Encouraging a Standardized ESKD Transition Pathway in Value-Based Care (VBC) Patients Is Associated with a High Optimal Dialysis Start Rate

Background: In 2022, Panoramic Health and several physician leaders from four practice groups developed a standardized ESKD transition pathway (Pathway) as part of a value-based care program. The Pathway led to a substantially higher optimal dialysis start rate, defined as initiation without a central venous catheter. This study aimed to determine if the Pathway could improve optimal start rates in other practice groups participating in the same program. Methods: The Pathway was taught to all physicians involved. Monthly feedback was provided on ESKD preparation, highlighting patients who were off-track based on Pathway guidelines. Dialysis starts were recorded, and the proportion of optimal starts was determined. Results: In 2022, the original four practice groups had a historical optimal start rate of 29% prior to Pathway implementation. By Q3, this rate increased to 37%, and by Q4, it reached 53%. In 2023, these groups achieved a 64% optimal start rate. Fourteen other practice groups, with a historical optimal start rate of 28%, reached 53% by the end of 2023. Additionally, two practice groups achieved over 70% optimal starts. One new practice group had a 76% optimal start rate with 50 starts, and one original practice group had a 78% rate with 91 starts. These successful groups shared ESKD preparation data transparently, held each other accountable, celebrated successes, and reviewed non-optimal starts to identify and address local access issues. Conclusion: The deployment of the Pathway is associated with a large increase in optimal starts. The Pathway can be taught to nephrologists that were not part of the development process with comparable results. and can be effectively taught to nephrologists not involved in its development. Transparent data sharing, peer accountability, and attention to local access processes may further enhance the Pathway's impact. Future efforts will focus on making the Pathway available to all patients.