Association of Provider-Patient Visit Frequency and Patient Outcomes on Hemodialysis

In January of 2004, the Centers for Medicare & Medicaid Services tied provider reimbursement for outpatient hemodialysis services to the number of provider-patient visits per month. We aimed to determine whether greater visit frequency associated with lower mortality and hospitalization rates among incident hemodialysis patients in a large, nationally representative contemporary cohort. Using US Renal Data System data for 130,892 patients who initiated in-center hemodialysis between October 1, 2003 and September 30, 2006, we determined associations between the frequency of provider visits and mortality, first hospitalization, multiple hospitalizations, and cause-specific hospitalizations. Our primary analysis used Cox proportional hazards models, but we also performed time-varying Cox proportional hazards and instrumental variable analyses. In the primary analysis, we did not detect a significance difference in mortality among patients with four provider visits per month compared with those patients with fewer provider visits (adjusted HR=0.98; 95% CI=0.96-1.01), but the risk for first hospitalization was 4% lower among those patients with more frequent visits (adjusted HR=0.96; 95% CI=0.95-0.97). The time-varying Cox analysis produced similar results. The fully adjusted instrumental variable analysis showed a 0.07% higher risk for death that was not statistically significant (P=0.88) but a significant 2.3% lower risk for first hospitalization (P=0.001) for patients with four provider visits per month. In summary, greater frequency of provider visits to hemodialysis patients associates with a small but significant reduction in hospitalizations, but it does not consistently associate with lower risk for death.