Association of Primary Care Continuity With Home Dialysis, Transplantation, and Utilization of Medical Services for Patients Starting Hemodialysis

Abstract

Rationale & Objective

Primary care may help patients starting dialysis with emotional support and access to health care services. It is unknown whether consistently visiting the same primary care physician (PCP) can strengthen patient confidence to select home dialysis, help facilitate medical appointments for transplantation, or increase care access.

Study Design

A population-based retrospective cohort study.

Setting & Participants

Patients initiating maintenance hemodialysis from 2007 to 2017 in Ontario, Canada.

Exposure

High PCP continuity using the usual provider of care index (an established measure of PCP continuity), defined as >75% of PCP visits with the same PCP in the 2 years before dialysis initiation.

Outcomes

Primary outcomes were time to home dialysis (peritoneal or hemodialysis) and transplantation. Secondary outcomes included specialist visits, cancer screening, influenza vaccination, and measures of diabetes care.

Analytical Approach

Propensity scores to match patients with high and low PCP continuity.

Results

We identified 9,530 matched pairs. High PCP continuity was not associated with increased home dialysis (14.0 events per 100 person-years vs 14.0 events per 100 person-years; subdistribution hazard ratio 1.00; 95% CI, 0.97-1.04) or transplantation (4.3 events per 100 person-years vs 4.5 events per 100 person-years; subdistribution hazard ratio 0.97; 95% CI, 0.90-1.04). High PCP continuity was associated with greater colon cancer screening (hazard ratio 1.07; 95% CI, 1.01-1.14), influenza vaccination (hazard ratio 1.33; 95% CI, 1.27-1.39), and comprehensive diabetes care (hazard ratio 1.23; 95% CI, 1.14-1.33).

Limitations

Residual confounding is possible.

Conclusions

High PCP continuity before dialysis initiation was not associated with increased utilization of home dialysis or transplantation but was associated with greater colon cancer screening, influenza vaccination, and comprehensive diabetes care. Additional work is needed to clarify how primary care may best benefit this patient population.

Plain Language Summary

Patients transitioning to maintenance hemodialysis require comprehensive health care. We investigated how closer relationships with a primary care physician (PCP) may complement nephrologists in caring for this patient population. We used administrative databases in Ontario, Canada, to conduct a retrospective population-based study, assessing how continuity with one PCP influenced the uptake of home dialysis, kidney transplantation, and patient access to health care services. We found that high PCP continuity before dialysis initiation was not associated with increased transition to home dialysis or kidney transplantation but did lead to increases in colon cancer screening, influenza vaccination, and diabetes assessment. Further work is required to determine how PCPs can help nephrologists best serve the multifaceted needs of patients transitioning to maintenance hemodialysis.