Chronic kidney disease represents an interesting illustration for evaluating an epidemic of chronic illness, the impact of care processes and technology on health outcomes, the impact of financial incentives and cost containment on health outcomes, and the choices society must consider in responding to a chronic illness. The evidence suggests that strong economic pressures exist in the care of chronic kidney disease and that cost containment is important. The results in large part reflect the impact of economic pressures on clinical decision making in the absence of good evidence on outcomes. To improve clinical decision making we need valid evidence linking specific processes of care to patient outcomes. Specific processes amenable to study include the provision of preventive services, physician and nurse technical and interpersonal care and adherence to clinical practice guidelines. The ESRD Quality Study (EQUAL) currently underway and supported by the National Institutes of Diabetes and Digestive and Kidney Diseases, may help to guide physicians and centers in caring for their patients with chronic kidney disease. This investigation examines the relation between process of care and outcomes and expands outcomes measure to include disease-specific quality-of-life measures and patient satisfaction and accounts for case mix using the Index of Co-Existent Disease, a measure of the extent of different comorbid diseases as well as their severity (18,19,20). Better data on how processes of care are linked to health outcomes can inform decision making and allow educated cost cutting and quality maintenance.