International Hemodialysis Patient Outcomes Comparisons Revisited

Abstract

The Dallas conference on ESRD in 1989 was a landmark meeting. Among the many presentations, the one by Philip Held stimulated a great deal of discussion. On the basis of data from three registries, the US Renal Data System (USRDS), the European Dialysis and Transplant Association (EDTA), and the Japanese Society of Dialysis and Transplantation (JSDT), he showed higher mortality in the United States than in the other two regions. Categories of age and reported cause of ESRD (diabetes versus other) were available in the registries, allowing for descriptions of outcomes by strata of age and diabetes, or adjustment for age and diabetes. The main outcome was 5-yr survival for all patients with ESRD (dialysis and transplantation combined). In virtually each age by diabetes group, a lower percentage of patients survived to 5 years in the US registry than in either the EDTA or the JSDT (1). These results, summarized in Figure 1, were widely quoted for many years. In this article, we ( 1 ) explore potential explanations for these international outcomes differences using more recent data, ( 2 ) consider trends in therapy during the past 20 years, and ( 3 ) describe how study of the associations of practice patterns with outcomes has informed regional differences in survival and can be used to identify opportunities to improve outcomes at the present time. Figure 1. Five-year renal replacement therapy survival by age in the United States versus Europe (1982 through 1987) and the United States versus Japan (1983 through 1987). US data from the Health Care Financing Administration, European data from EDTA, Japanese data from JSDT (1984 through 1988). European and Japanese age group rates and total rates are standardized to the United States. The findings of Held et al. (1) were considered controversial by many because of the concern that they might reflect or …