Table 1.

Clinical dialysis practice and its financing in the United States

Epidemiology of patients on dialysis
 Total patients with ESKD in the United States in 2017Incident patients: 124,500 (370.2 per million per year)2019 USRDS ADR (4)
Prevalent patients: 746,557 (2203.5 per million per year)
 Number of patients on dialysis (per million people in the general population), total (HD versus PD, 2017)Incident patients: 359.3 (232.0 versus 37.4)2019 USRDS ADR (4)
Prevalent patients: 1545.8 (1381.6 versus 155.6)
 Percent of patients with ESKD on home dialysis (2017)Incident patients: 11%2019 USRDS ADR (4)
Prevalent patients: 8%
 Primary cause of ESKD in incident patients on dialysis, total (HD versus PD, 2017)Diabetes: 47% (48% versus 44%)2019 USRDS ADR (4)
Hypertension: 29% (30% versus 28%)
GN: 7% (6% versus 13%)
Cystic kidney: 3% (2% versus 6%)
Other/Unknown: 14% (14% versus 8%)
 Standardized mortality rate, total (HD versus PD versus transplant, 2017)134 (167 versus 156 versus 29) per 1000 patient-yr2019 USRDS ADR (4)
 Hospitalization, HD versus PD, 20161.7 versus 1.7 per patient-yr2018 USRDS ADR (1)
 Proportion of readmission within 30 d of discharge, HD versus PD, 201638% versus 37%2018 USRDS ADR (1)
 Emergency department visit, HD versus PD, 20163.0 versus 2.3 per patient-yr2018 USRDS ADR (1)
 Observation stay, HD versus PD, 20160.4 versus 0.2 per patient-yr2018 USRDS ADR (1)
Pre-ESKD care
 Proportion of receiving pre-ESKD nephrology care>12 mo: 33%2019 USRDS ADR (4)
6–12 mo: 20%
0–6 mo: 14%
None: 19%
Unknown/missing: 14%
 Clinical characteristics by pre-ESKD nephrology care, >12 mo versus noneDietary care: 13% versus 0.3%2019 USRDS ADR (4)
Erythropoiesis-stimulating agent use: 22% versus 2%
AV fistula: 24% versus 2%
Central venous catheter: 52% versus 93%
eGFR <5 ml/min per 1.73 m2: 12% versus 20%
 Vascular access in patients on HD (2018)AV fistula: 63%2019 USRDS ADR (4)
AV graft: 18%
Central venous catheter 20%
Provision of care
 Average FTEPhysician FTEs: 0.05±0.47Shreay et al. (5)
Nursing FTEs: 4.24±3.59
Technician FTEs: 6.01±4.68
Other clinical FTEs: 0.70±1.81
 Average length of a dialysis session216.5±26.1 minFlythe et al. (6)
 Frequency of being seen by nephrologist during dialysis sessions<4 times per mo: 32%Kawaguchi et al. (7)
4 times per mo: 51%
>4 times per mo: 17%
 Type of dialysis units in 2020Profit: 89%US Centers for Medicare and Medicaid Services (8)
 Distribution of patients by unit affiliation in 2011 (proportion)Hospital based: 9% (13%)2013 USRDS ADR (9)
Large dialysis organizations: 63% (66%)
Independent units: 14% (13%)
Small dialysis organizations: 14% (12%)
Financing of dialysis
 Percent of insurance coverageAll patients with ESKD are eligible to Medicare coverageRettig (10)
 Government financing versus private insurance financing:Dominant payer: Medicare, as a federal health insurance programNational Institute of Diabetes and Digestive and Kidney Diseases (11)
Other payers: Medicaid, Veterans Affairs, private insurers, and other assistance programs
 Regulations in dialysis financingJanuary 2011: Implementation of the ESRD Prospective Payment System
January 2012: Implementation of ESRD Quality Incentive Program
October 2015: Implementation of Dialysis Facility Compare program (star ratings)
October 2015: Implementation of the Comprehensive ESRD Care Model by the creation of ESRD Seamless Care Organizations
July 2019: Launch of the federal executive order Advancing American Kidney Health
 Reimbursement per dialysis session in USDBase rate: $239.332020 CMS Prospective Payment System (12)
 Medicare expenditureTotal: $46.6 billion2019 USRDS ADR (4)
Medicare fee-for-service plan: $35.9 billion
Medicare advantage plan: $10.7 billion
 Medicare per person per year spending in 2017HD: $91.7952019 USRDS ADR (4)
PD: $78,159
Transplant: $35,817
  • USRDS, United States Renal Data System; ADR, Annual Data Report; HD, hemodialysis; PD, peritoneal dialysis; AV, arteriovenous; FTE, full-time employment; CMS, Centers for Medicare and Medicaid Services.