Predictors of type of vascular access in hemodialysis patients.
OBJECTIVE
Complications from vascular access account for 15% of hospital admissions among US hemodialysis patients. Complications are less frequent with arteriovenous fistulas than with synthetic grafts. We assessed clinical and nonclinical predictors of whether patients with end-stage renal disease (ESRD) starting hemodialysis receive a fistula or graft. We also investigated changes in practice between 1986-1987 and 1990.


METHODS
Cross-sectional study.


METHODS
United States hemodialysis population.


METHODS
Random, national samples of ESRD patients who started hemodialysis in 1986-1987 (n=2741) or 1990 (n=1409) from United States Renal Data System Special Studies.


METHODS
Type of permanent vascular access (arteriovenous fistula vs synthetic graft), analyzed using multivariate logistic regression.


RESULTS
Clinical and demographic factors as well as socioeconomic status, region of residence, and year starting hemodialysis predicted the type of vascular access. Overall, 56% of patients had grafts 30 days after starting dialysis, but graft use increased from 51% in 1986-1987 to 65% in 1990 (adjusted odds ratio [AOR], 1.67 for 1990 vs 1986-1987; 95% confidence interval [CI], 1.43-1.95; P<.001). Graft use (relative to fistula) varied by region of residence (ranging from AOR, 0.20; 95% CI, 0.14-0.28; P<.001 [New England], to AOR, 2.69; 95% CI, 2.03-3.58; P<.001 [East South Central]; both relative to the national average).


CONCLUSIONS
This national study documents large variations in the relative use of fistulas and grafts and a trend away from fistulas. The prevalence of comorbid conditions fails to explain these findings. Presentation and referral of patients early in the process of their ESRD, teaching surgeons to place fistulas, and training dialysis nurses to access fistulas may increase their use.
Hirth
R A
RA
Department of Health Management and Policy, University of Michigan, Ann Arbor 48109-2029, USA.
Turenne
M N
MN
Woods
J D
JD
Young
E W
EW
Port
F K
FK
Pauly
M V
MV
Held
P J
PJ
D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000706:statistics & numerical data* / Q000639:trends; D001807:Blood Vessel Prosthesis / Q000009:adverse effects / Q000706:statistics & numerical data* / Q000639:trends; D015897:Comorbidity; D003430:Cross-Sectional Studies; D003710:Demography; D006801:Humans; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000628:therapy*; D016015:Logistic Models; D015999:Multivariate Analysis; D011138:Polytetrafluoroethylene; D010818:Practice Patterns, Physicians' / Q000639:trends*; D006435:Renal Dialysis / Q000009:adverse effects / Q000379:methods / Q000639:trends; D012959:Socioeconomic Factors; D014481:United States / Q000453:epidemiology
D011138:Polytetrafluoroethylene