Executive Summary
Unplanned dialysis starts lead to significant challenges for patients, caregivers, providers, and health plans. This article emphasizes the importance of early dialysis access planning, timely nephrology engagement, patient education, and coordinated care to help patients prepare for dialysis before they need it. By proactively supporting access evaluation, modality education, and care coordination, healthcare organizations can reduce avoidable hospitalizations, improve treatment readiness, expand appropriate use of home dialysis, and lower the costs associated with crash dialysis starts.
The Challenge of Unplanned Dialysis Starts
Unplanned dialysis starts remain one of the most costly and disruptive events in kidney care. End-stage renal disease (ESRD) patients who begin dialysis without adequate preparation often face a more difficult transition to treatment, while health plans and providers may see higher rates of hospitalization, complications, and avoidable healthcare utilization.
Despite advances in chronic kidney disease (CKD) management, studies report that 40% to 60% or more patients still “crash” into dialysis without sufficient preparation.1 These unplanned starts can limit treatment options, increase clinical risk, and create significant stress for patients and their families.
Improving dialysis readiness requires more than determining when dialysis will begin. It involves ensuring that patients understand their treatment options, receive appropriate education, and have the necessary dialysis access in place before therapy becomes necessary.
Dialysis Readiness Starts With Access Planning
Dialysis access is the fistula, graft, or catheter through which dialysis treatment is delivered. Because different treatment modalities require different forms of access, planning should begin well before dialysis is expected to start.
For patients pursuing hemodialysis, there are three types of access options :
- Arteriovenous (AV) fistulas
- AV grafts
- Central venous catheters
Patients who choose peritoneal dialysis require placement of a peritoneal dialysis catheter before treatment begins.
Importantly, permanent access options such as fistulas and grafts require time to mature before they can be used effectively. In addition, patients pursuing home dialysis need time to complete training and prepare for treatment. Home peritoneal dialysis training typically takes approximately two weeks, while home hemodialysis training may require four to six weeks.
These realities make access planning a key component of dialysis readiness. Waiting until kidney failure is imminent may leave patients with fewer options and less time to prepare.
The Risks of Delayed Planning
When dialysis planning begins too late, patients are more likely to require urgent dialysis initiation and temporary access solutions. In many cases, dialysis begins during or following a hospitalization, creating additional challenges for patients, caregivers, and care teams.
The consequences extend beyond the initial dialysis start. Research has shown that patients who receive nephrology care before reaching ESKD typically experience meaningful long-term benefits. These patients are more likely to have high-quality vascular access, initiate home dialysis when appropriate, and experience improved survival.
Early planning also provides patients and caregivers with time to understand treatment options, ask questions, and participate in shared decision-making. Rather than responding to a crisis, patients can approach dialysis initiation as a planned step in their care journey.
Coordinated Care Improves Readiness
Successful dialysis preparation requires coordination among multiple stakeholders, including primary care providers, nephrologists, surgeons, dialysis providers, care managers, patients, and family caregivers.
Primary care providers often play a critical role in identifying patients whose kidney disease is progressing and ensuring a timely referral to a nephrologist. Nephrologists guide treatment planning and determine when vascular access evaluation and placement should occur. Surgeons and interventional specialists perform the procedures necessary to establish permanent vascular access.
Patient education is equally important. Patients who understand their dialysis modality options are often better positioned to make informed decisions and avoid delays that can contribute to an unplanned dialysis start.
Care coordination can help ensure that critical milestones do not fall through the cracks. These milestones may include nephrology referral, modality education, access evaluation, surgical scheduling, access maturation, and preparation for home dialysis when appropriate.
The Population Health Opportunity
For health plans and value-based care organizations, improving dialysis readiness represents an important opportunity to enhance both clinical and financial outcomes.
A planned dialysis start is associated with better patient preparation, greater likelihood of using home dialysis modalities, improved vascular access outcomes, and lower rates of complications. Conversely, dialysis crashes often trigger costly episodes of care that may have been avoidable with earlier intervention.
Healthmap Solutions’ experience demonstrates the value of a proactive approach. By educating patients and coordinating appropriate nephrology care and vascular access planning, our Kidney Population Health Management program supports an increase in planned dialysis starts by more than 50%.
Early planning can also help expand use of home dialysis. Through patient education and care coordination, the Healthmap program supports a 20% to 30% increase in new home dialysis starts, enabling patients to choose an option that may better align with their lifestyle and goals.
Conclusion
Dialysis readiness is not achieved in the weeks immediately before kidney failure. It is built through proactive planning, patient education, and coordinated care throughout the later stages of CKD.
By identifying patients at risk for progression, facilitating timely nephrology engagement, supporting informed treatment decisions, and ensuring dialysis access is established before it is needed, healthcare organizations can help more patients avoid unplanned dialysis starts and experience a smoother transition to renal replacement therapy.
For health plans, providers, patients, and caregivers alike, early dialysis planning is more than a procedural consideration. It is a critical step toward better kidney care outcomes.
Healthmap Solutions has the systems, experience, and clinical expertise to help healthcare organizations take this step.
References
1 https://pmc.ncbi.nlm.nih.gov/articles/PMC6419254/
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