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

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 < .001). These facilities had higher receipt of financial penalties (18.5% vs 11.5%, P < .001), more frequently had the highest payment cut of 5% (2.4% vs 0.7%; P = .003), and were less likely to achieve the highest bonus of 4% (0% vs 2.7%; P < .001). Compared with all other facilities, those in the highest quintile of treating uninsured patients or those covered by Medicaid experienced more financial penalties (17.4% vs 12.9%, P = .01) as did those in the highest quintile in the proportion of patients who were Black (18.5% vs 12.6%, P = .001). Conclusions: In the first year of the Centers for Medicare & Medicaid Services' ETC model, dialysis facilities serving higher proportions of patients with social risk features had lower performance scores and experienced markedly higher receipt of financial penalties.

Racial and Ethnic Disparities in Kidney Replacement Therapies Among Adults With Kidney Failure: An Observational Study of Variation by Patient Age.

RATIONALE & OBJECTIVE: Non-Hispanic Black and Hispanic patients present with kidney failure at younger ages than White patients. Younger patients are also more likely to receive transplants and home dialysis than in-center hemodialysis (ICHD), but it is unknown whether racial and ethnic disparities in treatment differ by age. We compared use of kidney replacement therapies between racial and ethnic groups among patients with incident kidney failure overall and by age. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 830,402 US adult (age >21 years) patients initiating kidney failure treatment during the period of 2011-2018. EXPOSURES: Patient race and ethnicity (non-Hispanic Black, non-Hispanic White, Hispanic, or other) and age group (22-44, 45-64, 65-74, or 75-99 years). OUTCOME: Treatment modality (transplant, peritoneal dialysis [PD], home hemodialysis [HHD], or ICHD) as of day 90 of treatment. ANALYTICAL APPROACH: Differences in treatment modalities were quantified for patient subgroups defined by race and ethnicity and by age. Log-binomial regression models were fit to estimate adjusted risk ratios. RESULTS: 81% of patients were treated with ICHD, 3.0% underwent transplants (85% preemptive, 57% living-donor), 10.5% were treated with PD, and 0.7% were treated with HHD. Absolute disparities in treatment were most pronounced among patients aged 22-44 years. Compared with non-Hispanic White patients, whose percentages of treatment with transplant, PD, and HHD were 10.9%, 19.0%, and 1.2%, respectively, non-Hispanic Black patients were less commonly treated with each modality (unadjusted percentages, 1.8%, 13.8%, and 0.6%, respectively), as were Hispanic patients (4.4%, 16.9%, and 0.5%, respectively; all differences P < 0.001). After adjustment, the largest relative disparities were observed for transplant among the 22-44-year age group; compared with non-Hispanic White patients, the adjusted risk ratios for non-Hispanic Black and Hispanic patients were 0.21 (95% CI, 0.19-0.23) and 0.47 (95% CI, 0.43, 0.51), respectively. LIMITATIONS: Race and ethnicity data not self-reported. CONCLUSIONS: Among adults with incident kidney failure, racial and ethnic disparities in transplant and home dialysis use are most pronounced among the youngest adult patient age group.

Paying for Frequent Dialysis.

In late 2017, the 7 regional contractors responsible for paying dialysis claims in Medicare proposed new payment rules that would restrict payment for hemodialysis treatments in excess of 3 weekly to exceptional acute-care circumstances. Frequent hemodialysis is performed more frequently than the traditional thrice-weekly pattern, and many stakeholders-patients, providers, dialysis machine manufacturers, and others-have expressed concern that these payment rules will inhibit the growth of this treatment modality's use among US dialysis patients. In this Perspective, we explain the role of these contractors in the context of Medicare's in-center hemodialysis-centric dialysis payment system and assess how well this system accommodates the higher treatment frequencies of both peritoneal dialysis and frequent hemodialysis. Then, given the available evidence concerning the relative effectiveness of these modalities versus thrice-weekly in-center hemodialysis and trends in their use, we discuss options for modifying Medicare's payment system to support frequent dialysis.

Effect of Medicaid Disenrollment on Health Care Utilization Among Adults With Mental Health Disorders.

BACKGROUND: Medicaid is an important source of insurance coverage for those with mental health (MH) disorders in the United States. Although disruptions in Medicaid coverage are common, little is known about the dynamic relationship between Medicaid disenrollment and MH care utilization. OBJECTIVE: We estimated changes in all-cause and MH-related health care use post Medicaid disenrollment among a nationwide cohort of adults with MH disorders. SUBJECTS: We identified 8841 persons (197,630 person-months) ages 18-64 with MH disorders and Medicaid coverage from Panels 4 to 19 Medical Expenditure Panel Survey. METHODS: Using a quasi-experimental design and propensity weighting, we estimated logit models examining changes in service utilization per-person-per-month. We used a "post" indicator to estimate average differences in service use postdisenrollment (vs. those with continuous Medicaid coverage) and a count variable measuring total months since coverage loss to estimate changes over time. OUTCOME MEASURES: All-cause outpatient visits, MH-related outpatient visits, and acute care visits. RESULTS: Becoming uninsured after Medicaid disenrollment was associated with average reductions of 52% [-14.75 percentage-points, 95% confidence interval (CI): -17.59, -11.91] in the likelihood of receiving any outpatient service, 35% (-2.23 percentage-points, 95% CI: -3.71, -0.75) in the likelihood of receiving any MH-related outpatient service, and 52% (-2.44 percentage-points; 95% CI: -3.35, -1.52) in the likelihood of receiving any acute service in a month. Health care use declined the most in the month immediately postdisenrollment, and declines continued over the next half-year (while uninsured). CONCLUSIONS: Insurance loss after disenrollment from Medicaid led to a persistent disruption in the receipt of health care services for beneficiaries with MH disorders.

Association Between Dialysis Facility Ownership and Access to Kidney Transplantation.

Importance: For-profit (vs nonprofit) dialysis facilities have historically had lower kidney transplantation rates, but it is unknown if the pattern holds for living donor and deceased donor kidney transplantation, varies by facility ownership, or has persisted over time in a nationally representative population. Objective: To determine the association between dialysis facility ownership and placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. Design, Setting, and Participants: Retrospective cohort study that included 1 478 564 patients treated at 6511 US dialysis facilities. Adult patients with incident end-stage kidney disease from the US Renal Data System (2000-2016) were linked with facility ownership (Dialysis Facility Compare) and characteristics (Dialysis Facility Report). Exposures: The primary exposure was dialysis facility ownership, which was categorized as nonprofit small chains, nonprofit independent facilities, for-profit large chains (>1000 facilities), for-profit small chains (<1000 facilities), and for-profit independent facilities. Main Outcomes and Measures: Access to kidney transplantation was defined as time from initiation of dialysis to placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. Cumulative incidence differences and multivariable Cox models assessed the association between dialysis facility ownership and each outcome. Results: Among 1 478 564 patients, the median age was 66 years (interquartile range, 55-76 years), with 55.3% male, and 28.1% non-Hispanic black patients. Eighty-seven percent of patients received care at a for-profit dialysis facility. A total of 109 030 patients (7.4%) received care at 435 nonprofit small chain facilities; 78 287 (5.3%) at 324 nonprofit independent facilities; 483 988 (32.7%) at 2239 facilities of large for-profit chain 1; 482 689 (32.6%) at 2082 facilities of large for-profit chain 2; 225 890 (15.3%) at 997 for-profit small chain facilities; and 98 680 (6.7%) at 434 for-profit independent facilities. During the study period, 121 680 patients (8.2%) were placed on the deceased donor waiting list, 23 762 (1.6%) received a living donor kidney transplant, and 49 290 (3.3%) received a deceased donor kidney transplant. For-profit facilities had lower 5-year cumulative incidence differences for each outcome vs nonprofit facilities (deceased donor waiting list: -13.2% [95% CI, -13.4% to -13.0%]; receipt of a living donor kidney transplant: -2.3% [95% CI, -2.4% to -2.3%]; and receipt of a deceased donor kidney transplant: -4.3% [95% CI, -4.4% to -4.2%]). Adjusted Cox analyses showed lower relative rates for each outcome among patients treated at all for-profit vs all nonprofit dialysis facilities: deceased donor waiting list (hazard ratio [HR], 0.36 [95% CI, 0.35 to 0.36]); receipt of a living donor kidney transplant (HR, 0.52 [95% CI, 0.51 to 0.54]); and receipt of a deceased donor kidney transplant (HR, 0.44 [95% CI, 0.44 to 0.45]). Conclusions and Relevance: Among US patients with end-stage kidney disease, receiving dialysis at for-profit facilities compared with nonprofit facilities was associated with a lower likelihood of accessing kidney transplantation. Further research is needed to understand the mechanisms behind this association.

Expanding Medicaid Access without Expanding Medicaid: Why Did Some Nonexpansion States Continue the Primary Care Fee Bump?

Six states that have rejected the Patient Protection and Affordable Care Act's (ACA) Medicaid expansion nonetheless extended the primary care "fee bump," by which the federal government increased Medicaid fees for primary care services up to 100 percent of Medicare fees during 2013-14. We conducted semistructured interviews with leaders in five of these states, as well as in three comparison states, to examine why they would continue a provision of the ACA that moderately expands access at significant state expense while rejecting the expansion and its large federal match, focusing on relevant economic, political, and procedural factors. We found that fee bump extension proposals were more successful where they were dissociated from major national policy debates, actionable with the input of relatively few stakeholder entities, and well aligned with preexisting policy-making structures and decision trends. Republican proposals to cap or reduce federal funding for Medicaid, if enacted, would compel states to contain program costs. In this context, states' established decision-making processes for updating Medicaid fee schedules, which we elucidate in this study, may shape the future of the Medicaid program.

Referral for Kidney Transplantation and Indicators of Quality of Dialysis Care: A Cross-sectional Study.

BACKGROUND: Dialysis facility performance measures to improve access to kidney transplantation are being considered. Referral of patients for kidney transplantation evaluation by the dialysis facility is one potential indicator, but limited data exist to evaluate whether referral is associated with existing dialysis facility quality indicators. STUDY DESIGN: Cross-sectional study. SETTING & PARTICIPANTS: 12,926 incident (July 2005 to September 2011) adult (aged 18-69 years) patients treated at 241 dialysis facilities with complete quality indicator information from US national registry data linked to transplantation referral data from all 3 Georgia kidney transplantation centers. FACTORS: Facility performance on dialysis quality indicators (high, intermediate, and low tertiles). OUTCOME: Percentages of patients referred within 1 year of dialysis therapy initiation at dialysis facility. RESULTS: Overall, a median of 25.4% of patients were referred for kidney transplantation within 1 year of dialysis therapy initiation. Higher facility-level referral was associated with better performance with respect to standardized transplantation ratio (high, 28.6%; intermediate, 25.1%; and low, 22.9%; P=0.001) and percentage waitlisted (high, 30.7%; intermediate, 26.8%; and low, 19.2%; P<0.001). Facility-level referral was not associated with indicators of quality of care associated with dialysis therapy initiation, including percentage of incident patients being informed of transplantation options. For most non-transplantation-related indicators of high-quality care, including those capturing mortality, morbidity, and anemia management, better performance was not associated with higher facility-level transplantation referral. LIMITATIONS: Potential ecologic fallacy and residual confounding. CONCLUSIONS: Transplantation referral among patients at dialysis facilities does not appear to be associated with overall quality of dialysis care at the facility. Quality indicators related to kidney transplantation were positively associated with, but not entirely correspondent with, higher percentages of patients referred for kidney transplantation evaluation from dialysis facilities. These results suggest that facility-level referral, which is within the control of the dialysis facility, may provide information about the quality of dialysis care beyond current indicators.

Discontinuity of Medicaid Coverage: Impact on Cost and Utilization Among Adult Medicaid Beneficiaries With Major Depression.

BACKGROUND: Gaps in Medicaid coverage may disrupt access to and continuity of care. This can be detrimental for beneficiaries with chronic conditions, such as major depression, for whom disruptions in access to outpatient care may lead to increased use of acute care. However, little is known about how Medicaid coverage discontinuities impact acute care utilization among adults with depression. OBJECTIVE: Examine the relationship between Medicaid discontinuities and service utilization among adults with major depression. SUBJECTS: A total of 139,164 adults (18-64) with major depression was identified using the 2003-2004 Medicaid Analytic eXtract Files. METHODS: We used generalized linear and two-part models to examine the effect of Medicaid discontinuity on service utilization. To establish causality in this relationship, we used instrumental variables analysis, relying on exogenous variation in a state-level policy for identification. OUTCOME MEASURES: Emergency department (ED) visits, inpatient episodes, inpatient days, and Medicaid-reimbursed costs. RESULTS: Approximately 29.4% of beneficiaries experienced coverage disruptions. In instrumental variables models, those with coverage disruptions incurred an increase of $650 in acute care costs per-person per Medicaid-covered month compared with those with continuous coverage, evidenced by an increase in ED use (0.1 more ED visits per-person-month) and inpatient days (0.6 more days per-person-month). The increase in acute costs contributed to an overall increase in all-cause costs by $310 per-person-month (all P-values<0.001). CONCLUSIONS: Among depressed adults, those experiencing coverage disruptions have, on average, significantly greater use of costly ED/inpatient services than those with continuous coverage. Maintenance of continuous Medicaid coverage may help prevent acute episodes requiring high-cost interventions.

Blood transfusion practices in dialysis patients in a dynamic regulatory environment.

BACKGROUND: In 2011, Medicare implemented a prospective payment system (PPS) covering an expanded bundle of services that excluded blood transfusions. This led to concern about inappropriate substitution of transfusions for other anemia management methods. STUDY DESIGN: Medicare claims were used to calculate transfusion rates among dialysis patients pre- and post-PPS. Linear probability regressions adjusted transfusion trends for patient characteristics. SETTING & PARTICIPANTS: Dialysis patients for whom Medicare was the primary payer between 2008 and 2012. PREDICTOR: Pre-PPS (2008-2010) versus post-PPS (2011-2012). OUTCOMES & MEASUREMENTS: Monthly and annual probability of receiving one or more blood transfusions. RESULTS: Monthly rates of one or more transfusions varied from 3.8%-4.8% and tended to be lowest in 2010. Annual rates of transfusion events per patient were -10% higher in relative terms post-PPS, but the absolute magnitude of the increase was modest (-0.05 events/patient). A larger proportion received 4 or more transfusions (3.3% in 2011 and 2012 vs 2.7%-2.8% in prior years). Controlling for patient characteristics, the monthly probability of receiving a transfusion was significantly higher post-PPS (ß = 0.0034; P < 0.001), representing an -7% relative increase. Transfusions were more likely for females and patients with more comorbid conditions and less likely for blacks both pre- and post-PPS. LIMITATIONS: Possible underidentification of transfusions in the Medicare claims, particularly in the inpatient setting. Also, we do not observe which patients might be appropriate candidates for kidney transplantation. CONCLUSIONS: Transfusion rates increased post-PPS, but these increases were modest in both absolute and relative terms. The largest increase occurred for patients already receiving several transfusions. Although these findings may reduce concerns regarding the impact of Medicare's PPS on inappropriate transfusions that impair access to kidney transplantation or stress blood bank resources, transfusions should continue to be monitored.

To extend or not to extend the primary care "fee bump" in Medicaid?

Policy makers and researchers are eager to learn the effects of the Patient Protection and Affordable Care Act of 2010 (ACA) and its many provisions, but to date, they have been frustrated by the dearth of robust evidence on the ACA's true impacts on important health care and patient outcomes (e.g., access to primary care services). The present limitations of evidence, often a consequence of delays and inconsistencies in the law's implementation, have begun to affect policy making in the ACA's wake. In this article, we consider the debates among state and federal policy makers about whether to extend the ACA's so-called fee bump provision, whereby Medicaid fees for primary care services were increased to 100 percent of Medicare levels during 2013 and 2014. We describe the difficulties state Medicaid programs have experienced in implementing the fee bump, as well as how the resulting evidence gap and the broader political context have shaped the deliberations. To conclude, we identify policy alternatives and other factors policy makers should consider when deciding whether to extend or reinstitute the fee bump in the coming years.

Kidney Transplantation Contraindications: Variation in Nephrologist Practice and Training Vintage.

Introduction: Health system leaders aim to increase access to kidney transplantation in part by encouraging nephrologists to refer more patients for transplant evaluation. Little is known about nephrologists' referral decisions and whether nephrologists with older training vintage weigh patient criteria differently (e.g., more restrictively). Methods: Using a novel, iteratively validated survey of US-based nephrologists, we examined how nephrologists assess adult patients' suitability for transplant, focusing on established, important criteria: 7 clinical (e.g., overweight) and 7 psychosocial (e.g., insurance). We quantified variation in nephrologist restrictiveness-proportion of criteria interpreted as absolute or partial contraindications versus minor or negligible concerns-and tested associations between restrictiveness and nephrologist age (proxy for training vintage) in logistic regression models, controlling for nephrologist-level and practice-level factors. Results: Of 144 nephrologists invited, 42 survey respondents (29% response rate) were 85% male and 54% non-Hispanic White, with mean age 52 years, and 67% spent ≥1 day/wk in outpatient dialysis facilities. Nephrologists interpreted patient criteria inconsistently; consistency was lower for psychosocial criteria (intraclass correlation coefficient: 0.28) than for clinical criteria (intraclass correlation coefficient: 0.43; P < 0.01). With each additional 10 years of age, nephrologists' odds of interpreting criteria restrictively (top tertile) doubled (adjusted odds ratio [aOR] 1.96; 95% confidence interval [CI]: 0.95-4.07), with marginal statistical significance. This relationship was significant when interpreting psychosocial criteria (aOR: 3.18; 95% CI: 1.16-8.71) but not when interpreting clinical criteria (aOR: 1.12; 95% CI: 0.52-2.38). Conclusion: Nephrologists interpret evaluation criteria variably when assessing patient suitability for transplant. Guideline-based educational interventions could influence nephrologists' referral decision-making differentially by age.

Pay-for-Performance Incentives for Home Dialysis Use and Kidney Transplant.

Importance: The Centers for Medicare & Medicaid Services' mandatory End-Stage Renal Disease Treatment Choices (ETC) model, launched on January 1, 2021, randomly assigned approximately 30% of US dialysis facilities and managing clinicians to financial incentives to increase the use of home dialysis and kidney transplant. Objective: To assess the ETC's association with use of home dialysis and kidney transplant during the model's first 2 years and examine changes in these outcomes by race, ethnicity, and socioeconomic status. Design, Setting, and Participants: This retrospective cross-sectional study used claims and enrollment data for traditional Medicare beneficiaries with kidney failure from 2017 to 2022 linked to same-period transplant data from the United Network for Organ Sharing. The study data span 4 years (2017-2020) before the implementation of the ETC model on January 1, 2021, and 2 years (2021-2022) following the model's implementation. Exposure: Receiving dialysis treatment in a region randomly assigned to the ETC model. Main Outcomes and Measures: Primary outcomes were use of home dialysis and kidney transplant. A difference-in-differences (DiD) approach was used to estimate changes in outcomes among patients treated in regions randomly selected for ETC participation compared with concurrent changes among patients treated in control regions. Results: The study population included 724 406 persons with kidney failure (mean [IQR] age, 62.2 [53-72] years; 42.5% female). The proportion of patients receiving home dialysis increased from 12.1% to 14.3% in ETC regions and from 12.9% to 15.1% in control regions, yielding an adjusted DiD estimate of -0.2 percentage points (pp; 95% CI, -0.7 to 0.3 pp). Similar analysis for transplant yielded an adjusted DiD estimate of 0.02 pp (95% CI, -0.01 to 0.04 pp). When further stratified by sociodemographic measures, including age, sex, race and ethnicity, dual Medicare and Medicaid enrollment, and poverty quartile, there was not a statistically significant difference in home dialysis use across joint strata of characteristics and ETC participation. Conclusions and Relevance: In this cross-sectional study, the first 2 years of the ETC model were not associated with increased use of home dialysis or kidney transplant, nor changes in racial, ethnic, and socioeconomic disparities in these outcomes.

State-Level Variation in Medicaid Managed Care Enrollment and Specialty Care for Publicly Insured Children.

Importance: Medicaid and Children's Health Insurance Program cover almost 50% of children with special health care needs (CSHCN). CSHCN often require specialty services and have been increasingly enrolled in Medicaid managed care (MMC) plans, but there is a dearth of recent national studies on specialty care access among publicly insured children and particularly CSHCN. Objective: To provide recent, nationwide evidence on the association of MMC penetration with specialty care access among publicly insured children, with a special focus on CSHCN. Design, Setting, and Participants: This cross-sectional study used nationally representative data from the 2016 to 2019 National Survey of Children's Health to identify publicly insured children in 41 states that administered comprehensive managed care organizations for Medicaid. Data analysis was performed from May 2022 to March 2023. Exposure: Form CMS-416 data were used to measure state-year level share of Medicaid-enrolled children who were covered by MMC (ie, MMC penetration). Main Outcomes and Measures: Measures of specialty care access included whether, in the past year, the child had (1) any visit to non-mental health (MH) specialists, (2) any visit to MH professionals, and (3) any unmet health care needs and (4) whether the caregiver ever felt frustrated getting services for their child. Logistic regression models were used to examine the association of MMC penetration with specialty care access among all publicly insured children, and separately for CSHCN and non-CSHCN. Results: Among 20 029 publicly insured children, 7164 (35.8%) were CSHCN, 9537 (48.2%) were female, 4110 (37.2%) were caregiver-reported Hispanic, and 2812 (21.4%) were caregiver-reported non-Hispanic Black (all percentages are weighted). MMC was not associated with significant changes in any visit to non-MH specialists and unmet health care needs. In addition, MMC penetration was positively associated with caregiver frustration among all children (adjusted odds ratio, 1.23; 95% CI, 1.03-1.48; P = .02) and was negatively associated with any visit to MH professionals among CSHCN (adjusted odds ratio, 0.75; 95% CI, 0.58-0.98; P = .04). Conclusions and Relevance: In this cross-sectional study evaluating MMC and specialty care access for publicly insured children, increased MMC enrollment was not associated with improved specialty care access for publicly insured children, including CSHCN. MMC was associated with less access to specialties like MH and increased frustrations among caregivers seeking services for their children.

Evaluating Medicaid Managed Care Network Adequacy Standards And Associations With Specialty Care Access For Children.

Medicaid managed care plans cover more than 80 percent of Medicaid-enrolled children, including many children with special health care needs (CSHCN). Federal rules require states to set network adequacy standards to improve specialty care access for Medicaid managed care enrollees. Using a quasi-experimental design and 2016-19 National Survey of Children's Health data, we examined the association between quantitative network adequacy standards and access to specialty care among 8,614 Medicaid-enrolled children, including 3,157 with special health care needs, in eighteen states. Outcomes included whether the child had any visit to non-mental health specialists, any visit to mental health professionals, or any unmet health care needs and whether the caregiver ever felt frustrated in getting services for the child in the past year. We observed no association between the adoption of any quantitative network adequacy standard and the above outcomes among Medicaid-enrolled children. Among CSHCN, however, adopting any quantitative standard was positively associated with caregivers feeling frustrated in getting services for the child, especially among CSHCN who visited non-mental health specialists. Without additional interventions, adopting new network adequacy standards may have unintended consequences for CSHCN.

Race, Age, and Kidney Transplant Waitlisting Among Patients Receiving Incident Dialysis in the United States.

Rationale & Objective: Patients with kidney failure from racial and ethnic minority groups and older patients have reduced access to the transplant waitlist relative to White and younger patients. Although racial disparities in the waitlisting group have declined after the 2014 kidney allocation system change, whether there is intersectionality of race and age in waitlisting access is unknown. Study Design: Retrospective cohort study. Setting & Participants: 439,455 non-Hispanic White and non-Hispanic Black US adults initiating dialysis between 2015 and 2019 were identified from the United States Renal Data System, and followed through 2020. Exposures: Patient race and ethnicity (non-Hispanic White and non-Hispanic Black) and age group (18-29, 30-49, 50-64, and 65-80 years). Outcomes: Placement on the United Network for Organ Sharing deceased donor waitlist. Analytical Approach: Age- and race-stratified waitlisting rates were compared. Multivariable Cox proportional hazards models, censored for death, examined the association between race and waitlisting, and included interaction term for race and age. Results: Over a median follow-up period of 1 year, the proportion of non-Hispanic White and non-Hispanic Black patients waitlisted was 20.7% and 20.5%, respectively. In multivariable models, non-Hispanic Black patients were 14% less likely to be waitlisted (aHR, 0.86, 95% CI, 0.77-0.95). Relative differences between non-Hispanic Black and non-Hispanic White patients were different by age group. Non-Hispanic Black patients were 27%, 12%, and 20% less likely to be waitlisted than non-Hispanic White patients for ages 18-29 years (aHR, 0.73; 95% CI, 0.61-0.86), 50-64 (aHR, 0.88; 95% CI, 0.80-0.98), and 65-80 years (aHR, 0.80; 95% CI, 0.71-0.90), respectively, but differences were attenuated among patients aged 30-49 years (aHR, 0.89; 95% CI, 0.77-1.02). Limitations: Race and ethnicity data is physician reported, residual confounding, and analysis is limited to non-Hispanic White and non-Hispanic Black patients. Conclusions: Racial disparities in waitlisting exist between non-Hispanic Black and non-Hispanic White individuals and are most pronounced among younger patients with kidney failure. Results suggest that interventions to address inequalities in waitlisting may need to be targeted to younger patients with kidney failure. Plain-Language Summary: Research has shown that patients from racial and ethnic minority groups and older patients have reduced access to transplant waitlisting relative to White and younger patients; nevertheless, how age impacts racial disparities in waitlisting is unknown. We compared waitlisting between non-Hispanic Black and non-Hispanic White patients with incident kidney failure, within age strata, using registry data for 439,455 US adults starting dialysis (18-80 years) during 2015-2019. Overall, non-Hispanic Black patients were less likely to be waitlisted and relative differences between the two racial groups differed by age. After adjusting for patient-level factors, the largest disparity in waitlisting was observed among adults aged 18-29 years. These results suggest that interventions should target younger adults to reduce disparities in access to kidney transplant waitlisting.

Mental Health Clinic Administrators' Perspectives on the Impact of Clinic-School Partnerships on Youth Mental Health Services Continuity and Quality.

Partnerships between mental health (MH) clinics and school systems in which providers deliver MH services on school grounds are growing. To date, however, there is little research examining MH clinic administrator perspectives on how this service delivery model affects continuity and quality of MH services among low-income youth. We conducted a state-wide (online and mail) survey of administrators at MH clinics (n = 60) to assess their perspectives on the advantages and challenges of school MH services for Medicaid-enrolled youth. Among survey respondents (n = 44), 86% reported that their clinic had at least one school partnership. With respect to advantages, more than four-fifths reported that school-based MH services (compared to clinic-based services) were very helpful or extremely helpful (versus not helpful at all, a little helpful, or somewhat helpful) for: (1) reducing gaps in MH treatment (86.8%); (2) improving communication between MH providers and teachers (86.9%), and (3) improving the overall quality of MH care (89.5%). In addition, the estimated no-show rate for appointments in school settings (7.2%) was lower than the estimated no show-rate for clinic appointments (23.9%; p < 0.01). Several challenges were also reported; more than two-thirds of respondents reported difficulties when delivering school-based services related to parent engagement (i.e., appointment attendance [89.5%], communication [81.6%], timely consent [68.4%]) that occurred sometimes, often, or always (versus rarely or never). As MH clinics continue to enter into and expand partnerships with schools, stakeholders should implement family-centered strategies to enhance engagement. Nevertheless, MH clinic administrators highlight potential benefits of school MH services (compared to clinic-based services) with respect to continuity and quality of MH care.

National Estimates of Mental Health Needs Among Adults With Self-Reported CKD in the United States.

Introduction: Among adults with chronic kidney disease (CKD), comorbid mental illness is associated with poorer health outcomes and can impede access to transplantation. We provide the first US nationally representative estimates of the prevalence of mental illness and mental health (MH) treatment receipt among adults with self-reported CKD. Methods: Using 2015 to 2019 National Survey on Drug Use and Health (NSDUH) data, we conducted an observational study of 152,069 adults (age ≥22 years) reporting CKD (n = 2544), with no reported chronic conditions (n = 117,235), or reporting hypertension (HTN) or diabetes mellitus (DM) but not CKD (HTN/DM, n = 32,290). We compared prevalence of (past-year) any mental illness, serious mental illness (SMI), MH treatment, and unmet MH care needs across the groups using logistic regression models. Results: Approximately 26.6% of US adults reporting CKD also had mental illness, including 7.1% with SMI. When adjusting for individual characteristics, adults reporting CKD were 15.4 percentage points (PPs) and 7.3 PPs more likely than adults reporting no chronic conditions or HTN/DM to have any mental illness (P < 0.001) and 5.6 PPs (P < 0.001) and 2.2 PPs (P = 0.01) more likely to have SMI, respectively. Adults reporting CKD were also more likely to receive any MH treatment (21% vs. 12%, 18%, respectively) and to have unmet MH care needs (6% vs. 3%, 5%, respectively). Conclusion: Mental illness is common among US adults reporting CKD. Enhanced management of MH needs could improve treatment outcomes and quality-of-life downstream.