1. What did we learn from the 1989 Dallas Morbidity and Mortality Meeting? Alan R. Hull, MD A teaching hospital of Harvard Medical School

2. 3 Questions proposed for the Dallas Meeting Is the mortality rate in the U.S. actually higher than other “industrialized” countries? Has the mortality rate in the U.S. been increasing? Can the differences between the countries be accounted for by the prescription and delivery of dialysis or the demographics/incidence rate of the patients?

3. A teaching hospital of Harvard Medical School The Requested Format for the Dallas Meeting Yearly acceptance rate (Incidence) Prevalence rate for the calendar year GROSS MORTALITY –Definition: deaths during the calendar year over the mid year census

4. A teaching hospital of Harvard Medical School 1987 – 88 Comparison of Registries RegistryIncidence*Prevalence*Transplant*Gross Mortality (%) Canada711863218.9 FRG763202710 France56254247.3 Japan137671<28.8 U.S (Current) 151 (360) 403 (1200) 3723.4 Australia481522513.5 *PMP/Y

5. A teaching hospital of Harvard Medical School

6. Summary of the Dallas Meeting The U.S. did have a higher mortality rate –Higher incidence rate Mortality rate was increasing over the previous 4 years (1984-88) Multiple theories –Most prevalent theory = prescription and delivery of dialysis

7. A teaching hospital of Harvard Medical School Contemporary Provocations and Final 3 Questions (1) Why do you support the current thrice weekly in-center hemodialysis system for your patients? The Bevan Story –Is it possible that the dialysis providers are following Bevan’s lead and the “gold” is the Medical Director’s fee? –A true story

8. A teaching hospital of Harvard Medical School Contemporary Provocations and Final 3 Questions (2) Is it possible, although you are the patient’s physician, that you are subjecting them to a treatment that you would not accept yourself - nor have your immediate family undertake?

9. A teaching hospital of Harvard Medical School Provocation: Therapies and Outcomes Possible Therapies –CAPD –CCPD –Conventional In Center –Nocturnal In Center –Conventional HHD –Nocturnal HHD –Short Daily HHD –Transplant Living Cadaveric –Palliative Therapies Stratified by Outcomes –Transplantation –Nocturnal HHD –Nocturnal In-center and Short Daily HHD –Conventional HHD –CAPD and CCPD –Conventional In Center –Palliative