Thorsteinsdottir Bjorg, Ramar Priya, Hickson LaTonya J, Reinalda Megan S, Albright Robert C, Tilburt Jon C, Williams Amy W, Takahashi Paul Y, Jeffery Molly M, Shah Nilay D
Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 55905, USA.
BMC Nephrol. 2017 Oct 25;18(1):322. doi: 10.1186/s12882-017-0728-x.
Efficient and safe delivery of care to dialysis patients is essential. Concerns have been raised regarding the ability of accountable care organizations to adequately serve this high-risk population. Little is known about primary care involvement in the care of dialysis patients. This study sought to describe the extent of primary care provider (PCP) involvement in the care of hemodialysis patients and the outcomes associated with that involvement.
In a retrospective cohort study, patients accessing a Midwestern dialysis network from 2001 to 2010 linked to United States Renal Database System and with >90 days follow up were identified (n = 2985). Outpatient visits were identified using Current Procedural Terminology (CPT)-4 codes, provider specialty, and grouped into quartiles-based on proportion of PCP visits per person-year (ppy). Top and bottom quartiles represented patients with high primary care (HPC) or low primary care (LPC), respectively. Patient characteristics and health care utilization were measured and compared across patient groups.
Dialysis patients had an overall average of 4.5 PCP visits ppy, ranging from 0.6 in the LPC group to 6.9 in the HPC group. HPC patients were more likely female (43.4% vs. 35.3%), older (64.0 yrs. vs. 60.0 yrs), and with more comorbidities (Charlson 7.0 vs 6.0). HPC patients had higher utilization (hospitalizations 2.2 vs. 1.8 ppy; emergency department visits 1.6 vs 1.2 ppy) and worse survival (3.9 vs 4.3 yrs) and transplant rates (16.3 vs. 31.5).
PCPs are significantly involved in the care of hemodialysis patients. Patients with HPC are older, sicker, and utilize more resources than those managed primarily by nephrologists. After adjusting for confounders, there is no difference in outcomes between the groups. Further studies are needed to better understand whether there is causal impact of primary care involvement on patient survival.
为透析患者提供高效且安全的护理至关重要。人们对责任医疗组织为这一高风险人群提供充分服务的能力提出了担忧。对于初级保健在透析患者护理中的参与情况知之甚少。本研究旨在描述初级保健提供者（PCP）参与血液透析患者护理的程度以及与该参与相关的结果。
在一项回顾性队列研究中，确定了2001年至2010年期间接入美国中西部透析网络、与美国肾脏数据库系统相关联且随访时间超过90天的患者（n = 2985）。使用当前程序术语（CPT）-4编码、提供者专业来识别门诊就诊情况，并根据每人每年（ppy）的初级保健提供者就诊比例将其分为四分位数。最高和最低四分位数分别代表初级保健水平高（HPC）或初级保健水平低（LPC）的患者。对患者特征和医疗保健利用情况进行测量并在患者组之间进行比较。
透析患者每人每年平均有4.5次初级保健提供者就诊，范围从初级保健水平低组的0.6次到初级保健水平高组的6.9次。初级保健水平高的患者更可能为女性（43.4%对35.3%）、年龄更大（64.0岁对60.0岁）且合并症更多（查尔森评分为7.0对6.0）。初级保健水平高的患者利用率更高（住院率为每人每年2.2次对1.8次；急诊科就诊率为每人每年1.6次对1.2次），生存率更差（3.9年对4.3年）且移植率更低（16.3%对31.5%）。
初级保健提供者在血液透析患者的护理中发挥着重要作用。与主要由肾病学家管理的患者相比，初级保健水平高的患者年龄更大、病情更重且使用的资源更多。在对混杂因素进行调整后，两组之间的结果没有差异。需要进一步研究以更好地了解初级保健参与对患者生存是否存在因果影响。
