Geographic disparities in arteriovenous fistula placement in patients approaching hemodialysis in the United States

Abstract

Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis (HD). Several factors associated with AVF placement have been identified (e.g., age, sex, race, comorbidities). We hypothesized that geographic location of patient residence might be associated with the probability of AVF placement as the initial access. We used the data from the United States Renal Data System (USRDS) database (2005-2008) linked to Medicare claims (2003-2008). Logistic regression was used to estimate specific characteristics of population associated with the AVF as first access placed or attempted for HD initiation. Our primary variable of interest was the geographic location, and the multivariate model was adjusted for age, sex, race, body mass index, primary cause of end-stage renal disease (ESRD), duration of pre-ESRD nephrology care, comorbidities, employment status, substance abuse, and income. Geographic location was determined using the data collected by the RUCA project and divided population into metropolitan, micropolitan, and rural categories. Patients (n = 111,953) identified from the USRDS database with linked Medicare claims were examined. Rates of fistula placement in the metropolitan, micropolitan, and rural population were 18.5%, 22.4%, and 21.6%, respectively. In comparison, patients who received catheter as the first access were 81.5%, 77.6% and 78.4%, respectively. The odds ratio of AVF placement as a first HD access in the rural and metropolitan population compared with the micropolitan population were 0.96 (0.90-1.03; P = 0.26) and 0.80 (0.76-0.84; P < 0.001), respectively. Our results indicate the presence of geographic disparities in AVF placement with decreased rates of AVF as the first access created in the metropolitan (but not rural) populations compared with the micropolitan communities.

Quality Improvement Targets for Regional Variation in Surgical End-Stage Renal Disease Care

“…An exhaustive root-cause analysis by Donca and Wish 37 enumerates the ways in which stakeholders along the ESRD care pathway contribute to differences at each level, many of which are not apparent from the available data. Combined with our study and others [10][11][12][13]23,24 quantifying these effects, there is a clear body of evidence for the need to redress regional inequities in ESRD patient care.…”

“…9 There is significant regional variation in ESRD prevalence by location within the United States, as depicted in a heat map published in the 2014 USRDS Atlas. 1 Therapy also differs; research examining national data gathered in the 1980s, 10 1990s, 11 and early 2000s 12,13 consistently recognized population density (ie, urban, suburban, or rural) as a driving force behind geographic disparities in AVF construction, among other inequities in ESRD care. Axelrod and coauthors 14 examined the kidney transplant population and defined residence within a referral region delineated by zip code as a unit of analysis.…”

Endogenous Serratia marcescens panophthalmitis: A case series

“…Nosocomial infections are not uncommon for endogenous endophthalmitis with Serratia marcescens , 11 and have been known to involve extremity dialysis ports 12 like Case 2. Additional reports of endogenous Serratia marcescens endophthalmitis and panophthalmitis may be expected now that arteriovenous fistula placement is recommended as first-line management for dialysis initiation and has approximately doubled in the past decade in the United States 13 . However, to our knowledge, our first case may be the only description to date of exclusively non-nosocomial Serratia marcescens causing rapidly progressing hypertensive, endogenous panophthalmitis with orbital cellulitis.…”

American Society of Nephrology Quiz and Questionnaire 2015: ESRD/RRT

“…No. Depending on geography and local institutional practices, it may take longer than 1-2 weeks for surgical referral and creation (28,29). Even if it could be created within 72 hours, it would still require approximately 4 weeks minimum to mature enough to support dialysis with the high blood flow rates prescribed in North America.…”