Dialysis delivery in Canada and the United States: a view from the trenches.

Although the general framework for health care delivery is vastly different in Canada and the United States, the framework for dialysis delivery is less divergent. However, the 2 systems have evolved very differently. Examined during the past 20 years, it is apparent that the dialysis system in the United States has undergone profound change, whereas the system in Canada is relatively stagnant. Most of the change in the United States has been positive, and this evolutionary change is expected to continue. In Canada, a system that historically has worked reasonably well is now showing severe signs of suboptimal performance that would be expected to get worse if no effort is made to improve it. This article, written from the perspective of 2 academic clinicians, tries to describe similarities and differences, identify strengths and weaknesses, and serve as a catalyst for discussions about improving both systems. Just as no dialysis treatment modality is perfect, the same can be said for dialysis delivery systems. Empirical methods to objectively evaluate the impact of change must be included in the design and implementation of new initiatives in the United States and Canada.