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OBJECTIVES: Unplanned "crash" dialysis starts are associated with worse outcomes and higher costs, a challenging problem for health systems participating in value-based care (VBC). We examined expenditures and utilization associated with these events in a large health system. STUDY DESIGN: Retrospective, single-center study at Cleveland Clinic, a large, integrated health system participating in VBC contracts, including a Medicare accountable care organization. METHODS: We analyzed beneficiaries who transitioned to dialysis between 2017 and 2020. Crash starts involved initiating inpatient hemodialysis (HD) with a central venous catheter (CVC). Optimal starts were initiated with either home dialysis or outpatient HD without a CVC. Suboptimal starts were initiated with outpatient HD with a CVC or inpatient HD without a CVC. RESULTS: A total of 495 patients initiated chronic dialysis: 260 crash starts, 130 optimal starts, and 105 suboptimal starts. Median predialysis 12-month cost was $67,059 for crash starts, $17,891 for optimal starts, and $7633 for suboptimal starts (P < .001). Median postdialysis 12-month cost was $71,992 for crash starts, $55,427 for optimal starts, and $72,032 for suboptimal starts (P = .001). Predialysis inpatient admission per 1000 beneficiaries was 1236 per 1000 for crash starts vs 273 per 1000 for optimal starts and 170 per 1000 for suboptimal starts (P < .001). Postdialysis inpatient admission for crash starts was 853 per 1000 vs 291 per 1000 for optimal starts and 184 per 1000 for suboptimal starts (P < .001). CONCLUSIONS: In a major health system, crash starts demonstrated the highest cost and hospital utilization, a pattern that persisted after dialysis initiation. Developing strategies to promote optimal starts will improve VBC contract performance. [ABSTRACT FROM AUTHOR]