Individuals with end-stage kidney disease (ESKD) have exceedingly high morbidity and mortality rates. In January 2004, in an attempt to improve patient outcomes, the Centers for Medicare &Medicaid Services (CMS) linked physician reimbursement for outpatient hemodialysis care to the number of monthly physician - patient visits on dialysis, thereby stimulating more frequent physician - patient contact. The new reimbursement policy resulted in increased visit frequency between physicians and their hemodialysis patients, but the effect of this increased visit frequency on patients'outcomes and costs remains unknown.
We aim to determine the association between physician-patient visit frequency and outcomes and costs among incident hemodialysis patients. This proposal outlines the use of several national datasets that include patient, physician, and dialysis facility characteristics, reliable vital statistic ascertainment, as well as longitudinal Medicare inpatient and outpatient claims data to efficiently evaluate the association between physician - patient visit frequency and patient outcomes and costs. We hypothesize that greater physician-patient visit frequency is associated with a reduced patient hospitalization and mortality rate, greater achievement of dialysis clinical performance targets, greater utilization of preventative services, and greater Medicare expenditures.
Our specific aims are as follows: To determine the association between increased physician-patient visit frequency and hospitalization and mortality rates among incident hemodialysis patients;To determine the association between increased physician-patient visit frequency and the achievement of dialysis clinical performance targets, dialysis process measures and utilization of preventative services;To determine whether the association between physician-patient visit frequency and patient health outcomes is altered by select patient, physician, and dialysis facility characteristics;To determine if increased physician-patient visit frequency is associated with higher Medicare expenditures;and to determine the incremental cost-effectiveness ratio of four or more physician-patient visits per month compared to fewer monthly visits. The proposed study will have a significant impact irrespective of findings as the first study to evaluate, on a national level, the relationship between physician-patient visit frequency and outcomes and to provide much-needed evidence for future policy changes related to frequency of visits between physicians and their patients.

Public Health Relevance

Strategies directed at providing efficient and cost-ffective care while improving outcomes in patients with ESKD are urgently needed.
We aim to determine if greater physician-patient contact frequency among incident hemodialysis patients improves patient health outcomes and influences the cost of providing care to those on dialysis. The research proposed will have significant impact, irrespective of findings. If increased physician-patient visit frequency on hemodialysis is found to improve health outcomes, frequent follow-up should become standard practice for all dialysis patients, and future Medicare reimbursement policies can further strengthen incentives for greater physician- patient visit frequency on dialysis. Alternatively, if increased patient-physician visit frequency does not influence health outcomes but significantly increases Medicare expenses, a randomized controlled trial should be conducted to determine if frequency of physician-patient visits on dialysis alters patient outcomes. Should the trial verify these findings, the current CMS policy should be revised, potentially leading to significant cost savings.

Agency
National Institute of Health (NIH)
Institute
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Type
Research Project (R01)
Project #
5R01DK082415-03
Application #
8287706
Study Section
Kidney, Nutrition, Obesity and Diabetes (KNOD)
Program Officer
Narva, Andrew
Project Start
2010-06-01
Project End
2014-03-31
Budget Start
2012-04-01
Budget End
2014-03-31
Support Year
3
Fiscal Year
2012
Total Cost
$250,422
Indirect Cost
$24,216
Name
University of Minnesota Twin Cities
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
555917996
City
Minneapolis
State
MN
Country
United States
Zip Code
55455
Slinin, Yelena; Guo, Haifeng; Li, Suying et al. (2014) Provider and care characteristics associated with timing of dialysis initiation. Clin J Am Soc Nephrol 9:310-7
Slinin, Yelena; Guo, Haifeng; Li, Suying et al. (2014) Hemodialysis patient outcomes: provider characteristics. Am J Nephrol 39:367-75