Outpatient Optimal Start Effect on Health Care Costs During Transition to Dialysis

Background: Optimal starts are increasingly important as a measure of high-quality nephrology care. The definition of optimal starts often focus on access type rather than hospitalization. Little is known about the ability of this measure to impact costs during the transition to dialysis. We evaluated the cost differences between patients who initiated dialysis in an outpatient setting (OP-only), an inpatient setting transitioned to outpatient dialysis (IP-OP), and an inpatient dialysis but no outpatient dialysis (IP-only). Methods: We evaluated Medicare beneficiaries with CKD stages 4 or 5 in three Evergreen nephrology partner practices between 1/1/2023 and 12/31/2023. We utilized claims data to characterize costs and dialysis initiation. We defined IP dialysis starts as an IP dialysis claim within 30 days prior to an OP dialysis claim. We assessed differences in per member per month (PMPM) costs between the groups via ANOVA. Results: We identified 6050 aligned beneficiaries. 310 of these (5.1%) initiated dialysis. 111 (1.8%) initiated dialysis as OP-only, 141 (2.3%) as IP-OP, and 58 (1.0%) as IP only. Together all three groups (4.5% of the cohort) comprised 16.5% of the total medical expense incurred by the sample over the observation period. Median PMPM costs were significantly higher for inpatient dialysis starts (p<.01): $2935.83 (IQR $1889.59-$4561.04) for OP-only, $7843.04 (IQR $5063.69 – $13817.00) for IP-OP, and $7518.91 (IQR $3817.00 - $14422.13) for IP-only. The optimal start rate (as defined by no CVC) for the OP-only cohort was 88.5%, whereas the rate for the IP-OP group was 41.8%. Conclusion: There are significant and persistent cost differences between initiating dialysis in an inpatient setting versus an outpatient setting. While current optimal starts measures focus only on the dialysis access, our data demonstrate that including focus on initiating dialysis in an outpatient versus inpatient setting will have positive impact on reducing total cost of care and improving outcomes.Figure 1