Primary Care Involvement May Reduce Emergency Department Use in Patients With End-Stage Kidney Disease

Patients with end-stage kidney disease (ESKD) receiving dialysis who have a primary care physician (PCP) may experience fewer emergency department (ED) visits, according to a cross-sectional analysis of over 181,000 Medicare beneficiaries published in JAMA Network Open. The findings suggest that integrating primary care into dialysis management could help reduce costly emergency care utilization in this high-risk population.¹

Study Design and Population

Researchers analyzed data from 181,520 patients with ESKD receiving hemodialysis between January 2018 and December 2019. The study used an instrumental variable approach based on differential distance to dialysis facilities with high primary care utilization to address confounding factors. Patients were older on average (mean age: 62.6 years), predominantly male (56.7%), and racially diverse (39.6% Black, 15.0% Hispanic, 53.8% White).¹

Primary care involvement was defined as having at least 1 evaluation and management visit with a PCP in 2018. Approximately 66% of patients had documented primary care involvement during the study period.¹

Top-line Findings

The instrumental variable model revealed substantial differences in ED utilization based on primary care involvement. Patients estimated to have primary care involvement had an approximate 51.2% (95% CI, 49.7%-52.7%) risk of ED visits not resulting in hospitalization compared with 72.1% (95% CI, 69.2%-74.9%) among those without primary care involvement (P < .001). The risk of any ED visit was also lower with primary care involvement (69.4% [95% CI, 68.1%-70.7%] vs 75.0% [95% CI, 72.5%-77.6%]; P = .003).¹

However, no significant difference in hospitalization rates was found between the groups (51.0% [95% CI, 49.6%-52.4%] with primary care vs 48.7% [95% CI, 45.9%-51.4%] without). An analysis of ambulatory care–sensitive ED visits showed patients with primary care had a 19.8% (95% CI, 18.6%-21.0%) risk of such visits compared with 23.7% (95% CI, 21.4%-26.0%) for those without primary care (P = .03).¹

These findings differed notably from a patient-level model that showed higher utilization among patients with PCPs. The authors attributed this discrepancy to residual confounding, as patients with primary care in the unadjusted comparison were older and had greater comorbidity burden. The instrumental variable approach better addressed these confounding factors by leveraging geographic variation in access to dialysis facilities with integrated primary care services, providing a more accurate description of the role of PCPs.¹

Health Care Utilization Context

ED visits represent a substantial driver of costs for patients with ESKD, who use emergency services at 4 times the national rate for Medicare beneficiaries. Medicare spending for this population totaled $34.7 billion in 2021, with ED visits and hospitalizations accounting for a significant proportion. Many ED visits stem from exacerbations of chronic conditions such as diabetes and congestive heart failure, which are highly prevalent in patients receiving dialysis.^1-3

Pharmacist Implications

Pharmacists working with dialysis patients can play essential roles in supporting care coordination between nephrology and PCPs. Understanding which patients have established primary care relationships helps pharmacists identify those who may need additional support accessing urgent care for non–dialysis-related concerns.

Patients without primary care involvement may rely more heavily on EDs for managing acute illnesses and medication-related problems. Pharmacists can help bridge this gap by providing accessible consultation for urgent medication questions, minor illness management where appropriate within the scope of practice, and facilitating connections to primary care providers in the community. Offering extended pharmacy hours or urgent consultation services may reduce unnecessary ED visits for medication concerns.

Care transitions present another opportunity for pharmacist intervention. When patients undergoing dialysis are discharged from the hospital, coordinating medication reconciliation between the nephrology team and PCP helps prevent errors and readmissions. Pharmacists can ensure both providers have updated medication lists and understand any changes made during hospitalization.^1,4

Key Takeaway

The data suggest primary care involvement is associated with reduced ED utilization among dialysis patients. Future payment models that explicitly incentivize primary care integration may help reduce costs while improving access to appropriate care for this vulnerable population.¹

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 Netw Open. 2026;9(3):e260807. doi:10.1001/jamanetworkopen.2026.0807

2. Johansen KL, Gilbertson DT, Li S, et al. US Renal Data System 2024 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis. 2025;85(6S1):A8-A11. doi:10.1053/j.ajkd.2025.02.602

3. Lovasik BP, Zhang R, Hockenberry JM, et al. Emergency department use and hospital admissions among patients with end-stage renal disease in the United States. JAMA Intern Med. 2016;176(10):1563-1565. doi:10.1001/jamainternmed.2016.4975

4. Medicare. National Kidney Foundation. Accessed March 10, 2026. https://www.kidney.org/kidney-topics/medicare