PCP's Role in Reducing ER Use Among ESKD Patients on Dialysis

Having a primary care physician (PCP) along with a nephrologist for patients with end-stage kidney disease (ESKD) receiving dialysis may help reduce emergency department (ED) utilization, a major driver of healthcare costs in this patient population.1

"We kind of hypothesize that having a primary care physician, separate from the nephrologist, might help reduce health care utilization,” said Vahakn Shahinian, MD, MS, Co-Chief of Dow Division of Health Services Research, Professor of Internal Medicine and Urology at the Medical School at the University of Michigan, in an interview with HCPLive. “They might be more available after hours on an urgent basis to see patients and head off issues, and overall just kind of help the management of a lot of the underlying chronic conditions that accompany most patients on dialysis."

The > half a million patients receiving dialysis for ESKD in the US represent 4 times the national mean rate for all Medicare beneficiaries. Furthermore, approximately 98% of patients with ESKD have ≥1 comorbidity, with 83 to 90% living with hypertension and up to 69% living with diabetes. While a majority of these patients see a nephrologist to manage their dialysis, study investigators wondered whether having a PCP would impact ED visits.2

To address this gap in the benefit of PCPs in this patient population, Shaninian and colleagues conducted a national, retrospective, cross-sectional study of 181,520 patients receiving maintenance hemodialysis to assess the association between primary care involvement and ED utilization and hospitalization in this population.

Upon analysis, In the instrumental variable model comparing patients estimated to have a 100% probability of having a PCP with those estimated to have a 0% probability of having a PCP, there was not a significant difference in the estimated risk of any hospitalization (51.0%; 95% Confidence Interval [CI], 49.6%-52.4% vs 48.7%; 95% CI, 45.9%-51.4%), but there was a difference in estimated risk of any ED visit (69.4%; 95% CI, 68.1%-70.7% vs 75.0%; 95% CI, 72.5%-77.6%; P = .003), particularly in estimated risk of any ED visit not resulting in hospitalization (51.2%; 95% CI, 49.7%-52.7% vs 72.1%; 95% CI, 69.2%-74.9%; P < .001).

"What we saw was that having a primary care physician really didn't make a difference with respect to being hospitalized. Where it made its biggest difference was ER visits that didn't result in hospitalization... to me, the story that our paper seems to suggest is that's where primary care can potentially help, in perhaps heading off issues early on before they become very serious or just less serious issues."

Editor’s Note: Shahinian reports no relevant disclosures.

References

1. Bailoor K, Hirth RA, Guro P, Oerline MK, Hollingsworth JM, Shahinian VB. Primary Care Involvement and Health Care Utilization Among Patients With End-Stage Kidney Disease. JAMA Network Open. 2026;9(3):e260807. doi:https://doi.org/10.1001/jamanetworkopen.2026.080

2. MacRae C, Mercer SW, Guthrie B, Henderson D. Comorbidity in chronic kidney disease: a large cross-sectional study of prevalence in Scottish primary care. British Journal of General Practice. 2020;71(704):e243-e249. doi:https://doi.org/10.3399/bjgp20x714125