Self-Governance Tribes concur with this assessment, and urge the Committee to ask HHS, for reasons stated by the Senate Committee on Appropriations, to permanently abandon this proposed IHS budget consolidation proposal. CONCLUSION In conclusion, I thank Chairman Campbell and the Committee members for this opportunity to share our experiences from the "front lines," and to have a say in legislative and agency policy-making that impacts our operations. I welcome your questions. For more information, contact: Don Kashevaroff, President & Chairman Testimony for the Written Record S. 556, Indian Health Care Improvement Act Reauthorization of 2003 Committee on Indian Affairs United States Senate April 2, 2003 Submitted by: National Kidney Foundation, Inc. New York, NY 10016 The Burden of Chronic Kidney Disease Among American Indians End Stage Renal Disease (ESRD) is a life-threatening illness. Individuals with chronic kidney disease that has progressed to ESRD need regular dialysis treatments for the rest of their lives or a kidney transplant in order to survive. Driven by an explosion in the incidence of type 2 diabetes among American Indians, the ESRD prevalence rate in the American Indian population is 3.5 times that of white Americans. There is significant regional variation, with some tribes experiencing ESRD rates over twenty times that of whites. In addition, the number of American Indians with ESRD continues to grow. According to the United States Renal Data System (USRDS), there were 5,861 Native Americans with ESRD as of December 31, 2000, up from 2,662 at year-end in 1991. (1) Most of them have their dialysis treatments covered by Medicare and/or Medicaid. Since chronic kidney disease tends to worsen gradually over time, the size of the population at risk for ESRD is many times that of the dialysis and transplant community. A National Kidney Foundation Work Group was able to provide rough estimates of the extent of chronic kidney disease among adults in this country based on the Third National Health and Nutrition Examination Study (NHANES III). The Work Group calculated that, while there are approximately 300,000 Americans with ESRD, there could be as many as 19,200,000 Americans in the various stages of chronic kidney disease that precede it. (2) Similarly, it is possible to project that hundreds of thousands of American Indians may have chronic kidney disease. While only a fraction of these individuals will ultimately experience ESRD, many more will suffer from the complications of chronic kidney disease such as bone disease, anemia and cardiovascular disorders. Interventions for Chronic Kidney Disease The personal and economic toll of chronic kidney disease can often be prevented or delayed through early identification and treatment. Furthermore, early stages of chronic kidney disease can be detected through routine laboratory measurement. For these reasons, the National Kidney Foundation has developed the "Kidney Early Evaluation Program" (KEEP). KEEP is a community-based initiative designed to identify persons at risk for kidney disease. Interventions to slow the progression of kidney disease and its complications should be considered for all patients with chronic kidney disease. These might include: strict glucose control in diabetes, strict blood pressure control, use of pharmacological agents such as angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers, dietary protein restriction, lipid-lowering therapy, and correction of anemia by means of (1) United States Renal Data System, 2002 Annual Report, Atlas of End Stage Renal Disease in the United States, Table B.1, page 297. (2) National Kidney Foundation, Kidney Disease Outcomes Quality Initiative, "Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification and Stratification," American Journal of Kidney Diseases, February, 2002, Table 14. recombinant erythropoetin. (3) These interventions should be available to American Indians with chronic kidney disease through the Indian Health Service (IHS). Furthermore, there is reason to believe that disease management strategies could enhance the effectiveness of the interventions listed above. IHS should sponsor pilot projects to assess the benefit of disease management for American Indians with chronic kidney disease. ESRD Care for American Indians About 40% of American Indians live on reservations that are removed from population centers where health care facilities are located. Accordingly many tribes have sought the establishment of dialysis clinics on or near reservations so as to eliminate the need for ESRD patients to travel long distances three times a week for dialysis treatments. The need to open more dialysis units at or near reservations will increase as the number of American Indians with End Stage Renal Disease escalates. Unfortunately, it is difficult to recruit and retain qualified health care professionals to work in these remote facilities. This phenomenon is compounded by the fact that Medicare dialysis reimbursement rates are adjusted downward for rural providers and staffing costs are the largest single expense in operating a dialysis clinic. Consequently several dialysis clinics that serve American Indians have been forced to close in the last year. We respectfully request that the Committee explore approaches to assure the economic viability of dialysis clinics that serve American Indians. Secondly, pilot projects should be undertaken to test ways to make it easier for American Indians to choose the option of home dialysis. Not only does home dialysis eliminate the need for clinic visits but home dialysis patients tend to have better outcomes. Finally, we need to improve American Indian access to transplantation. At the end of 1999, only 22% of the American Indian ESRD population had functioning kidney transplants, compared with 36% of white US ESRD patients. American Indians are less likely than whites to be placed on the transplant waiting list, and those listed wait longer for a transplant. (4) Summary While American Indians bear a disproportionate burden of kidney disease, implementation of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines should provide opportunities to improve the health and well being of American Indians with chronic kidney disease and End Stage Renal Disease. Additional resources for the Indian Health Service and the Health Resources and Services Administration and through the Centers for Medicare and Medicaid Services may be necessary to make these opportunities a reality. We appreciate the opportunity to submit these comments for the written record. (3) Ibid., Guideline 13. (4) Andrew S. Narva, "The Spectrum of Kidney Disease in American Indians." Kidney International, Vol. 63, Supplement 83 (2003), p.3. |