Association of Provider–Patient Visit Frequency and Patient Outcomes on Hemodialysis

Abstract

In January of 2004, the Centers for Medicare & Medicaid Services tied provider reimbursement for outpatient hemodialysis services to the number of provider-patient visits per month. We aimed to determine whether greater visit frequency associated with lower mortality and hospitalization rates among incident hemodialysis patients in a large, nationally representative contemporary cohort. Using US Renal Data System data for 130,892 patients who initiated in-center hemodialysis between October 1, 2003 and September 30, 2006, we determined associations between the frequency of provider visits and mortality, first hospitalization, multiple hospitalizations, and cause-specific hospitalizations. Our primary analysis used Cox proportional hazards models, but we also performed time-varying Cox proportional hazards and instrumental variable analyses. In the primary analysis, we did not detect a significance difference in mortality among patients with four provider visits per month compared with those patients with fewer provider visits (adjusted HR=0.98; 95% CI=0.96-1.01), but the risk for first hospitalization was 4% lower among those patients with more frequent visits (adjusted HR=0.96; 95% CI=0.95-0.97). The time-varying Cox analysis produced similar results. The fully adjusted instrumental variable analysis showed a 0.07% higher risk for death that was not statistically significant (P=0.88) but a significant 2.3% lower risk for first hospitalization (P=0.001) for patients with four provider visits per month. In summary, greater frequency of provider visits to hemodialysis patients associates with a small but significant reduction in hospitalizations, but it does not consistently associate with lower risk for death.

Associations of Frequency and Duration of Patient-Doctor Contact in Hemodialysis Facilities with Mortality

“…[8][9][10] We provide new information extending results of previous studies and demonstrate that both PDC frequency and duration, as well as total PDC time, are associated with all-cause mortality. Assuming our findings are valid, they suggest that more face-to-face encounters with physicians, whether more frequently or longer, may contribute to better patient outcomes.…”

“…Additionally, in that previous study, the investigators were unable to distinguish between frequencies of 4 times per month and .4 times per month (the intermediate and high groups in our study) because of limitations of the billing codes used as the data source. 10 The association between PDC frequency and mortality in our study was monotonic (Table 3, model 4a). By dichotomizing the exposure variable and limiting the sample to patients in the United States to approximate the methods of the previous study, 10 we observed that the adjusted HR for mortality associated with a frequency ,4 times per month was 1.08 (95% CI, 0.96 to 1.22) compared with $4 times per month; inversely, the HR for mortality was 0.92 (95% CI, 0.82 to 1.04) in association with a frequency $4 times per month compared with ,4 times per month in the patients from the DOPPS in the United States.…”

“…10 The association between PDC frequency and mortality in our study was monotonic (Table 3, model 4a). By dichotomizing the exposure variable and limiting the sample to patients in the United States to approximate the methods of the previous study, 10 we observed that the adjusted HR for mortality associated with a frequency ,4 times per month was 1.08 (95% CI, 0.96 to 1.22) compared with $4 times per month; inversely, the HR for mortality was 0.92 (95% CI, 0.82 to 1.04) in association with a frequency $4 times per month compared with ,4 times per month in the patients from the DOPPS in the United States. Slinin et al reported a HR of 0.98 (95% CI, 0.96 to 1.01) for $4 times per month compared with ,4 times per month.…”

“…A recent study based on analysis of data from the USRDS (n=130,892) also showed that PDC frequency, although associated with lower hospitalization, was not consistently associated with mortality. 10 One potential explanation for this unexpected result could be that the study targeted only one country, which may have less variability in practice patterns: Forty percent of dialysis patients were seen ,4 times per month. In the DOPPS, the proportions of facilities with PDC frequency ,4 times per month were 32% in the United States and 16% in other countries (ranging from 0% in Germany to 87% in the United Kingdom).…”

“…Previous studies from the United States showed that less frequent PDC was associated with lower patient satisfaction, lower patient adherence, lower patient achievement of clinical performance targets, and higher hospitalization, but more frequent PDC was not necessarily related to longer patient survival. [8][9][10] A recent study based on data from the U.S. Renal Data System (USRDS) also reported no difference in survival for PDC frequency of ,4 times per month compared with 4 times per month. 10 However, the study was limited to one country and was unable to evaluate differences in outcomes between 4 times per month and .4 times per month because of limitations of the billing codes and relatively low proportion of high PDC frequency in the United States.…”