REFLECTIONS ON SUPPLY-DEMAND MISMATCH IN DIALYSIS SERVICES IN ONTARIO

The population-based dialysis rate in Ontario more than doubled betwee n 1981 and 1992, yet there is concern about over-loaded facilities, de layed treatment and denial of dialysis through nonreferral and implici t rationing. A working party involving several stakeholders has been e stablished in Ontario to address these issues. However, clinical polic y making concerning dialysis services is impeded in all provinces by a lack of information. The causes of the moderately large variations in dialysis rates from province to province remain unclear. The exact ex tent and risks of delayed therapy have not been well defined. Dialysis protocols vary inexplicably among centres, and cost data on different methods of providing dialysis are limited. Many steps could be taken in Ontario and other provinces to generate a better information base f or planning and managing dialysis services. Predialysis clinics with o ut-reach programs could help to ensure equitable access to this life-s aving therapy. Criteria for choosing modes and intensities of renal-re placement therapy must be reviewed. In areas of clear disagreement and uncertainty, patients could be randomly assigned to different protoco ls and outcomes studied in areas of agreement, the criteria should be standardized. Advance directives may help ascertain patients' wishes c oncerning the initiation or continuation of dialysis, and more accurat e data on prognosis of different patient subgroups would aid in early identification of patients in a hopelessly deteriorating situation. La st, studies comparing the ''output'' (e.g., hours on hemodialysis) per dollar of different dialysis units and modalities are also needed to ensure that all facilities are operating efficiently without compromis ing patient outcomes.