A standardized care pathway increases optimal dialysis starts

Abstract

Objective: To determine whether an intensive value-based care educational program that includes a standardized end-stage renal disease (ESRD) transition pathway would improve the number of optimal starts within Kidney Contracting Entities (KCEs).

Study design: Retrospective cohort study.

Methods: We recorded optimal starts, defined as the initiation of dialysis without a central venous catheter, and the initial modality type (hemodialysis vs peritoneal dialysis [PD]) in adult Medicare patients in a Comprehensive Kidney Care Contracting program. The setting was 4 KCEs within a single physician-led nephrology organization. Data were recorded each quarter (Q) during 2022. During Q1-Q2, patients and clinicians received formal instruction on the benefits of optimal starts. Starting in Q3, we implemented a standardized care pathway for patients at high risk for transition to ESRD. The proportion of optimal starts and the proportion of initial PD from Q1-Q2 vs Q3-Q4 were compared using the χ2 test.

Results: A total of 328 study-eligible patients initiated dialysis in 2022, including 166 (50.6%) in Q1-Q2. The proportion of optimal starts increased from 42.8% (71/166) in Q1-Q2 to 58.0% (94/162) in Q3-Q4 (P = .006). The proportion of PD starts increased from 18.7% (31/166) in Q1-Q2 to 28.4% (46/162) in Q3-Q4 (P = .038).

Conclusions: Optimal starts are a key metric of success in value-based care models. We observed a significant increase in optimal starts and in the number of patients starting on PD after implementing a standardized ESRD transition pathway as part of an intensive value-based care educational program.