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Health Policy for Dialysis Care in Canada and the United States

Marcello Tonelli, Raymond Vanholder and Jonathan Himmelfarb
CJASN November 2020, 15 (11) 1669-1677; DOI: https://doi.org/10.2215/CJN.14961219
Marcello Tonelli
1Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Raymond Vanholder
2Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium, European Kidney Health Alliance
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Jonathan Himmelfarb
3Kidney Research Institute, School of Medicine, Seattle, Washington
4Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
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    Figure 1.

    Selected characteristics related to dialysis treatment (all modalities) for Canada and the United States. Sources: (A) the United States Renal Data System (USRDS) (70). (B) The USRDS (70) and the Canadian Organ Replacement Register (CORR) (23). (A) Comparison of the prevalence of dialysis treatment in Canada and the United States per million population. It shows that the prevalence of ESKD has been consistently higher over time in the United States (P<0.001), with a slight widening of this difference in recent years. (B) Comparison of eGFR at initiation of dialysis in Canada versus the United States. It shows fluctuations in both countries over time, with eGFR at dialysis progressively increasing from 2005 to 2010 and then decreasing thereafter. eGFR at initiation of dialysis has been slightly higher in Canada than in the United States (P<0.001).

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    Figure 2.

    Survival after initiation of dialysis (all modalities) differ for Canada and the United States. Sources: the USRDS (70) and the CORR (23). The figure compares unadjusted survival at various time points (3 months and 1, 3, and 5 years) after initiation of dialysis among patients treated in Canada versus the United States. The figure shows that mortality at 1, 3, and 5 years is consistently lower in Canada than in the United States (for 1 and 3 years; all P<0.001) but that these between-country differences have tended to narrow over time. For survival at 3 months, mortality was lower in the United States than in Canada during 2014–2016 (P<0.001), although the magnitude of the difference was very small.

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    Figure 3.

    Timeline of the regulatory landscape changes for ESKD in the United States, 2008–2016. The figure shows key changes in the regulatory landscape for ESKD in the United States since 2008. The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 established the current expanded prospective payment system (PPS) for reimbursement for the care of patients with ESKD in the United States. There have been no substantive changes in the regulatory landscape for ESKD in Canada over this period. CMS, Centers for Medicare and Medicaid Services; ESCO, ESRD Seamless Care Organizations; HHS, US Department of Health and Human Services; MAT, Measure Assessment Tool; QIP, Quality Incentive Program. Image credit: Matt Rivara, M.D.

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    Table 1.

    Characteristics of patients on kidney replacement for Canada versus the United States

    Patients Treated with Any Form of Kidney ReplacementUnited StatesCanada
    Modality of kidney replacement among incident patients
     In-center hemodialysis89.7 (89.5 to 89.9)74.3 (73.1 to 75.4)
     Home hemodialysis0.3 (0.3 to 0.3)0.7 (0.4 to 0.9)
     Peritoneal dialysis10.0 (9.8 to 10.2)22.5 (21.4 to 23.6)
     Preemptive transplantation1.6 (1.6 to 1.7)0.9 (0.8 to 1.1)
    Modality of kidney replacement among prevalent patients
     In-center hemodialysis62.0 (61.9 to 62.1)44.1 (43.6 to 44.6)
     Home hemodialysis1.2 (1.2 to 1.3)2.9 (2.7 to 3.0)
     Peritoneal dialysis7.1 (7.0 to 7.1)11.6 (11.3 to 11.9)
     Transplantation29.7 (29.6 to 29.8)41.5 (41.0 to 42.0)
    • Data are reported as percentage (95% confidence interval). Data from the United States were extracted from the United States Renal Data System annual data report (70). The US cohort includes Medicare and non-Medicare patients living in the 50 states, the District of Columbia, Puerto Rico, and the US territories. Data from Canada were extracted from the Canadian Organ Replacement Register annual statistics (23). The Canadian cohort includes all provinces and territories except Quebec, which was excluded because of significant under-reporting between 2011 and 2014.

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    Table 2.

    Characteristics of patients on incident dialysis for Canada versus the United States

    Incident Patients Treated with DialysisUnited StatesCanada
    Age, yr, % (95% confidence interval)
     <4511.5 (11.3 to 11.7)11.2 (10.4 to 12.0)
     45–6437.8 (37.5 to 38.1)34.4 (33.1 to 35.7)
     65–7427.3 (27.0 to 27.6)27.4 (26.2 to 28.6)
     75+23.4 (23.2 to 23.6)27.0 (25.8 to 28.2)
    Women, %42.1 (41.8 to 42.4)37.8 (36.5 to 39.1)
    Race, %
     White67.1 (66.8 to 67.4)63.4 (62.1 to 64.7)
     Black26.1 (25.9 to 26.3)3.3 (2.8 to 3.8)
     Asian4.2 (4.1 to 4.3)17.4 (16.4 to 18.4)
     Other2.5 (2.4 to 2.6)11.8 (10.9 to 12.7)
     Unknown0.1 (0.1 to 0.1)4.0 (3.5 to 4.5)
    Rural residence location, %—18.7 (17.6 to 19.8)
    Baseline comorbidities, %
     Diabetes56.9 (56.7 to 57.1)56.0 (54.7 to 57.3)
     Heart diseasea34.7 (34.5 to 34.9)28.8 (27.6 to 30.0)
     Cerebral vascular8.4 (8.3 to 8.5)12.7 (11.8 to 13.6)
     Lung disease9.3 (9.2 to 9.4)12.3 (11.4 to 13.2)
     Hypertension87.0 (86.9 to 87.1)77.9 (76.8 to 79.0)
     Peripheral vascular disease11.2 (11.1 to 11.3)14.8 (13.9 to 15.7)
    • Data are reported as percentage (95% confidence interval). Data from the United States were extracted from the United States Renal Data System annual data report (70). The US cohort includes Medicare and non-Medicare patients living in the 50 states, the District of Columbia, Puerto Rico, and the US territories. Data from Canada were extracted from the Canadian Organ Replacement Register annual statistics (23). The Canadian cohort includes all provinces and territories except Quebec, which was excluded because of significant under-reporting between 2011 and 2014.

    • ↵a The United States includes atherosclerotic heart disease and other cardiac disease; Canada includes myocardial infarction, angina, and coronary artery bypass graft.

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Clinical Journal of the American Society of Nephrology: 15 (11)
Clinical Journal of the American Society of Nephrology
Vol. 15, Issue 11
November 06, 2020
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Health Policy for Dialysis Care in Canada and the United States
Marcello Tonelli, Raymond Vanholder, Jonathan Himmelfarb
CJASN Nov 2020, 15 (11) 1669-1677; DOI: 10.2215/CJN.14961219

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Health Policy for Dialysis Care in Canada and the United States
Marcello Tonelli, Raymond Vanholder, Jonathan Himmelfarb
CJASN Nov 2020, 15 (11) 1669-1677; DOI: 10.2215/CJN.14961219
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  • Article
    • Abstract
    • Introduction
    • Transnational Comparisons
    • Overview of Dialysis Care in the United States
    • Overview of Dialysis Care in Canada
    • Utilization of Health Policy Levers to Improve Care
    • Summary
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    • Funding
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More in this TOC Section

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Keywords

  • dialysis
  • health policy
  • innovation
  • transnational comparisons
  • kidney failure
  • Chronic
  • peritoneal dialysis
  • Renal Insufficiency
  • Health Care Costs
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