OBJECTIVES:  The use of home dialysis modalities such as peritoneal dialysis and home haemodialysis varies across Europe and North America from today <5% in Germany to 28% in Denmark.  These differences have often been attributed to reimbursement and renal care organization factors. This analysis was undertaken to quantify the strength of association of potential factors influencing usage of home dialysis modalities with the intent to later facilitate evidence based policy choices. METHODS: A 4-pillar framework including 8 different factors (home target, reimbursement level, payment flow, pre-dialysis education, assisted dialysis, home guideline/policy, incentives for home, monitoring/planning tool) was postulated to explain the variation in home dialysis usage across countries. A semi-quantitative scoring algorithm was developed and used to rate the renal care organization of 12 European countries, Canada, and the USA based on publicly available information. A regression analysis was used to explore the relationship between the score and the use of home dialysis modalities as retrieved from the latest available renal registry reports. The most significant factors were identified by analysis of variance. RESULTS: A significant (r2=0.694; p<0.001) correlation was found between the total score and home dialysis usage. Countries like Denmark and Sweden achieving a score of 5 have a 26-28% usage of home modalities. In comparison, Germany had a score of -2 and <5% of dialysis patients are on home modalities. Three factors were especially significant: well funded and independent pre-dialysis education (p<0.001), clinical guideline/policy favouring home modalities (p=0.002), and (absence of) provider-driven demand (p=0.035). CONCLUSIONS: The 4-pillar framework appears to be useful to identify gaps in a country renal care policy and decide on further actions to be taken when intending to increase usage of home dialysis modalities. Actions to implement/correct pre-dialysis education, clinical guideline/policy favouring home modalities and (absence of) provider-driven demand should probably be prioritized.