Facility Hemodialysis Vascular Access Use and Mortality in Countries Participating in DOPPS: An Instrumental Variable Analysis

Association of Vascular Access Type with Mortality, Hospitalization, and Transfer to In-Center Hemodialysis in Patients Undergoing Home Hemodialysis

“…Numerous studies over the past two decades have shown associations between CVC use and higher risk for adverse clinical outcomes in patients undergoing in-center HD (10)(11)(12)(13)(14)(20)(21)(22). However, there are important ways in which home HD differs from in-center HD that may substantially alter the risks associated with CVC use.…”

“…In patients undergoing in-center HD, use of CVCs is associated with greater risk of adverse clinical outcomes, including higher rates of mortality and hospitalization, at least in part because of greater incidence of infection-related complications (10)(11)(12)(13)(14). In contrast, there are only limited data examining the association of vascular access type with clinical outcomes for patients undergoing home HD, individuals in whom incidence of nosocomial infection may be lower (15).…”

International Hemodialysis Patient Outcomes Comparisons Revisited

“…Thus, the question arises whether differences in patient survival between regions is in part explained by differences in VA practice. Pisoni et al (10) recently addressed this question in analyses of DOPPS I and II data. US HD patients had 36 to 40% higher adjusted mortality risk than HD patients in five European DOPPS countries; however, when Figure 2.…”

“…Because patients who undergo dialysis by a catheter tend to be sicker than those who undergo dialysis by a fistula, higher mortality among catheter users may be largely because these patients are sicker than those with an arteriovenous fistula (AVF) or graft. Because we observed in the DOPPS that the type of VA use varies widely from one dialysis facility to another, even in the same country ( Figure 6) and when adjusting for differences in case mix between facilities, we were able to study the differences in mortality risk by greater versus lower facility catheter use (specifically, the percentage of patients who used a catheter in each facility) while adjusting for detailed patient characteristics, country, and year (10). This statistical approach of applying the practice (e.g., facility catheter use) to patient survival models is similar to "instrumental variable analysis," a technique widely Case-mix adjusted hazard ratio (HR) of mortality for HD patients in the United States versus five European DOPPS I and II countries (n ϭ 24,398), with and without adjustment for differences in facility VA use (case-mix adjusted percentage of facility patients using a catheter and the percentage using a graft referenced to the percentage using a native AVF).…”

Geographic Concentration of Poverty and Arteriovenous Fistula Use among ESRD Patients

“…For example, use of an arteriovenous fistula (AVF) for hemodialysis vascular access, which is associated with decreased morbidity and mortality, varies by a patient's race and gender, and low use clusters geographically. 4,5 The reasons why AVF use differs among patient groups and geographic regions are unclear, and it has been suggested that poverty may contribute to these variations. 6 This study examines the degree to which incident and prevalent AVF use are associated with the poverty in the county where a treatment center is located.…”