In the United States, multiple stakeholders have impacted the timing of dialysis initiation for patients with end-stage renal disease. The optimal policy to start dialysis for this vulnerable population remains unknown. Historically, patients initiated dialysis weeks after the appearance of uremic symptoms. This changed not only due to an evolution in medical providers' practice but also due to changes in the care delivery system, the political imperatives, and the economic driving forces surrounding the care of these patients. One large randomized control trial looked at patient outcomes with strategies of early versus late start. The trial included an economic analysis. Depending on the specific comparison, cost was either lower in the late-start group or was equivalent between groups. This result would tend to favor a late-start strategy, where patients had an additional 6 months of dialysis-free time. However, the generalizability of this analysis has been questioned. Future care models that would include patients before and after dialysis initiation would be ideal to study cost and quality at the time of this transition of care. The recently implemented CMS Quality Incentive Program is one mechanism that could use such findings to implement a high-value strategy for patients starting chronic dialysis therapies.
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