Social Risk and Dialysis Facility Performance in the First Year of the ESRD Treatment Choices Model

• Published in: JAMA : the journal of the American Medical Association 2024-01, Vol.331 (2), p.124-131
• Main Authors: Koukounas, Kalli G, Thorsness, Rebecca, Patzer, Rachel E, Wilk, Adam S, Drewry, Kelsey M, Mehrotra, Rajnish, Rivera-Hernandez, Maricruz, Meyers, David J, Kim, Daeho, Trivedi, Amal N
• Format: Article
• Language: English
• Subjects: Aged; Black People; Cross-Sectional Studies; Dialysis; End-stage renal disease; Female; Fines & penalties; Government programs; Hemodialysis; Hispanic people; Humans; Kidney diseases; Kidney Failure, Chronic - therapy; Kidney transplantation; Kidney transplants; Kidneys; Male; Medicaid; Medical treatment; Medicare; Original Investigation; Renal Dialysis; United States
• ISSN: 0098-7484; 1538-3598; 1538-3598
• DOI: 10.1001/jama.2023.23649

IMPORTANCE: The End-Stage Renal Disease Treatment Choices (ETC) model randomly selected 30% of US dialysis facilities to receive financial incentives based on their use of home dialysis, kidney transplant waitlisting, or transplant receipt. Facilities that disproportionately serve populations with high social risk have a lower use of home dialysis and kidney transplant raising concerns that these sites may fare poorly in the payment model. OBJECTIVE: To examine first-year ETC model performance scores and financial penalties across dialysis facilities, stratified by their incident patients’ social risk. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study of 2191 US dialysis facilities that participated in the ETC model from January 1 through December 31, 2021. EXPOSURE: Composition of incident patient population, characterized by the proportion of patients who were non-Hispanic Black, Hispanic, living in a highly disadvantaged neighborhood, uninsured, or covered by Medicaid at dialysis initiation. A facility-level composite social risk score assessed whether each facility was in the highest quintile of having 0, 1, or at least 2 of these characteristics. MAIN OUTCOMES AND MEASURES: Use of home dialysis, waitlisting, or transplant; model performance score; and financial penalization. RESULTS: Using data from 125 984 incident patients (median age, 65 years [IQR, 54-74]; 41.8% female; 28.6% Black; 11.7% Hispanic), 1071 dialysis facilities (48.9%) had no social risk features, and 491 (22.4%) had 2 or more. In the first year of the ETC model, compared with those with no social risk features, dialysis facilities with 2 or more had lower mean performance scores (3.4 vs 3.6, P = .002) and lower use of home dialysis (14.1% vs 16.0%, P