Supply and Distribution of Vascular Access Physicians in the United States: A Cross-Sectional Study

Lee, Shoou Yih D.; Xiang, Jie; Kshirsagar, Abhijit V.; Steffick, Diane; Saran, Rajiv; Wang, Virginia

doi:10.34067/kid.0002722020

Cited by 13 publications

(8 citation statements)

References 26 publications

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“…A recent publication highlighted geographic differences in the supply of surgeons performing vascular access procedures. 7 This study found lower surgeon supply in areas with greater proportions of Black residents, higher poverty rates, and lower availability of nephrologists, in agreement with the findings in the current study. In geographic areas with a lower surgeon supply, there could potentially be longer delays in achieving a mature AVF.…”

Section: Discussionsupporting

confidence: 91%

“…A recent study reported substantial geographic variation in the supply of vascular access surgeons by Hospital Referral Region (HRR), calculated as the number of surgeons performing access procedures per 1000 prevalent patients with ESKD. 7 Specifically, the supply of surgeons was lower in HRRs with a higher unemployment rate and a lower supply of primary care physicians and nephrologists. This observation suggests that vascular access surgeons are less likely to practice in socioeconomically disadvantaged areas.…”

mentioning

confidence: 99%

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Racial Disparities in Arteriovenous Fistula Use Among Hemodialysis Patients: The Role of Surgeon Supply

Zhang

Thamer

Lee

et al. 2022

Kidney International Reports

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Section: Discussionsupporting

confidence: 91%

mentioning

confidence: 99%

Racial Disparities in Arteriovenous Fistula Use Among Hemodialysis Patients: The Role of Surgeon Supply

Zhang

Thamer

Lee

et al. 2022

Kidney International Reports

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“…Considering the indirect association between patient education and vascular access creation, one could argue that our results merely reflect a better quality or model of pre-ESKD nephrology care. At the same time, more than half of KDE cohort initiated their hemodialysis with a CVC, highlighting the importance of multiple additional practice-related factors, including the availability of and coordination with the proficient vascular access creation team (20). Overall, at the minimum, our analyses serve to identify a unique marker for what some have described as the “optimal initiation of dialysis,” with more than doubling the rates of both incident home dialysis and incident vascular access use.…”

Section: Discussionmentioning

confidence: 99%

Provision of Kidney Disease Education Service Is Associated with Improved Vascular Access Outcomes among US Incident Hemodialysis Patients

et al. 2022

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Background: Pre-end stage renal disease (ESRD) Kidney Disease Education (KDE) has been shown to improve multiple chronic kidney disease (CKD) outcomes but, its impact on vascular access outcomes is not well-studied. In 2010, Medicare launched KDE reimbursements policy for patients with advanced CKD. Methods: In this retrospective USRDS analysis, we identified all adult incident hemodialysis patients with a minimum of 6-months of pre-ESRD Medicare coverage during the first five-years of CMS-KDE policy and divided them into CMS-KDE services recipients (KDE-cohort) and non-recipients (non-KDE cohort). The primary outcome was incident arteriovenous fistula (AVF) and the composite of incident AVF or arteriovenous graft (AVG) utilization. Secondary outcomes were central venous catheter (CVC) with maturing AVF/AVG and pure CVC utilizations. Step-wise multivariate analyses were performed in four progressive models (model 1: KDE alone, model 2: multivariate model encompassing model 1 with socio-demographics, model 3: model 2 with comorbidity and functional status, and model 4: model 3 with pre-ESRD nephrology care). Results: Of the 211,990 qualifying incident hemodialysis patients during the study period, 2,887(1.4%) received KDE services before dialysis initiation. The rates of incident AVF and composite AVF/AVG were more than double (29.7% and 34.9% respectively, compared to 14.2% and 17.2%) and pure catheter use about a third lower (40.4% compared to 64.5%) in the KDE cohort compared to the non-KDE cohort. Maximally adjusted odds ratio(99% confidence interval) in model 4 for study outcomes were: incident AVF use: 1.78 (1.55-2.05), incident AVF/AVG use: 1.78 (1.56-2.03), incident CVC with maturing AVF/AVG: 1.69 (1.44-1.97)and pure CVC without any AVF/AVG: 0.51 (0.45-0.58). The benefits of KDE service were maintained even after accounting for the presence, duration and facility of ESRD care. Conclusion: Occurrence of pre-ESRD KDE service is associated with significantly improved incident vascular access outcomes. Targeted studies are needed to examine the impact of KDE on patient engagement and self-efficacy as a cause for improvement in vascular access outcomes.

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“…Centers for transplantation may be far from dialysis clinics (44) and may not have the capacity to handle a surge of referrals. The availability of surgeons and the supporting infrastructure vary greatly (44,60). Homelessness, food insecurity, and a lack of insurance can create significant hurdles for choices for KRT (61,62).…”

Section: Potential Unintended Consequencesmentioning

confidence: 99%

Keys to Driving Implementation of the New Kidney Care Models

Kshirsagar

Weiner

Mendu

et al. 2022

CJASN

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Contemporary nephrology practice is heavily weighted toward in-center hemodialysis, reflective of decisions on infrastructure and personnel in response to decades of policy. The Advancing American Kidney Health initiative seeks to transform care for patients and providers. Under the initiative’s framework, the Center for Medicare and Medicaid Innovation has launched two new care models that align patient choice with provider incentives. The mandatory ESRD Treatment Choices model requires participation by all nephrology practices in designated Hospital Referral Regions, randomly selecting 30% of all Hospital Referral Regions across the United States for participation, with the remaining Hospital Referral Regions serving as controls. The voluntary Kidney Care Choices model offers alternative payment programs open to nephrology practices throughout the country. To help organize implementation of the models, we developed Driver Diagrams that serve as blueprints to identify structures, processes, and norms, and generate intervention concepts. We focused on two goals that are directly applicable to nephrology practices and central to the incentive structure of the ESRD Treatment Choices and Kidney Care Choices: (1) increasing utilization of home dialysis, and (2) increasing the number of kidney transplants. Several recurring themes became apparent with implementation. Multiple stakeholders from assorted backgrounds are needed. Communication with primary care providers will facilitate timely referrals, education, and comanagement. Nephrology providers (nephrologists, nursing, dialysis organizations, others) must lead implementation. Patient engagement at nearly every step will help achieve the aims of the models. Advocacy with federal and state regulatory agencies will be crucial to expanding home dialysis and transplantation access. Although the models hold promise to improve choices and outcomes for many patients, we must be vigilant that they not do reinforce existing disparities in health care or widen known racial, socioeconomic, or geographic gaps. The Advancing American Kidney Health initiative has the potential to usher in a new era of value-based care for nephrology.

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Supply and Distribution of Vascular Access Physicians in the United States: A Cross-Sectional Study

Cited by 13 publications

References 26 publications

Racial Disparities in Arteriovenous Fistula Use Among Hemodialysis Patients: The Role of Surgeon Supply

Racial Disparities in Arteriovenous Fistula Use Among Hemodialysis Patients: The Role of Surgeon Supply

Provision of Kidney Disease Education Service Is Associated with Improved Vascular Access Outcomes among US Incident Hemodialysis Patients

Keys to Driving Implementation of the New Kidney Care Models

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