When patients were seen more frequently by a nephrologist or advanced practitioner in the first 90 days of hemodialysis (HD), they were more likely to have early surgery for the creation of an arteriovenous (AV) fistula or placement of an AV graft, a new study finds.

These results coincide with previous research showing an association between pre-dialysis visits and AV fistula and graft placement.

Medicare reimbursement policy encourages frequent visits with end-stage renal disease patients. “Current reimbursement encourages visits to all patients, irrespective of their health needs,” wrote the researchers led by Kevin Erickson, MD, of the Stanford University School of Medicine in Stanford, Calif. “Policies that encourage more frequent visits to patients who actually benefit from additional visits, such as patients who recently started dialysis or who were recently discharged from the hospital, could lead to improvements in health outcomes.”

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Why would early dialysis visits matter? More face-to-face encounters could help providers stabilize sick patients so they are better candidates for surgery. Patients also may be more willing to undergo surgery when it’s recommended by a provider they learn to trust.

For the study, published online ahead of print in The Journal of the American Society of Nephrology, the researchers analyzed national registry records for 35,959 patients aged 67 or older who were starting HD.

One additional nephrologist or advanced practitioner visit per month in the first 90 days of HD was associated with a 21% increase in the odds of AV fistula creation or graft placement during that period. It increased the absolute probability of the vascular access surgery by an average 4.5%.

“We estimate that one additional…visit per month in the first 90 days of hemodialysis could reduce the absolute probability of death in the first year of hemodialysis by 0.3%-0.8%, to the extent that the association we observe between visit frequency and vascular access surgery represents a causal connection,” the investigators stated.

The AV fistula or graft offers advantages over the central venous catheter. Dialysis via these permanent access methods has been associated with prolonged survival and fewer hospitalizations, according to previous research.


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