Individuals diagnosed with ESRD may be influenced by a variety of factors when choosing the type of dialysis to receive. One factor that may influence the individual’s choice of dialysis is the individual’s awareness about the different types of dialysis available. For example, some individuals may not be aware that peritoneal dialysis is an option to replace kidney functioning and, as a result, would not choose to undergo peritoneal dialysis. The individual’s choice of which dialysis to perform can also be influenced by the type of dialysis that the individual’s physician recommends and if the individual has a partner to assist with dialysis treatments. Additionally, some individuals may have physical conditions that prevent them from self-performing dialysis—such as vision problems or dexterity issues. The individual’s choice may also be influenced by how quickly the dialysis treatments need to begin—as individuals who need to urgently start dialysis may not have time to be trained in conducting dialysis at home. Hemodialysis conducted in a facility typically consists of three dialysis treatments per week. Peritoneal dialysis is conducted daily. Recent technological changes in hemodialysis equipment have occurred, making it easier for hemodialysis to be done more frequently. For example, a new hemodialysis machine—designed for use at home—requires patients to dialyze five to seven times per week and is reported by some dialysis providers to be more user-friendly than traditional dialysis machines. As a result, most home hemodialysis patients dialyze five to seven times per week. Data from USRDS show that, compared to patients who dialyzed in a facility, in 2006, home dialysis patients were more likely to be younger, white, located in rural areas, employed, and have employer or group health insurance coverage, and were less likely to be Hispanic. USRDS data for 2006 also indicate that patients who received home dialysis may be healthier than patients who dialyzed in a facility. Home dialysis patients were more likely to be on the wait-list for a kidney transplant (which requires a certain level of health status) and had lower rates of diabetes and hypertension as the primary disease that caused their ESRD compared with patients who received dialysis in a facility. Limited evidence suggests and several dialysis provider officials and medical experts we interviewed believe that home dialysis results in better clinical outcomes for individuals with ESRD. These better clinical outcomes include better control over fluid levels, less need for dialysis drugs, fewer hospitalizations, and better quality of life. Improved clinical outcomes may be due to the features of home dialysis that its supporters believe more closely mimic natural kidney functioning—home dialysis can be done more frequently with less time between treatments, for longer periods of time than dialysis received in a facility, three times a week. Perhaps as a result of this more frequent dialysis, USRDS reported that the overall Medicare costs for peritoneal dialysis patients—including hospitalization costs as well as costs for dialysis services—were about 26 percent less than the total Medicare costs for hemodialysis patients in 2006. Similarly, a Medicare health maintenance organization (HMO) reported to us that moving some of its patients from facility hemodialysis to home hemodialysis has substantially reduced hospitalizations, and overall health costs, for those patients. That HMO has also published a study documenting relatively low hospitalization rates for its home hemodialysis patients. However, in general, it is challenging to determine the causes of differences in clinical outcomes between patients who receive dialysis at home versus in a facility because—as we previously noted—the characteristics of patients who dialyze at home are different than those who dialyze in a facility. The National Institutes of Health (NIH) is conducting randomized clinical trials that are intended to provide information on the clinical outcomes associated with more frequent dialysis received in a facility compared to dialysis received three times a week in a facility, and with home nocturnal hemodialysis compared to three times weekly home hemodialysis. Results from the NIH trials are expected to be available in 2010. The self-reported cost information we obtained from the six dialysis providers indicated variation in the cost to provide home dialysis when compared with dialysis provided in a facility. The six dialysis providers reported lower costs per treatment to provide home dialysis than to provide dialysis at a facility, though the amount by which home dialysis costs were lower varied widely among the providers. Because patients who dialyze at home typically receive dialysis treatments more than three times per week, some providers’ costs to provide home dialysis on a weekly basis can be higher than their costs to provide dialysis at a facility. However, other dialysis providers reported lower costs per week to provide home dialysis compared with dialysis provided in a facility. Additionally, several dialysis providers indicated that, for home dialysis patients, the costs of a dialysis treatment with a training session were significantly higher than the costs of a dialysis treatment without a training session. The self-reported cost information that we obtained from six dialysis providers indicated that the average costs per treatment for home dialysis were lower than the average costs per treatment for dialysis provided in a facility. However, there was a wide range among the dialysis providers in terms of how much lower the average costs per treatment for home dialysis were than dialysis provided in a facility. For home hemodialysis, dialysis providers reported to us that their average costs per treatment were 17 to 50 percent lower than the average costs per treatment for dialysis provided in a facility. For peritoneal dialysis, dialysis providers reported to us that their average costs per treatment were 48 to 68 percent lower than the average costs per treatment for hemodialysis provided in a facility. The average costs per treatment that the dialysis providers reported to us include costs for certain items associated with providing dialysis services, including supplies, equipment, drugs, overhead, and staff. Officials from dialysis providers indicated to us that supply costs are higher for home dialysis compared with dialysis provided in a facility. One reason that supply costs for home dialysis patients are higher is because certain supplies that can be reused for patients who receive dialysis in a facility often cannot be reused by home patients. For example, patients who receive dialysis in a facility can reuse their own dialyzer—the artificial kidney used to filter the blood during hemodialysis—because the facility is able to sterilize the dialyzer between dialysis treatments. Patients who dialyze at home need to use dialyzers that are intended for one-time use, which results in higher supply costs. In contrast, other cost items (such as drugs and staff) were reported to be lower for home dialysis than for dialysis provided in a facility. For example, after home dialysis patients have been trained to conduct dialysis, there are lower staffing costs associated with home dialysis because patients require less staffing resources—as the patients (or their caregiver) are performing the dialysis treatments at home that are performed by staff for dialysis provided in a facility. Table 1 provides one dialysis provider’s self-reported average costs per treatment in 2008 for hemodialysis provided in a facility compared to hemodialysis provided at home, which indicates that the supply costs are higher for home hemodialysis while the other items are lower for home hemodialysis compared with hemodialysis provided in a facility. Table 2 provides another dialysis provider’s self-reported average costs per treatment in 2006 for hemodialysis provided in a facility compared to peritoneal dialysis provided at home. The provider reported that its supply costs were higher for peritoneal dialysis provided at home, while the other items were lower for peritoneal dialysis compared with hemodialysis provided in a facility. All six dialysis providers in our review reported lower average costs per treatment for home dialysis when compared to dialysis provided in a facility; however, some dialysis providers reported higher costs per week for home dialysis compared with dialysis provided in a facility, while others reported lower costs per week for home dialysis. For home hemodialysis, three of the five dialysis providers included in our review reported higher costs per week for providing home hemodialysis compared with the costs per week of providing dialysis in a facility. Officials from these three dialysis providers indicated that the costs per week for patients who dialyze at home were higher because these patients typically dialyze more frequently than three times per week. Home hemodialysis is often performed five to seven times per week. For example, using one provider’s self-reported average costs per treatment from table 1, the average costs per treatment for home hemodialysis were lower ($133 per treatment) compared with dialysis provided in a facility ($243 per treatment); however, for patients who received six dialysis treatments per week, the provider’s weekly costs for home hemodialysis were higher ($798 for six treatments during the week) compared with dialysis provided in a facility ($729 for three treatments per week). The other two providers reported lower costs per week for home hemodialysis compared with dialysis provided in a facility. However, one of these providers indicated that their home hemodialysis patients only dialyze three times per week, which is not more frequent than patients who dialyze in a facility. Providers also reported varying costs per week for peritoneal dialysis compared to dialysis provided in a facility. Of the five dialysis providers in our review, two providers indicated that their costs per week for providing peritoneal dialysis were higher than the weekly costs of providing dialysis in a facility. In contrast, three of the five dialysis providers in our review indicated that the costs per week of providing peritoneal dialysis were lower than the weekly costs of providing dialysis in a facility. Using one provider’s self-reported average costs per treatment from table 2, the average costs per treatment for peritoneal dialysis were lower ($94 per treatment) compared with dialysis provided in a facility ($251 per treatment) and the weekly costs of peritoneal dialysis were also lower ($658 for 7 days of peritoneal dialysis during the week) compared with dialysis provided in a facility ($753 for three treatments per week). Based on self-reported cost information from dialysis providers, the costs per week of providing peritoneal dialysis were lower than the costs of providing hemodialysis in a facility, in part, because costs for drugs, staff, and overhead were lower for peritoneal dialysis patients.