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

Zarkowsky, Devin S.; Hicks, Caitlin W.; Arhuidese, Isibor; Canner, Joseph K.; Obeid, Tammam; Qazi, Umair; Schneider, Eric B.; Abularrage, Christopher J.; Black, James H.; Freischlag, Julie A.; Malas, Mahmoud B.

doi:10.1001/jamasurg.2015.1126

Cited by 16 publications

(14 citation statements)

References 33 publications

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“…examined the presence of incident functional arteriovenous fistula in a cohort of 464,547 patients beginning hemodialysis, and found marked regional variation in incident functional arteriovenous fistula, and risk-adjusted ESRD mortality among ESRD networks where the networks representing Texas and other areas in the American South had the lowest percentage in incident arteriovenous fistula and highest mortality risk. 37 Furthermore, analyses by Yan et al. showed that Middle Atlantic and Southern states exhibited lower than average probability of receipt of pre-ESRD nephrology care; 18 , 19 interestingly, these areas correspond to some of the clusters identified in our report.…”

Section: Discussionsupporting

confidence: 71%

Geographic Variation and US County Characteristics Associated With Rapid Kidney Function Decline

Bowe

Xie

Xian

et al. 2017

Kidney International Reports

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IntroductionGeographic variation in the prevalence of chronic kidney disease and incidence of end-stage renal disease has been previously reported. However, the geographic epidemiology of rapid estimated glomerular filtration rate (eGFR) decline has not been examined.MethodsWe built a longitudinal cohort of 2,107,570 US veterans to characterize the spatial epidemiology of and examine the associations between US county characteristics and rapid eGFR decline.ResultsThere were 169,029 (8.02%) with rapid eGFR decline (defined as eGFR slope < –5 ml/min per 1.73 m2/year). The prevalence of rapid eGFR decline adjusted for age, race, gender, diabetes, and hypertension varied by county from 4.10%–6.72% in the lowest prevalence quintile to 8.41%–22.04% in the highest prevalence quintile (P for heterogeneity < 0.001). Examination of adjusted prevalence showed substantial geographic variation in those with and without diabetes and those with and without hypertension (P for heterogeneity < 0.001). Cohort participants had higher odds of rapid eGFR decline when living in counties with unfavorable characteristics in domains including health outcomes (odds ratio [OR] = 1.15; confidence interval [CI] = 1.09–1.22), health behaviors (OR = 1.08; CI = 1.03–1.13), clinical care (OR = 1.11; CI = 1.06–1.16), socioeconomic conditions (OR = 1.15; CI = 1.09–1.22), and physical environment (OR = 1.15; CI = 1.01–1.20); living in counties with high percentage of minorities and immigrants was associated with rapid eGFR decline (OR = 1.25; CI = 1.20–1.31). Spatial analyses suggest the presence of cluster of counties with high prevalence of rapid eGFR decline.DiscussionOur findings show substantial geographic variation in rapid eGFR decline among US veterans; the variation persists in analyses stratified by diabetes and hypertension status; results show associations between US county characteristics in domains capturing health, socioeconomic, environmental, and diversity conditions, and rapid eGFR decline.

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Section: Discussionsupporting

confidence: 71%

Geographic Variation and US County Characteristics Associated With Rapid Kidney Function Decline

Bowe

Xie

Xian

et al. 2017

Kidney International Reports

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“…Multiple prior studies have identified longer duration of pre-dialysis nephrology care as the strongest predictor of decreasing incident CVC use. [ 2 , 10 , 19 – 23 ] This graded association was significant in our cohort as well, supporting an assertion that earlier nephrology referrals are key to increasing rates of incident AVF usage, regardless of the population. In addition, we observed a strong association between uninsured status and higher incident CVC use in our cohort.…”

Section: Discussionsupporting

confidence: 84%

“…National data reveal substantial variation in incident AVF rates from 11.1% to 22.2% among regional ESRD networks, and significant disparities in incident AVF use by race, gender, and insurance status [ 9 , 10 ]. Because blacks, Hispanics, women, and the uninsured are significantly less likely to have a functioning AVF at the time of HD initiation, these vulnerable populations disproportionately bear the burden of complications due to CVC use.…”

Section: Introductionmentioning

confidence: 99%

A mixed-methods investigation of incident Hemodialysis access in a safety-net population

et al. 2017

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BackgroundDespite improved health outcomes associated with arteriovenous fistulas, 80% of Americans initiate hemodialysis using a catheter, influenced by low socioeconomic status among other factors. Risk factors for incident catheter use in safety-net populations are unknown. Our objective was to identify factors associated with incident catheter use among hemodialysis patients at one safety-net hospital, with a goal of informing fistula placement initiatives targeted at safety-net populations more generally.MethodsWe performed a retrospective review of all incident hemodialysis patients at a single urban safety-net hospital from January 1, 2010 - December 31, 2015 (n = 241), as well as semi-structured interviews with a multi-lingual convenience sample of patients (n = 10) from this cohort. The primary outcome was incident vascular access modality. Multivariable logistic regression was used to identify factors associated with incident catheter use. Interview transcripts were coded using a directed content analysis framework based on a model describing barriers to healthcare access.ResultsSubjects were 61.8% male, racially/ethnically diverse (19.5% white, 29.5% black, 28.6% Hispanic, 17.4% Asian), with a mean age of 52.4 years. Eighty-eight percent initiated hemodialysis using a catheter. In multivariable analysis, longer duration of nephrology care was associated with decreased catheter use (>12 months vs. 0–6 months: adjusted Odds Ratio [aOR] 0.07, 95% CI 0.02–0.23, p < 0.001), whereas uninsured status increased odds of catheter use (aOR 3.96, 1.23–12.76, p = 0.02). There was a decrease in catheter use after vascular surgery services became available in-hospital (OR 0.40, 95% CI 0.16–0.98, p = 0.04), however this association was not significant in multivariable analysis (aOR 0.48, 0.17–1.36, p = 0.17). During interviews, patients cited emotional responses to disease, lack of social and financial resources, and limited health knowledge as barriers to obtaining fistula surgery.ConclusionsThe rate of catheter use in this urban safety-net population is above the national average. Access to health insurance, early referrals to nephrology, and provision of in-hospital vascular surgery should be prioritized in the safety-net. Additionally, services that support patients’ emotional and learning needs may decrease delays in fistula placement.

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“…Slinin et al found that survival at one year after HD initiation was associated with the number of evidence-based KDOQI guidelines met, and also found that 81% of incident HD patients began HD with an HC, despite more than 57% being in the care of a nephrologist prior to initiation of HD [17]. Indeed, Zarkowsky et al found that there is marked regional variation in AVF placement [18] and that a third of ESRD patients initiating HD with an HC had been in the care of a nephrologist for over six months [19]. This has led to the creation of simulation models to help nephrologists predict when to refer for AVF placement [20], however we found that initiating HD with an HC remained common.…”

Section: Discussionmentioning

confidence: 99%

Transplant waitlisting attenuates the association between hemodialysis access type and mortality

et al. 2019

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Prior studies have shown that beginning hemodialysis (HD) with a hemodialysis catheter (HC) is associated with worse mortality than with an arteriovenous fistula (AVF) or arteriovenous graft (AVG). We hypothesized that transplant waitlisting would modify the effect of HD access on mortality, given waitlist candidates’ more robust health status. Using the US Renal Data System, we studied patients with incident ESRD who initiated HD between 2010–2015 with an AVF, AVG, or HC. We used Cox regression including an interaction term for HD access and waitlist status. There were 587,607 patients that initiated HD, of whom 82,379 (14.0%) were waitlisted for transplantation. Only 26,264 (4.5%) were transplanted. Among patients not listed, those with an AVF had a 34% lower mortality compared to HC (adjusted hazard ratio [aHR] 0.66, 95% confidence interval [CI] 0.65–0.67) while those with an AVG had a 21% lower mortality compared to HC (aHR 0.79, 95% CI 0.77–0.81). Transplant waitlisting attenuated the association between hemodialysis access type and mortality (interaction p<0.001 for both AVF and AVG vs HC). Among patients on the waitlist, those with an AVF had a 12% lower mortality compared to HC (aHR 0.88, 95% CI 0.84–0.93), while those with an AVG had no difference in mortality (aHR 0.95, 95% CI 0.84–1.08). While all patients benefit from AVF or AVG over HC, the benefit was attenuated in waitlisted patients. Efforts to improve health status and access to healthcare for non-waitlisted ESRD patients might decrease HD-associated mortality and improve rates of AVF and AVG placement.

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

Cited by 16 publications

References 33 publications

Geographic Variation and US County Characteristics Associated With Rapid Kidney Function Decline

Geographic Variation and US County Characteristics Associated With Rapid Kidney Function Decline

A mixed-methods investigation of incident Hemodialysis access in a safety-net population

Transplant waitlisting attenuates the association between hemodialysis access type and mortality

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