International Journal for Quality in Health Care Advance Access originally published online on February 21, 2005
International Journal for Quality in Health Care 2005 17(2):115-121; doi:10.1093/intqhc/mzi010
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Frequency of patient–physician contact in chronic kidney disease care and achievement of clinical performance targets
1 Department of Medicine, Johns Hopkins University School of Medicine, 2 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, 3 Independent Dialysis Foundation, Baltimore, 4 Renal Research Institute, New York, NY, 5 Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, 6 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Objective. To examine whether the frequency of physician contact is associated with accepted quality of care measures reflecting clinical performance in chronic kidney disease patients.
Design. Prospective cohort study of end-stage renal disease patients begun in 1995, followed for 2.5 years.
Setting. 76 not-for-profit US dialysis clinics.
Study participants. 678 incident hemodialysis patients for whom we had information on average frequency of patient–physician contact at each clinic (low, monthly or less frequent; intermediate, between monthly and weekly; high, more than weekly), determined by clinic survey.
Main outcome measures. Achievement of accepted 6 month clinical performance targets of albumin (
3.5 g/dl), calcium-phosphate (Ca-P) product (<60 mg2/dl2), dialysis dose (Kt/V 1.2), vascular access type (fistula), and hemoglobin (11 g/dl).
Results. By logistic regression, patients treated at clinics reporting less frequent physician contact had lower odds of achieving most targets, statistically significantly for albumin [low, adjusted odds ratio (OR) = 0.83, 95% confidence interval (CI), 0.55–1.25; intermediate, adjusted OR = 0.62, 95% CI, 0.42–0.93; reference, high] and dialysis dose (low, adjusted OR = 0.26, 95% CI, 0.08–0.89; intermediate, adjusted OR = 0.67, 95% CI, 0.20–2.27); however, they had greater odds of achieving the hemoglobin target (low, adjusted OR = 1.94, 95% CI, 1.24–3.04; intermediate, adjusted OR = 1.89, 95% CI, 1.27–2.83). Additionally, the number of targets reached was statistically significantly lower in the monthly or less group (adjusted OR = 0.43, 95% CI, 0.20–0.94).
Conclusions. More frequent patient–physician contact is positively associated with the achievement of clinical performance targets in chronic kidney disease care.
Keywords: chronic kidney disease, clinical performance, patient–physician contact, patient outcomes, quality of care
Address reprint requests to Neil R. Powe, Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 E. Monument Street, Suite 2-600, Baltimore, MD 21205, USA. Tel: +1-410-955-6953; Fax: +1-410-955-0476; E-mail: npowe{at}jhmi.edu
Accepted for publication October 18, 2004.
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Introduction |
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The quality of health care for chronic disease care worldwide has received considerable attention in recent years, in part because patient outcomes are not optimal. For example, in chronic kidney disease, a Healthy People 2010 focus area in the United States [1], the 5 year survival of end-stage renal disease (ESRD) in 1992–1999 (31–34%) was lower than that of some cancers (breast, 89%; colorectal, 64%) [2,3]. It has been suggested that the processes involved in chronic kidney disease care, as measured by clinical factors such as anemia treatment and vascular access placement, could still be improved [4] and that, in fact, the quality would improve if treatment centers were held more accountable for ESRD patient outcomes, including not just mortality but also more proximal clinical outcomes, such as hemoglobin levels [6]. Clinical performance measures for ESRD care, including those established by clinical performance guideline panels [7], have included such proximal clinical outcomes.
The physician’s role in improving the quality of chronic disease care is thought to be crucial [8]. More frequent patient–physician contact in chronic disease management would provide physicians with greater opportunities to improve patient communication and build trust, monitor treatments, and detect new medical problems. Frequent contact is also perceived to be integral to patient-centered care [9,10]. However, physicians may not be better compensated for additional time spent with patients: in the United States, until recently, physicians received a fixed, capitated payment for each dialysis session, but now payment reflects time spent with patients [11].
Hemodialysis treatments to remove toxins and fluid are provided by a team of health professionals (nurses, technicians, physicians), typically three times a week, but the frequency of physician contact during treatment varies across clinics. More frequent contact is thought to result in better outcomes for ESRD patients [12,13]; however, evidence of such an association is sparse. Less frequent contact in a hemodialysis care setting was associated with decreased satisfaction with the frequency of contact but not with worse long-term outcomes (i.e. mortality and hospitalization [14]). We therefore conducted a study to examine whether the amount of patient–physician contact in hemodialysis care is associated with more proximal outcomes of clinical performance.
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Methods |
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Study design
Our study design was a national cohort study, the ESRD Quality (EQUAL) study, of hemodialysis patients cared for at 76 not-for-profit, free-standing outpatient dialysis clinics in the United States. The cohort was assembled from the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) study in which 1041 incident dialysis (767 hemodialysis and 274 peritoneal dialysis) patients were enrolled in the study at 81 dialysis clinics in 19 states between October 1995 and June 1998. To be eligible, patients had to be more than 18 years of age and speak either English or Spanish. Median time from dialysis initiation to enrollment was 45 days, with 98% enrolling within 4 months of initial dialysis. Informed consent was obtained from each patient. Institutional review boards for the Johns Hopkins University School of Medicine and clinical centers approved the study protocol.
Data collection
A questionnaire was administered to medical directors or head nurses at the 81 participating clinics in October 1998 to ascertain each clinic’s customary practice with regard to the frequency of patient–physician contact during hemodialysis treatments. The questionnaire item consisted of the question ‘How often does a physician visit each patient while on hemodialysis?’ and the response categories ‘Every treatment’, ‘Weekly’, ‘Monthly’, ‘Every 2 months’, ‘Every 3 months or longer’, and ‘Other, please specify’. Responses to this questionnaire item were available from 76 of 81 clinics (94%). These responses (including ‘Other’) were collapsed into three categories: high frequency (every treatment or more than once a week), intermediate frequency (weekly or more than once a month), and low frequency (monthly or less often) and linked by clinic to relevant patient-level data. The validity of this measure was supported by its strong correlation with patients’ views of the frequency with which they were being seen by the nephrologist, determined independently by patient questionnaire [14].
Measures of whether patients reached clinical performance ‘targets’ at 6 months after enrollment in the study served as the proximal outcome variables for this study. The clinical performance targets included 6 month values for albumin (3.5 mg/dl), calcium-phosphate (Ca-P) product (<60 mg2/dl2), dialysis dose (Kt/V 1.2), vascular access type (presence of functioning arteriovenous fistula), and hemoglobin (11 g/dl). Targets of these measures were based upon professional society guidelines {Kidney Disease Outcomes Quality Initiative (DOQI), Canadian Society for Nephrology, and European guidelines [15–17]}, Centers for Medicare and Medicaid Services and other studies of clinical performance measures currently in use in the United States [18–21], and clinical judgment. Laboratory values from blood (albumin, calcium, phosphate, and hemoglobin) were obtained from clinic records. Vascular access information was obtained on a subset of individuals through review of discharge summaries, dialysis flow sheets, and dialysis clinic progress notes. Single-pool dialysis dose (Kt/V), a measure of the quality of blood cleansing, was calculated from clinic-supplied values of blood urea nitrogen, pre- and post-dialysis weight, and dialysis duration using the second-generation Daugirdas formula [22].
In addition to the independent and outcome variables, we collected extensive individual-level data on demographic, laboratory, and clinical characteristics. Data regarding patient demographics, socioeconomic status, body mass index, and comorbidity, as measured by the Index of Coexistent Disease (ICED), were collected as described previously [14].
Statistical methods
We first compared individual-level patient characteristics by frequency of patient–physician contact using Pearson’s c2 tests for categorical variables and analysis of variance for continuous variables. In bivariate analyses, for each item, we compared crude percentages of achieving individual targets according to clinic practice of patient–physician contact (Pearson’s 
2 tests). We used logistic regression to examine the association between clinic frequency of patient–physician contact and achievement of individual 6 month clinical performance targets. Because event rates were high and odds ratios can overestimate risk or benefit when the outcome is common, we also calculated relative probabilities [23], to more closely estimate the risk or benefit associated with physician contact. Ordinal logistic regression models were used to analyze the total number of targets achieved: first, by combining all targets with individual associations in the same direction and, second, by combining all targets together, regardless of the direction of their associations. Because these independent variables included more than two categories, relative probabilities could not be calculated. Adjusted odds ratios for achieving the target versus not achieving the target by clinic frequency of patient–physician contact were generated; adjustment was performed using only the value(s) (closest to first dialysis) of the clinical performance measure(s) in question, as these were the only major confounders of the association of physician contact frequency and clinical targets.
Patients at the same clinic cannot reasonably be considered independent observations [24]. We accounted for this consideration (Stata option cluster) by obtaining robust variance–covariance matrix estimates in all logistic regression models. All analyses were performed using Stata v. 7.
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Patients and their characteristics
A total of 678 incident in-center hemodialysis patients treated at 76 clinics were included in our analyses, most of whom were seen at an intermediate frequency (Table 1). Many of the patient characteristics did not differ significantly by frequency of contact; however, a significantly higher proportion of white and unemployed patients received visits at a clinic with a practice of less frequent contact. The most common group (intermediate frequency) had the oldest patients and the lowest creatinine values.
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Proportion of patients achieving clinical performance targets
For each individual clinical performance measure, the majority of patients achieved the 6 month target: 84%, 77%, 83%, and 61% of patients achieved the 6 month albumin, Ca-P product, dialysis dose, and hemoglobin targets, respectively. However, only 27% of patients achieved the vascular access target of having an arteriovenous fistula by 6 months. Proportions were statistically significantly different between frequency of contact groups for dialysis dose and hemoglobin (Table 2). Overall, there were no patients who did not reach at least one of the five targets (Figure 1), and the majority (82%) reached three or more targets. Considering only those measures showing a positive association with increasing frequency of contact (excluding hemoglobin), the majority of patients (95%) reached two or more targets.
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Association of frequency of patient–physician contact with individual clinical performance targets
Lower frequency of patient–physician contact was associated with decreased odds of achieving most of the individual clinical performance targets, relative to the highest frequency of contact (Table 2). This association was statistically significant for albumin and dialysis dose. For hemoglobin, the results were in the opposite direction: those in the less frequent contact groups were more likely to reach the hemoglobin target than those in the most frequent group. Adjustment for the high event rates using relative probabilities (RPs) showed attenuated but still significant results: lower probability of achieving albumin (intermediate versus high frequency, RP = 0.92, 95% CI, 0.84–0.99), and dose (low versus high frequency, RP = 0.77, 95% CI, 0.45–0.99) targets, and higher probability of achieving the hemoglobin target (intermediate, RP = 1.33, 95% CI, 1.13–1.52; and low, RP = 1.34, 95% CI, 1.11–1.55, versus high frequency). Race, creatinine, and employment status were associated with frequency of contact (Table 1), but adjustment for these factors did not substantially change the results in either magnitude or statistical significance.
Association of frequency of patient–physician contact with number of targets reached
Total number of targets reached was also assessed as an outcome in those persons with information on every target (Figure 1). A statistically significant decrease in proportional odds for the number of targets reached was seen for the least frequent (monthly or less) group versus the every treatment group when the four clinical performance targets showing a positive association with frequency of physician contact were considered (OR = 0.43, 95% CI, 0.20–0.94). This association was not statistically significant when hemoglobin was considered together with the other four targets.
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Discussion |
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Delivery and payment models for chronic kidney disease vary worldwide [25]. Recently there has been interest in creating payment systems to improve the quality of care [26]. For example, for two decades, CMS, the agency that makes policy for public insurance programs in the United States, paid physicians delivering dialysis care a composite or capitated fee for care provided at each dialysis treatment. This fee involved supervision of other personnel as well as physicians’ direct face-to-face time with patients. In the mid-1990s, CMS as well as the dialysis community began to focus on quality of care under this capitated payment system, with development of clinical performance measures [15,18] aimed at intermediate outcomes of care. CMS, without direct evidence that more physician time improves outcomes, changed payment policy in January 2004 [11], which incentivized physicians to provide more face-to-face time with patients.
This study, in one of the largest cohorts of dialysis patients, provides evidence that more patient–physician contact may improve certain aspects of care. It suggests that patients with chronic kidney disease who were treated at hemodialysis clinics with a practice of more patient–physician contact were more likely to reach most of the 6 month clinical performance targets developed by the major public payer in the United States and the dialysis community. More frequent physician contact may encourage patients to adhere to treatment regimens and may help physicians identify areas in need of improvement, which may in turn lead to increased chance of achieving 6 month clinical performance targets.
Less frequent contact was associated with statistically significantly lower odds of achieving the 6 month albumin target. Albumin concentrations in the blood or serum are an important measure of overall health and nutrition status, and lower levels of albumin are highly predictive of poor ESRD patient outcomes [19]. Although many factors affect serum albumin levels [27], this study provides evidence that physician contact may influence albumin levels, through dialysis prescriptions and overall management of comorbid conditions and also through encouragement of patient adherence to diet recommendations.
Lower frequency of physician contact was associated with lower odds of achieving the Ca-P product target, although the association was not statistically significant. The Ca-P product can be viewed as a measure of the quality of management of mineral metabolism and bone disease; however, it is also a measure of patient adherence to diet and medications. More frequent physician contact may result in more discussion about how the patient may help prevent complications (e.g. hyperphosphatemia and hypocalcemia) through such interventions as phosphate-lowering medications [28].
We found that dialysis dose targets were significantly less likely to be achieved in the less frequent contact groups. Delivered dialysis dose of at least Kt/V of 1.2 is considered optimal for patient outcomes [15]. More frequent contact with the physician may lead to better oversight of the delivery of optimal dialysis dose by several possible interventions, such as increasing dialysis time, choosing a more effective dialysis filter, or performing surgical procedures to improve blood flow during dialysis (i.e. vascular access surgery).
Vascular access type was not statistically significantly associated with frequency of physician contact, although there was a trend toward a decrease in chance of achieving the target in the least frequent group. Arteriovenous fistulas, using a patient’s native artery and vein, are the preferred vascular accesses for hemodialysis patients because of their less frequent need for expensive revisions [15]. Although the DOQI guidelines recommend an arteriovenous fistula as the preferred access type, this recommendation is conditional upon the possibility of placement, which may be affected by patient factors, such as vessel size and comorbidity, or surgical expertise.
Finally, severe kidney disease is usually associated with anemia, and hemoglobin levels in the blood can be considered a measure of the quality of anemia management. In our study, we found that the odds of achieving the hemoglobin target actually increased with less frequent physician contact. This result may not be surprising, considering the fact that a majority of dialysis units have been implementing anemia medication management protocols for many years [29]. Although the physician certainly plays a role, anemia management is most often monitored by a nurse [30]. It is possible that less frequent physician contact is associated with more frequent nurse contact.
The associations we found in this analysis suggest that frequency of physician contact does have an important effect on clinical performance measures, even if no associations between the clinical endpoints mortality and hospitalizations and frequency of physician contact were shown previously in this cohort [14]. Of course, the nature of the contact (e.g. data gathering, relationship and partnership building, and counseling) during encounters is likely as important as the frequency of contact [31], and the amount of non-face-to-face time physicians spend on behalf of individual patients is likely to be important to overall outcomes as well. Also, although we found no evidence of a ‘dose response’ in the association of clinical performance with patient–physician contact (i.e. a clear trend in decreasing chance of achieving targets with each decrease in frequency of contact), it may be that we simply did not have the sample size in each frequency group to detect such a trend.
Possible limitations of this study deserve mention. Firstly, although we have data on the frequency of patient–physician contact, we do not know the nature of that contact. Actions that physicians take during their contact with the patient, such as monitoring of vascular access, are more relevant. Secondly, our measure of frequency patient–physician contact reflects practice patterns at the clinic level but not the experience of individual study participants: variations in patient–physician contact may exist within clinics as well as between clinics, resulting in misclassification of individual patients. The frequency of physician contact at our facilities may be more or less intensive than the average national frequency. Also, the majority of patients in this cohort were treated at clinics from the same not-for-profit chain, which may limit or enhance heterogeneity in treatment patterns. Thirdly, although the performance measures we used are those suggested by national quality improvement efforts, including CMS measures, some of the measures (e.g. serum albumin) have been questioned for this purpose [27]. Fourthly, we must consider possible selection bias or residual confounding due to unmeasured patient factors. Finally, although we know that other health care workers, especially nurses, physician assistants, and nurse practitioners, may extend the physician’s capacity, we do not know how often patients were seen by these physician extenders.
In conclusion, this study provides an examination of the relation between patient–physician contact in chronic kidney disease care and quality of care. We found that less frequent contact is associated with a decreased chance of achieving clinical performance targets at 6 months. Future work examining the role of physicians as well as members of the entire health care team is needed to guide appropriate deployment of resources to optimal care of not just chronic kidney disease but all chronic disease.
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We thank the patients, staff, and medical directors of the participating clinics at Dialysis Clinics Inc. and St. Raphael’s Hospital who contributed to the study. This work was supported by grant RO1 DK 59616 from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); grant R01HS08365 from the Agency for Health Care Research and Quality; grant R01 HL 62985 from the National Heart Lung and Blood Institute, Bethesda, MD; grants K24DK02643 (N.R.P.) and K24 DK02856 (M.J.K.) from the NIDDK; and a Clinician Scientist Award from the Johns Hopkins School of Medicine (B.G.J.). This work was presented in part at the American Society of Nephrology Annual Meeting in St Louis, Missouri, in October 2004.
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