvenous fistulas as the primary mode of vascular access: Fistulas have demonstrated to improve health outcomes for the patient and are recommended as a first line of defense for improving outcomes for patients receiving dialysis.

4-5: Increase the proportion of dialysis patients registered on the waiting list for transplantation: Renal transplantation can markedly improve quality of life. However, many patients suffering with chronic renal disease do not explore this option.

4-6: Increase the proportion of patients with treated chronic kidney failure who receive a transplant within 3 years of registration on the waiting list. Again renal transplantation can improve overall quality of life for patients struggling with this condition.

4-7: Reduce kidney failure due to diabetes: Type II diabetes is a significant contributor to chronic kidney disease. Reducing and preventing diabetes can effectively reduce the number of cases of chronic renal failure.

4-8: Increase the proportion of persons with type 1 or type 2 diabetes and proteinuria who receive recommended medical therapy to reduce progression to chronic renal insufficiency. This measure would help improve health outcomes for the patient and reduce the overall impact of the disease on the general population.

Relevance of the Objectives and Desired Outcomes

The objective outlined as the principle focus of improving health in this area is targeted toward reducing the complications and costs associated with chronic renal failure. Reviewing the data provided with regard to the sub-objectives, it seems reasonable to argue that this target goal is the most feasible given the specific parameters of the condition. Research from DHHS (2000, Chronic Kidney Disease) demonstrates that chronic kidney disease is often a silent disease which has no specific symptoms. As a result, individuals diagnosed with renal disease often face considerable health challenges as their overall health quickly deteriorates. Further, data from DHHS indicates that there is no effective cure for the disease and the organization reports that treatment does not dramatically improve overall quality of life.

Based on this data, it seems reasonable to argue that efforts to improve health outcomes with regard to this disease must focus on preventative measures that: 1) prevent or delay the onset of the disease; 2) treat the disease at various points during its progression to reduce its impact and improve health outcomes over the long-term; and 3) more aggressively seek transplantation as a principle means to improve health outcomes for individual patients. The data included under each of the sub-objectives demonstrates the salience of each of the research objectives by clearly outlining the number of individuals involved in each of the proposed interventions. In total, the data indicates that the proposed sub-objectives would allow public health officials to effectively reach the bulk of individuals that will be or are impacted by this condition.

Is Each a Valid Strategy for the Outcome?

The sub-objectives outlined above clearly have merit with respect to improving outcomes for the population. However, a critical review of the sub-objectives indicates that there are some objectives that appear to be more difficult to achieve overall. For instance, the third objective outlined by DHHS is "Increase the proportion of treated chronic kidney failure patients who have received counseling on nutrition, treatment choices and cardiovascular care 12 months before the start of renal replacement therapy." Although this service can be provided to patients that are diagnosed with the condition in its early stages, the reality is that most individuals with this condition are not diagnosed until the disease has progressed substantially. As such, this goal does not appear to have real salience for meeting the target objective for the HP 2010.

Additionally, DHHS recommends that the number of dialysis patients placed on the renal transplantation list should be increased. Given that the total number of kidneys available for transplantation has remained stable over the last several years (Chronic Kidney Disease, 2006) it seems reasonable to argue that increasing the number of patients on the transplant list will not improve overall health outcomes for patients with this condition. Clearly, in this case, the issue is one of supply and demand. With no additional supply of kidneys available, the number of patients receiving these donated organs will not increase.

Rationale for a Personal View

Synthesizing of the data provided by DHHS with respect to chronic renal failure, it seems reasonable to argue that most of the objectives developed by the organization are valid and will have direct implication for reducing the number of cases and reducing the overall impact of the disease on public health. Based on the focus of the recommendations it is evident that treatment and prevention of chronic kidney disease represent the most salient means for improving patient outcomes when it comes to chronic kidney disease. Although DHHS has developed a wide range of potential areas in which improvements can be made, a critical analysis of these goals seems to suggest that some should be eliminated or redesigned. Specifically, the two objectives noted above do not appear to have any real salience for improving health outcomes for patients with this condition.

Although health improvement with respect to chronic kidney disease indicates that there are a host of areas in which improvements can be made, preventative measures that stem from reducing the incidence of cardiovascular disease and type II diabetes appear to be the most viable means for prevention. Data in this area suggests that individuals that develop these conditions are most vulnerable to developing chronic renal failure. Considerable research on both cardiovascular disease and type II diabetes has been undertaken in an effort to reduce risk factors and prevent these diseases. Further emphasis in these areas could provide the needed to dramatically reduce the overall rate of chronic kidney disease.

Midcourse Review Data

Midcourse Review Outcomes

The Midcourse Review (2006) provided by DHHS states that there are two goals for improving overall public health. These include: increasing the quality and years of healthy life and eliminating health disparities. A review of the specific progress that has been made with respect to these individual goals suggests that while some progress has been made toward achieving both significant gaps in both improving quality of life and eliminating health disparities remains. With this in mind, it is helpful to consider the progress and problems based on each of the goals. Data for this was retrieved from DDHS (2006) Midcourse Review on Chronic Kidney Disease:

Increase Quality and Years of Healthy Life: With regard to progress in this area DDHS reports that arteriovenous fistulas have been developed and promoted as a central means to improve outcomes for dialysis patients. According to the organization "Fistula use results in lower complication rates, better flow and lower associated illness" (p. 4-4). Although improve health can be achieved, this technology is limited in application as more education is needed to advance its use. With respect to problems that remain in this area, DHHS reports that are currently five areas in which progress is moving away from targets. These include: new cases of end-stage renal disease (ESRD), cardiovascular disease deaths in patients with chronic renal failure, registration for kidney transplantation, waiting time for kidney transplantation, and kidney failure due to diabetes (p. 4-4).

Eliminating Health Disparities: Critically reviewing the data provided by DDHS (2006, Chronic Kidney Disease) it becomes evident that while the number of cases of chronic kidney disease became stable in some patients, various groups are still at higher risk for developing this condition. Despite this however, DDHS does demonstrate that the percentage increase in the number of patients with the condition has declined in most of the ethnic groups investigated. Thus, some clear progress has been made toward reducing the ethnic and cultural gap that exists with regard to this disease.

Additionally, DDHS (2006) Midcourse Review on Chronic Kidney Disease reports that of the eight original sub-objectives identified in HP 2010 for chronic kidney diseases, only one of the objectives was modified at midcourse: 4-8, medical evaluation and treatment of persons with type 1 or type 2 diabetes. According to the organization, "Issues concerning the availability of data for this developmental objectives led to rewording and the addition of two sub-objectives" (p. 4-4). The sub-objectives included the following:

4-8a: Increase the proportion of persons with type 1 or type 1 diabetes and chronic kidney disease who receive recommended medical evaluation.

4-8b: Increase the proportion of persons with type 1 or 2 diabetes and chronic kidney disease who receive recommended treatment to reduce progression to chronic renal insufficiency.

DHHS argues that once these changes were made to the goals, it was possible to effectively measure outcomes with regard to this specific objective.

Classification of Objectives and Sub-Objectives in the Midcourse Review

While the above review provides a general overview of the specific changes that have occurred as a result of the implementation of efforts to improve outcomes in this area, it is pertinent to consider the two HP 2010 goals with respect to the specific chronic kidney disease outcomes that were achieved. Examining the data provided in the DDHS (2006) Midcourse Review on Chronic Kidney Disease, the following progress/problems were identified:

Increase Quality and Years of Healthy Life: Objective 4-4 was advanced at midcourse. However, objectives 4-1, 4-2, 4-5, 4-6, and 4-7 were not met. Data on 4-3 and 4-8(a and b) could not be effectively assessed. With respect to problems the data indicates that: the total number of ESRD cases increased (4-1) and that the number of cardiovascular deaths among renal failure patients increased as well (4-2). Further, the number of dialysis patients being placed on renal transplant lists decreased (4-5) the number of patients receiving kidney transplant within three years declined as well (4-6). Finally, diabetic ESRD increased since setting the initial HP 2010 goals (4-7).

Eliminating Health Disparities: The data reported with regard to specific objectives and eliminating health disparities demonstrates that some progress was made in various populations. However, only by examining the data is it possible to assign specific changes to the particular objectives outlined by DHHS.

White, non-Hispanics had the lowest rate of new cases of ESRD (4-1) and kidney failure due to diabetes (4-7). This population also had the highest rate of kidney transplantation within three years (4-6).

Asian Pacific Islander population increased registration for kidney transplantation wait list (4-5). This population also had the highest medical evaluation rate (4-8a) and the lowest cardiovascular death rate (4-2). Additionally, this population had the highest use of fistulas (4-4).

Women had a lower rate of ESRD (4-1) and a lower rate of diabetic ESRD (407). Men had a higher rate of fistula use (4-4) and were more likely to register on the transplant list (4-5). Further men had a shorter wait time for renal failure before kidney transplantation (4-6). Women had a higher cardiovascular death rate than men (4-2).

African-Americans continued to have the highest rate of chronic kidney disease (4-1) and the highest rate of ESRD (4-1). American Indian or Alaska Native population had the highest rate of diabetic kidney disease (4-7).

Although ESRD increased (4-1) the total increase declined between 1999 and 2002. The American Indian or Alaska Native population showed the most notable decline in ESRD at 28% (4-1).

Legitimacy of Objectives/Sub-Objectives

Although the data provided by DHHS indicates that clear efforts have been made to both examine and understand the data, the reality is that some of the objectives provided by the organization do not appear to be supported based on current circumstances. For instance, DHHS believes that it can improve health outcomes for the population by increasing the overall number of renal patients that register for transplantation (4-5). Although encouraging patients to register for the renal wait list is a noble goal, the reality is that the specific factors that will contribute to success in this area are not within the control of DHHS or renal patients. In fact, DHHS (2006, Chronic Kidney Disease) reports that one of the most pressing emerging issues is a lack of organs available for transplant: