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To create a world without kidney diseases, the ASN Alliance for Kidney Health elevates care by educating and informing, driving breakthroughs and innovation, and advocating for policies that create transformative changes in kidney medicine throughout the world.

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Kidney Week

Abstract: TH-OR44

Encouraging a Standardized ESKD Transition Approach in a Comprehensive Kidney Care Contracting (CKCC) Program Is Associated with Increased Optimal Dialysis Starts

Session Information

Category: Dialysis

  • 801 Dialysis: Hemodialysis and Frequent Dialysis


  • Marcus, Roy G., Clinical Renal Associates Ltd, Exton, Pennsylvania, United States
  • Miller, Dave M., Panoramic Health, Tempe, Arizona, United States
  • Nathanson, Brian Harris, OptiStatim, Longmeadow, Massachusetts, United States
  • Henry, Steven, Panoramic Health, Tempe, Arizona, United States
  • Vakharia, Nirav, Panoramic Health, Tempe, Arizona, United States

The standard care for chronic kidney disease (CKD) is shifting from a “fee-for-service” model that focuses on volume of care and profitability of services to a Value Based Care (VBC) model that rewards better outcomes. It is well-established that starting ESKD care with peritoneal dialysis (PD) or hemodialysis (HD) with either an arteriovenous (AV) fistula or AV graft, instead of HD with a central venous catheter (CVC), produces better mortality, morbidity, and cost outcomes. The purpose of this study was to determine if a standardized ESKD transition pathway could improve the number of optimal starts within Kidney Care Entities (KCEs).


All patients were in the Comprehensive Kidney Care Contracting (CKCC) program. The CKCC program defines an optimal start to be the initiation of dialysis without a CVC. We recorded the proportion of optimal starts and the initial modality type (HD vs PD) in adult Medicare patients at 4 geographically diverse KCEs within a single physician-led nephrology organization. Data were recorded quarterly (Q) during 2022. During Q1-Q2, patients and clinicians were formally instructed on the benefits of optimal starts only. Starting in Q3, a standardized care pathway was deployed for patients at high risk for transition to ESKD across all 4 KCEs, inclusive of electronic health record and analytics tools, and treatment teams were provided lists of patients who met the high risk criteria. The proportion of optimal starts and the proportional of initial PD from Q1-Q2 versus Q3-Q4 were compared with Student’s t-test for proportions.


In 2022, the 4 KCEs treated 9,099 patients with 5,457 (60.0%) having CKD. 371 patients initiated dialysis during the study period with 164 (44.2%) in Q1-Q2. The proportion of optimal starts increased from 37.2% (61/164) in Q1-Q2 to 53.1% (110/207) in Q3-Q4, p = 0.002. The proportion of PD starts increased from 11.0% (18/164) in Q1-Q2 to 26.1% (54/207) in Q3-Q4, p <0.001.


The deployment of a standardized ESKD transition pathway as part of an intensive VBC educational program is associated with a significant increase in both optimal starts and the number of patients starting on PD.