Importance: In 2021, Medicare launched the End-Stage Renal Disease Treatment Choices (ETC) model, which randomly assigned approximately 30% of dialysis facilities to new financial incentives to increase use of transplantation and home dialysis; these financial bonuses and penalties are calculated by comparing living-donor transplantation, transplant wait-listing, and home dialysis use in ETC-assigned facilities vs benchmarks from non-ETC-assigned (ie, control) facilities. Because model participation is randomly assigned, evaluators may attribute any downstream differences in outcomes to facility performance rather than any imbalance in baseline characteristics. Objective: To identify preintervention imbalances in dialysis facility characteristics that should be recognized in any ETC model evaluations. Design, Setting, and Participants: This cross-sectional study compared ETC-assigned and control dialysis facility characteristics in the United States from 2017 to 2018. A total of 6062 facilities were included. Data were analyzed from February 2021 to May 2022. Exposures: Assignment to the ETC model. Main Outcomes and Measures: Dialysis facilities' preintervention transplantations and home dialysis use, facility characteristics (notably, profit and chain status), patient demographic characteristics, and community socioeconomic characteristics. Results: Among 316927 patients, with 6178855 attributed patient-months, the mean (SD) age in January 2017 was 59 (11) years, and 132462 (42%) were female. Patients in ETC-assigned facilities had 9% (0.2 [95% CI, 0.1-0.2] percentage points) lower prevalence of living donor transplantation, 12% (3.2 [95% CI, 3.0-3.3] percentage points) lower prevalence of transplantation wait-listing, and 4% (0.4 [95% CI, 0.3-0.4] percentage points) lower prevalence of peritoneal dialysis use compared with control facilities. ETC-assigned facilities were 14% (5.1 [95% CI, 0.9-9.4] percentage points) more likely than control facilities to be owned by the second largest dialysis organization. Relative to control facilities, ETC-assigned facilities also treated 34% (6.6 [95% CI, 6.5-6.7] percentage point) fewer patients with Hispanic ethnicity and were located in communities with median household incomes that were 4% ($2500; 95% CI, $500-$4500) lower on average. Conclusions and Relevance: In this study, dialysis facilities in ETC-assigned regions had lower preintervention prevalence of transplantation wait-listing, living donor transplantation, and peritoneal dialysis use, relative to control facilities. ETC-assigned and control facilities also differed with respect to other facility, patient, and community characteristics. Evaluators should account for these preintervention imbalances to minimize bias in their inferences about the model's association with postintervention outcomes..

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.

Rationale & Objective: There are many barriers to meeting the goal of increasing kidney transplants in the United States. It is important to understand dialysis and transplant center providers’ existing practices and identified barriers to increasing the number of dialysis patients who are evaluated for and get wait-listed for a transplant. Study Design: Cross-sectional survey of dialysis unit and transplant center staff in End Stage Renal Disease Network 6 (Georgia, North Carolina, South Carolina). Setting & Participants: Ninety-one transplant staff from all 9 transplant centers in the region and 421 dialysis staff from 421 facilities responded to the survey. Predictors: N/A Outcome: Provider perceptions of barriers faced by patients in the kidney transplant evaluation process and suggestions for improving care. Analytical Approach: Mixed methods. Descriptive analyses of responses to multiple-choice questions and qualitative analysis of open-ended survey responses. Results: The top 5 barriers to kidney transplantation as reported by transplant staff were transportation (63.7%), low health literacy (50.5%), lack of understanding about the transplant process (37.4%), distance to transplant center (29.7%), and low socioeconomic status (28.6%). When asked how dialysis units can help patients complete the evaluation process, the most common responses from transplant center staff were educating patients about transplant (54%), helping patients through steps in the process (35%), and better communication with transplant centers (15%). When dialysis unit staff were asked what could be done to help the facility improve its transplant wait-list rate, the most common responses were educational materials for patients and staff (55%), better communication with transplant centers (12%), and transportation and financial assistance (9%). Limitations: Survey responses are from 1 end stage renal disease network. Conclusions: Dialysis units, transplant centers, and ESRD networks can work together to help patients address key barriers to transplantation to improve the country's transplantation rate.