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.

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)…