Disclaimer: The analysis upon which this publication is based were performed under Contract Number HHSM-500-2006-NW016C and HHSM-500- 2006-NW012C entitled End Stage Renal Disease Networks Organization for the States of Alaska, Idaho, Montana, Oregon, and Washington, and for the States of Iowa, Kansas, Missouri, and Nebraska, respectively, sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare and Medicaid Services, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore, required no special funding on the part of this contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.