Pulling the goalie: What the United States and the world can learn from Canada about growing home dialysis.

Both peritoneal dialysis (PD) and home haemodialysis (HHD) offer well-documented advantages and are typically associated with lower total costs in high-income countries. In the United States (US), the last decade has seen growth in these modalities, at least partially driven by payment changes, and continuing during the COVID-19 global pandemic (Figure 1). Despite this growth, prevalent utilisation of home dialysis in the US still lags utilisation in other high-income countries, including Australia (25%), Canada (25%), New Zealand (44%) and the United Kingdom (17%). The Presidential Executive Order on Advancing American Kidney Health (AAKH), promulgated in July 2019, set a 2025 target of 80% of patients with newly diagnosed endstage kidney disease (ESKD) initiating kidney replacement therapy with either home dialysis or a pre-emptive kidney transplant. Although this goal is not compulsory, both mandatoryand voluntary-participation payment models have been developed to drive progress towards this goal. These models include financial bonuses (up to 8%) and penalties (up to 10%) for dialysis provider organisations and nephrologists to increase utilisation of home dialysis and kidney transplantation. Of course, there are many barriers to home dialysis. Whether a predominantly financial approach will be effective is uncertain, considering a mixed track record of financial incentives successfully expanding home dialysis use outside the US.