Last month, NN&I published its 18th annual ranking of the largest dialysis providers in the United States. Since 1995—the first year we published our ranking—the chart has always divided hemodialysis patients (including home hemodialysis) and peritoneal dialysis patients as part of the total patient count for each provider. In that first year, we listed 11,954 patients on peritoneal dialysis, representing 15.8% of the total patient population.

For our 14th annual ranking in 2008, we began asking providers to list their home hemodialysis patients separately. In that year, with PD and HHD patients combined, the percentage of home patients was 8.3%. Clearly, home dialysis was in a downward spiral.

A bright spot
For our 2012 survey, however, there was some good news.The percentage of home patients among these 10 largest providers now sits at 10%: of the 352,235 patients treated as of May 2012, 35,535 patients were getting their therapy at home. Still a far cry from years past, but signaling positive signs. No doubt much of that growth has come from NxStage Medical. Last year, the manufacturer announced it had 5,000 patients using its SystemOne home hemodialysis machine. Beyond the 2% growth in the prevalent count of home patients, however, is something more significant: more and more patients being treated by these providers as new patients––whether as new starts or through acquisitions of clinics––are choosing home therapy as a modality choice.

Of the 40,602 patients added by these providers over the last three years, 8,191 have been home dialysis patients––about 20% of the total. As noted, growth in patient populations in a set group of providers can happen in two ways: new starts when providers build new clinics or add additional shifts, or through acquisitions of other providers. Thus, home dialysis patient growth by one provider may in fact be from an acquisition of another provider (Fresenius Medical Care, for example, acquired Liberty Dialysis Holdings last year. Liberty, after its merger with Renal Advantage Inc., had 12.6% of its patients on home dialysis. That acquisition helped boost Fresenius’ home patient growth by 1% in 2012).

Work to be done
Despite those positive signs, providers can do better. A paltry 10% of home patients contrasts with surveys completed by nephrologists who overwhelmingly pick home dialysis as their first choice if they had renal disease. Our 2012 ranking shows that the percentage of prevalent home dialysis patients among the largest providers remains between 8.2% and 11.3% (Satellite Healthcare being an exception at 22.5%). Our ranking doesn’t include other providers with a high percentage of home patients, like Seattle-based Northwest Kidney Centers with 16% of their patients at home. Last month, NN&I produced the webinar, “Home Dialysis: Next Steps.” Over 1,300 people listened to the near two-hour program (a replay is available at NN&I’s website at as speakers identified some of the barriers that remain to increasing the home dialysis population.

Everything from a lack of professional education to a tried-and-true focus on in-center hemodialysis to patient concerns –– and nephrologists’ concerns for their patients as well––about doing self-care, is hindering a modality option that studies continue to show offers better quality of life and better outcomes for many patients. The growth we have been seeing over the last three years is promising; with new financial incentives from Medicare to get more providers to open up and build home dialysis programs, we might see a return to 1995––or perhaps, even better.

Mr. Neumann has been executive editor of Nephrology News & Issues since 1989.