Variation in Nephrologist Visits to Patients on Hemodialysis across Dialysis Facilities and Geographic Locations

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100

A focus of health care reform has been on reducing 30-day hospital readmissions. Patients with ESRD are at high risk for hospital readmission. It is unknown whether more monitoring by outpatient providers can reduce hospital readmissions in patients receiving hemodialysis. In nationally representative cohorts of patients in the United States receiving in-center hemodialysis between 2004 and 2009, we used a quasiexperimental (instrumental variable) approach to assess the relationship between frequency of visits to patients receiving hemodialysis following hospital discharge and the probability of rehospitalization. We then used a multivariable regression model and published hospitalization data to estimate the cost savings and number of hospitalizations that could be prevented annually with additional provider visits to patients in the month following hospitalization. In the main cohort (n=26,613), one additional provider visit in the month following hospital discharge was estimated to reduce the absolute probability of 30-day hospital readmission by 3.5% (95% confidence interval, 1.6% to 5.3%). The reduction in 30-day hospital readmission ranged from 0.5% to 4.9% in an additional four cohorts tested, depending on population density around facilities, facility profit status, and patient Medicaid eligibility. At current Medicare reimbursement rates, the effort to visit patients one additional time in the month following hospital discharge could lead to 31,370 fewer hospitalizations per year, and $240 million per year saved. In conclusion, more frequent physician visits following hospital discharge are estimated to reduce rehospitalizations in patients undergoing hemodialysis. Incentives for closer outpatient monitoring following hospital discharge could lead to substantial cost savings.

Section: Discussionmentioning

confidence: 99%

Physician Visits and 30-Day Hospital Readmissions in Patients Receiving Hemodialysis

Erickson

Winkelmayer

Chertow

et al. 2014

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100

“…26 Despite this, a recent study of variation in visit frequency found that patients who were recently hospitalized were 2% less likely to be seen four or more times than patients without a recent hospitalization. 27 Moreover, the depth of interaction may also be important, as demonstrated by data from the Dialysis Outcomes and Practice Patterns Study, which found that patients experienced improved survival when their providers spent more time conducting face-to-face visits at the outpatient hemodialysis unit. 28 Fourth, given the time constraints of dialysis, patients may be using the emergency department as a surrogate for their primary care provider.…”

Section: Discussionmentioning

confidence: 99%

Rehospitalizations and Emergency Department Visits after Hospital Discharge in Patients Receiving Maintenance Hemodialysis

Harel

Wald

McArthur

et al. 2015

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Clinical outcomes after a hospital discharge are poorly defined for patients receiving maintenance in-center (outpatient) hemodialysis. To describe the proportion and characteristics of these patients who are rehospitalized, visit an emergency department, or die within 30 days after discharge from an acute hospitalization, we conducted a population-based study of all adult patients receiving maintenance in-center hemodialysis who were discharged between January 1, 2003, and December 31, 2011, from 157 acute care hospitals in Ontario, Canada. For patients with more than one hospitalization, we randomly selected a single hospitalization as the index hospitalization. Of the 11,177 patients included in the final cohort, 1926 (17%) were rehospitalized, 2971 (27%) were treated in the emergency department, and 840 (7.5%) died within 30 days of discharge. Complications of type 2 diabetes mellitus were the most common reason for rehospitalization, whereas heart failure was the most common reason for an emergency department visit. In multivariable analysis using a cause-specific Cox proportional hazards model, the following characteristics were associated with 30-day rehospitalization: older age, the number of hospital admissions in the preceding 6 months, the number of emergency department visits in the preceding 6 months, higher Charlson comorbidity index score, and the receipt of mechanical ventilation during the index hospitalization. Thus, a large proportion of patients receiving maintenance in-center hemodialysis will be readmitted or visit an emergency room within 30 days of an acute hospitalization. A focus on improving care transitions from the inpatient setting to the outpatient dialysis unit may improve outcomes and reduce healthcare costs.

“…Instead, local provider practice patterns and economic incentives faced by individual providers explain a higher fraction of the variation in visit frequency. 19 Current reimbursement encourages visits to all patients, irrespective of their health needs. Policies that encourage more frequent visits to patients who actually benefit from additional visits, such as patients who recently started dialysis or who were recently discharged from the hospital, could lead to improvements in health outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…The theoretical basis for our choice of instrument comes from previous findings that provider visit frequency in hemodialysis is determined to a greater degree by dialysis facility location than individual patient characteristics, in addition to similarities among physician networks and observations that providers working in close proximity to one another share practice patterns. 19,[34][35][36][37] Using a two-stage least-squareslinear probability model,we measured the association between predicted visits in the first 90 days of dialysis and each outcome of interest. We controlled for patient demographic, socioeconomic, and comorbidity characteristics listed in Table 2.…”

Section: Instrumental Variable Analysesmentioning

confidence: 99%

“…18 Despite a common financial incentive to see patients frequently, variation in visit frequency continues to exist among providers. 19 In this study, we examine whether patients seen more frequently by their nephrologist or advanced practitioner in the first 90 days of hemodialysis were more likely to undergo surgery to create an AV fistula or place an AV graft during that period.…”

mentioning

confidence: 99%

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Provider Visits and Early Vascular Access Placement in Maintenance Hemodialysis

Erickson

Mell

Winkelmayer

et al. 2015

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Medicare reimbursement policy encourages frequent provider visits for patients with ESRD undergoing hemodialysis. We hypothesize that patients seen more frequently by their nephrologist or advanced practitioner within the first 90 days of hemodialysis are more likely to undergo surgery to create an arteriovenous (AV) fistula or place an AV graft. We selected 35,959 patients aged $67 years starting hemodialysis in the United States from a national registry. We used multivariable regression to evaluate the associations between mean visit frequency and AV fistula creation or graft placement in the first 90 days of hemodialysis. We conducted an instrumental variable analysis to test the sensitivity of our findings to potential bias from unobserved characteristics. One additional visit per month in the first 90 days of hemodialysis was associated with a 21% increase in the odds of AV fistula creation or graft placement during that period (95% confidence interval, 19% to 24%), corresponding to an average 4.5% increase in absolute probability. An instrumental variable analysis demonstrated similar findings. Excluding visits in months when patients were hospitalized, one additional visit per month was associated with a 10% increase in odds of vascular access surgery (95% confidence interval, 8% to 13%). In conclusion, patients seen more frequently by care providers in the first 90 days of hemodialysis undergo earlier AV fistula creation or graft placement. Payment policies that encourage more frequent visits to patients at key clinical time points may yield more favorable health outcomes than policies that operate irrespective of patients' health status.