Higher Rates of Preventive Care Seen for Dialysis Patients Who Visit Primary Care Physicians

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Can dialysis patients benefit from having a primary care physician (PCP) or a more patient-centered approach to care? Updated data from a study presented at Kidney Week 2015 suggest improvements in some aspects of preventive care associated with PCP involvement.

Although most dialysis patients say they have visited a PCP in the previous year or two, at least one-third have not. That suggests opportunities to improve the outcomes and costs of care for ESRD, according to the new research by Vahakn B. Shahinian, MD, and colleagues of the University of Michigan.

Meanwhile, new approaches to providing more comprehensive care are emerging, including a patient-centered medical home (PCMH) project being evaluated by Anna Porter, MD, and colleagues at the University of Illinois at Chicago (UIC).

Shahinian and colleagues used US Renal Data System data to explore patterns of PCP involvement in the care of dialysis patients. “We know that the chronic dialysis population has a high illness index, and a lot of that comes not only from the dialysis issues, but because of the constellation of comorbidities that they have,” Shahinian said.

“We wanted to get a national snapshot of how often these patients were seeing primary care physicians in addition to their nephrologist, and then, secondarily, whether that had any kind of impact on the kind of care that they were getting.” The analysis included nearly 250,000 Medicare beneficiaries on chronic dialysis during 2012 and 2013.

Overall, 63 percent of patients had one or more claims for an outpatient visit to a family practitioner, general internist, or geriatrician in the past year. Patients with PCP involvement were more likely to have diabetes as the primary cause of ESRD: about 46 percent compared with 38 percent of those without PCP involvement. Patients who saw a PCP were also older (mean age of 58 versus 53 years old) and more likely to be women and white.

Specific aspects of preventive care were more likely to be in evidence for patients who saw a PCP. For diabetic patients, rates of hemoglobin A1c testing, lipid measurement, and diabetic eye examination were all higher with PCP involvement. About one-third of diabetic patients with PCP involvement received all three tests compared with less than one-fourth of those who had not seen a PCP.

Primary care involvement was also associated with a higher rate of influenza vaccination: 76 percent versus 64 percent.

Delivery of recommended primary care is a key component of efforts to improve health care quality and value. The new results suggest that, although most chronic dialysis patients do continue to see a general internist or other PCP, a substantial minority do not: 30 to 45 percent depending on the definition of PCP involvement used. The findings also draw attention to the need to improve some aspects of care—especially recommended testing for patients with diabetes, which remains suboptimal even for patients who see a PCP.

Could primary care involvement affect other ESRD outcomes as well? “That’s the next big question, is to see how much of an impact does it have to have a PCP,” Shahinian said. “Do these patients live longer if they have a primary care physician involved? That’s certainly something that we are planning to look at moving ahead.” The researchers are also interested in looking at other outcomes, such as hospitalization and health care costs.

But there will be challenges to performing such analyses. “We know that patients who have PCPs are somewhat older and are more likely to have comorbidities … It will require quite a bit of statistical adjustments in order for us to really try to get at the actual impact of having a PCP or not on the outcome.”

A medical home for ESRD

The snapshot of PCP involvement in care of dialysis patients will be “unsurprising to most nephrologists,” commented Porter. “All nephrologists in practice who see dialysis patients have the impression that the patients absolutely need primary care physicians and that having a PCP would really help improve the health and quality of life of these patients.”

“And even though it’s sort of intuitive … there really isn’t a lot of good information out there about how to facilitate [increased] PCP involvement,” she added. One factor is that patients do not necessarily understand the importance of having a PCP.

“But beyond that it’s so difficult and burdensome for these patients when they’re seeing a physician on dialysis once a week and the burden of their dialysis treatments themselves is consuming such a huge chunk of their time.”

Porter and colleagues of the Institute of Health Research and Policy at UIC are testing a PCMH for patients with kidney disease, with funding from the Patient-Centered Outcomes Research Institute (PCORI). Denise Hynes, PhD, is the principal investigator.

The project “adds a few members” to the usual dialysis care team of dialysis nurse, technician, social worker, and dietician, according to Porter. “We have a primary care physician who comes to the dialysis unit and sees the patients. We also have a pharmacist who rounds with the team and an advanced practice nurse who’s available for patient care issues.”

The PCMH team also includes some health promoters. “The health promoters are lay people who have been trained in acting as care liaisons and helping patients to negotiate whatever health challenges they’re having,” Porter explained. For example, “[i]f they’re having difficulty taking their medications or scheduling follow-up appointments, the health promoters can help them with those things.”

The PCMH approach is being evaluated at a freestanding university-affiliated dialysis center and a nearby Fresenius unit. An 18-month evaluation is planned in the spring of 2016, focusing on outcomes, such as quality of life and emergency department visits.

Porter noted that the PCORI-funded project is not collecting data on cost savings. “But certainly that is an intuitive thing that would result from better coordination of care,” she added.

Shahinian mentioned the Comprehensive ESRD Care Model being evaluated as a demonstration project by the Centers for Medicare & Medicaid Services. The project has implemented 13 ESRD Seamless Care Organizations nationwide to evaluate a payment and care delivery model specific to ESRD. Nephrologists and other team members will work as a group to provide a “more holistic kind of care,” according to Shahinian: “Not just limited to dialysis aspects of care, but also these more general preventive care and primary care aspects as well.”

The project will evaluate per capita Medicare expenditures as well as beneficiary health outcomes. “If there’s an expectation that dialysis facilities and the nephrologists and the whole team there is going to provide primary care or preventive care, then it might require some change in the way current quality of care initiatives are being done and how reimbursement is done,” Shahinian said.

“So much of the focus right now is on dialysis and dialysis quality,” Shahinian added. “There might need to be a shift toward incentivizing and reimbursing the dialysis providers for providing these additional aspects of care.”