Primary Care Involvement and Health Care Utilization Among Patients With End-Stage Kidney Disease

Importance: Patients with end-stage kidney disease receiving dialysis have disproportionate rates of emergency department utilization and hospitalization. Models of care with primary care physicians may be able to reduce these events, although prior literature has not clearly demonstrated a benefit in the population of patients with end-stage kidney disease. Objective: To determine whether having a primary care practitioner is associated with lower risk of hospitalization and emergency department utilization in the population of patients with end-stage kidney disease. Design, Setting, and Participants: Retrospective, cross-sectional study of patients for whom Medicare Fee for Service was the primary payer with end-stage kidney disease in the contiguous US receiving dialysis between January 1, 2018, and December 31, 2019. Differential distance to a dialysis facility with a high level of primary care involvement was an instrumental variable. Data were analyzed from January 1, 2019 to December 31, 2019. Exposure: Presence or absence of primary care physician; instrument of differential distance defined as difference between distance to nearest high primary care-utilizing dialysis facility and distance to nearest dialysis facility of any type, using above or below median differential distance as instrumental variable. Main Outcomes and Measures: Any emergency department visit, emergency department visit not resulting in hospitalization, or hospitalization. Results: Among 181 520 patients (mean [SD] age, 62.6 [14.1]; 102 966 [56.7%] male; 71 953 [39.6%] Black, 27 215 [15.0%] Hispanic, and 97 661 [53.8%] White) with end-stage kidney disease receiving hemodialysis, patients estimated to have primary care involvement by our instrument had a lower estimated risk of any emergency department visit not resulting in hospitalization (51.2%; 95% CI, 49.7%-52.7%) relative to those not estimated to have primary care involvement (72.1%; 95% CI, 69.2%-74.9%; P < .001). There was a lower estimated risk of any emergency department visit in this population as well (69.4%; 95% CI, 68.1%-70.7% in those estimated to have primary care involvement vs 75.0%; 95% CI, 72.5%-77.6% in those not estimated to have primary care involvement). There was no significant difference in estimated risk of any hospitalization. Conclusions and Relevance: In this cross-sectional study of patients with end-stage kidney disease receiving dialysis, primary care physician involvement was associated with reduced emergency department utilization.