Project Summary: The prevalence and cost of end-stage kidney disease (ESKD) continue to rise in the US. As of 2016, >726,000 patients have ESKD and >$35 billion annually is spent through Medicare. Peritoneal dialysis (PD) is a form of home dialysis that can provide better quality of life and slower loss of residual renal function with no difference in mortality compared to hemodialysis (HD). On average, PD also costs $15,000 less per person per year for Medicare compared to HD, according to the 2018 United States Renal Data System report. Despite clinical and economic advantages, while up to 78% of ESKD patients meet eligibility criteria for PD, only 9.7% started PD in 2016. In 2019, the US Department of Health and Human Services announced the Advancing American Kidney Health Initiative (AAKH). The primary goal of AAKH is to have 80% of new ESKD patients initiate home dialysis (PD or home HD) or receive a kidney transplant by the end of 2025. Achieving this goal would result in a paradigm shift in care delivery that dramatically improves patient outcomes. However, several stakeholders, including patient advocacy groups, the American Society of Nephrology and dialysis organizations have raised concerns about the achievability of this 80% target. Research is needed to help inform the clinical outcomes associated with choosing a more achievable target (such as 20%, 40% or 60%), as well as to identify cost- effective ways to achieve this target. Assisted PD (a modality of PD where trained staff assist with PD at home) could be a cost-effective way to improve home dialysis utilization in line with the AAKH initiative. We propose a modeling-based approach to i) examine the clinical and economic impact of the AAKH initiative and alternative targets and ii) evaluate the clinical and budgetary impact of implementing assisted PD to improve home dialysis in the US alongside the AAKH initiative. This relates to the mission of NIDDK. ESKD is a debilitating and costly chronic disease, and we seek to understand and inform novel ways to improve the outcomes of patients with ESKD in a cost-effective manner. To achieve my goals, I will pursue didactic training through formal coursework focused on 1) developing a Markov model with Monte Carlo simulation, 2) calibration and validation of models, 3) cost-effectiveness and budgetary impact analysis and 4) modeling uncertainty through sensitivity analysis. As a clinical research fellow in the Renal Division at Brigham and Women's Hospital and the Medical Practice Evaluation Center at Massachusetts General Hospital, I am in an innovative collaborative environment. My mentors are Drs. Rochelle Walensky, an expert in cost-effectiveness analysis around chronic disease care; Krishna Reddy, an expert in policy-oriented modeling research; and Mallika Mendu, an expert in PD and population health management. Through the support of my mentors, my institution and the training supported by this award, I will be closer to my ultima...