Mortality, hospital admissions, and medical costs of end-stage renal disease in the United States and Manitoba, Canada

OBJECTIVES: National registry data suggest that mortality rates among patients with end-stage renal disease are lower in Canada than in the United States. Casemix and treatment variables, although limited in such instances, do not explain this difference. Using a more complete set of casemix and treatment variables from clinical databases, this study assesses mortality, hospital admission, and the cost of medical care for patients with end-stage renal disease treated in Manitoba, Canada and the United States. METHODS: Mortality rates were compared in patients with end-stage renal disease treated in the Province of Manitoba and a random sample of US patients enrolled in the US Renal Data System Casemix Severity Study. Hospital admission rates and costs of care were compared in Manitoba patients and in patients with end-stage renal disease in a large health care organization in Detroit, Michigan. RESULTS: Levels of serum creatinine, urea, and estimated glomerular filtration rate indicated more severe renal impairment at the outset of treatment in Manitoba than in the United States. Manitoba patients were more than twice as likely to receive kidney transplants as US Renal Data System patients. No patients in Manitoba used reprocessed dialyzers, compared with 57% of US Renal Data System patients. After adjustment for all casemix and treatment variables, the mortality rate was 47% higher in the United States. The hospital admission rate in Detroit was 41% lower than the hospital admission rate in Manitoba, which primarily reflects the doubled rate of transplantation in Manitoba. Adjusted total monthly costs were $503 higher in Detroit than in Manitoba. CONCLUSIONS: The higher mortality rates in the United States cannot be fully explained by adjustments for observable casemix or treatment variables. Further research is needed to identify factors that explain how Manitoba achieves a lower mortality rate while paying less for end-stage renal disease care than the United States. (July 1997)