Patients with end-stage kidney disease have fewer emergency department visits if they have a primary care physician (PCP), according to a new study published in JAMA Network Open.

More than 800,000 Americans have end-stage kidney disease, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Nearly 90% of these people have at least one comorbidity, the most common being diabetes, hypertension, coronary artery disease, or heart failure.

For these patients, “it’s so crucial to have a team of people addressing all the different aspects of the patient’s health, whether it’s better management of some of the comorbidities like diabetes or heart failure, or administering preventative things like vaccines,” said Kunal Bailoor, MD, nephrologist at the University of Michigan Health in Ann Arbor, Michigan, who led the latest study.

Bailoor and his colleagues analyzed data from the US Renal Data System database, which included 181,520 Medicare Fee-for-Service beneficiaries who received dialysis between January 2018 and December 2019.

To determine whether having a PCP could reduce visits to the emergency department, they used proximity to dialysis centers as a proxy for whether a patient had a PCP. Some dialysis centers strongly encourage or require patients to establish a relationship with primary care.

Patients who lived within 8.6 miles of one of these dialysis facilities were classified as having a PCP. People who lived farther away or closer to a center that did not require patients to establish that relationship were classified as not having a PCP.

The aim of using this proxy method was to avoid confounding associated with end-stage kidney disease patients who have more primary care visits. These patients are usually sicker and older and have more comorbidities than patients who do not have an established PCP.

Using the matched groups, Bailoor and his team counted every visit to the emergency department, including for complications of conditions such as chronic obstructive pulmonary disease or congestive heart failure, which could have been prevented in primary care.

Patients in the primary care group were about 6% less likely to visit the emergency department for any reason (69.4% vs 75.0%; P = .003) than those in the other group. They also were about 22% less likely to be admitted to the hospital as the result of an emergency visit (51.2% vs 72.1%; P < .001). No differences were observed between groups for hospitalizations.

“The fact that there is a difference in emergency department visits, but not hospital, tells me things like symptom management or infection may have been managed by a primary care doctor,” said Lilia Cervantes, MD, internist and professor of hospital medicine at the University of Colorado Anschutz in Aurora, Colorado, who was not involved with the study.

Patients with end-stage kidney disease often receive fragmented care across specialists, said Cervantes, who studies disparities among this patient population.

“When a nephrologist can connect seamlessly with a primary care physician, it makes caring for that patient so much easier,” she said. “A nephrologist may not be able to provide comprehensive care.”

In his nephrology practice, Bailoor said PCPs are extremely valuable.

“I have a couple patients who live far from me, but their PCPs are really good about getting their blood work in, so they don’t have to come see me all the time; I can do virtual visits with them,” he said.

Although often stretched thin, PCPs can sometimes accommodate urgent issues that nephrologists cannot, helping patients manage medications before their next dialysis appointment.

“Many of these patients have kidney failure have depression, diabetes, all these comorbidities, and then they have to navigate the dialysis schedule, their medications, their comorbidities, their preventative care,” she said. “It is not surprising that people who have a PCP avoid the emergency department.”

Kaitlin Sullivan is a journalist living in Colorado.