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Kidney Week

Abstract: PO2404

CKD Healthcare Utilization Preceding Unplanned Dialysis in a Large Accountable Care Organization

Session Information

Category: CKD (Non-Dialysis)

  • 2101 CKD (Non-Dialysis): Epidemiology, Risk Factors, and Prevention


  • Wong, Leslie P., Cleveland Clinic, Cleveland, Ohio, United States
  • Ghosh, Anindita, Cleveland Clinic, Cleveland, Ohio, United States

Unplanned dialysis initiation or “crash starts” is associated with worse outcomes and higher costs in chronic kidney disease (CKD). Avoiding these events should be a quality improvement priority for accountable care organizations (ACOs). We examined care utilization associated with unplanned dialysis initiation in a large ACO.


Cleveland Clinic is an academic health system with a 100,000+ member ACO and value-based care (VBC) program. A claims analysis of CKD patients who transitioned to dialysis attributed to the ACO or a VBC contract in 2020 with a lookback 2017-2020 was done. Crash start patients initiated hemodialysis (HD) with a central venous catheter in the hospital. Optimal start patients initiated dialysis with outpatient HD or peritoneal dialysis (PD). Those with acute kidney injury, hospital death, urgent start PD, or preemptive transplant were excluded.


A total of 261 patients met criteria for crash starts and 133 for optimal starts. Outpatient utilization and average visits per specialty by patient category are shown in Table 1. Forty percent of crash start patients had no preceding nephrology care in the 12 months prior to dialysis. Optimal start HD patients had more visits with nephrologists and vascular surgery than crash start patients. PD patients had the highest percentage and number of nephrologist visits. Crash start patients with outpatient pre-dialysis care saw a mix of employed nephrologists (45%), independent nephrologists (35%), and non-ACO nephrologists (20%). Average total cost of care was $95,036 for crash starts versus $25,671 for optimal starts in the 12 months prior to dialysis start date including the index admission.


In a large ACO, unplanned dialysis initiation was associated with lower pre-dialysis nephrology and vascular surgery utilization and substantially higher costs. ACOs managing CKD population risk should address the systemic factors leading to crash dialysis starts.

CKD care utilization in 12 months prior to dialysis initiation
 Crash start n=261Optimal HD start n=96Optimal PD start n=37
Any PCP visit88%74%80%
Average PCP visits7.37.76.2
Any nephrologist visit60%61%73%
Average nephrologist visits2.23.13.8
Any vascular surgeon visit23%62%10%
Average vascular surgeon visits0.41.10.2

PCP = primary care provider