title: Enhanced training in vascular access creation predicts arteriovenous fistula placement and patency in hemodialysis patients: results from the Dialysis Outcomes and Practice Patterns Study.
abstract: OBJECTIVE
  To investigate whether intensity of surgical training influences type of vascular access placed and fistula survival.
  
  
  BACKGROUND
  Wide variations in fistula placement and survival occur internationally. Underlying explanations are not well understood.
  
  
  METHODS
  Prospective data from 12 countries in the Dialysis Outcomes and Practice Patterns Study were analyzed; outcomes of interest were type of vascular access in use (fistula vs. graft) in hemodialysis patients at study entry and time from placement until primary and secondary access failures, as predicted by surgical training. Logistic and Cox regression models were adjusted for patient characteristics and time on hemodialysis.
  
  
  RESULTS
  During training, US surgeons created fewer fistulae (US mean = 16 vs. 39-426 in other countries) and noted less emphasis on vascular access placement compared with surgeons elsewhere. Significant predictors of fistula versus graft placement in hemodialysis patients included number of fistulae placed during training (adjusted odds ratio [AOR] = 2.2 for fistula placement, per 2 times greater number of fistulae placed during training, P < 0.0001) and degree of emphasis on vascular access creation during training (AOR = 2.4 for fistula placement, for much-to-extreme emphasis vs. no emphasis, P = 0.0008). Risk of primary fistula failure was 34% lower (relative risk = 0.66, P = 0.002) when placed by surgeons who created > or = 25 (vs. < 25) fistulae during training.
  
  
  CONCLUSIONS
  Surgical training is key to both fistula placement and survival, yet US surgical programs seem to place less emphasis on fistula creation than those in other countries. Enhancing surgical training in fistula creation would help meet targets of the Fistula First Initiative.
authors.affiliation: Division of Nephrology, Department of Internal Medicine, Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan 48103-4262, USA. rsaran@umich.edu
authors.forename: Rajiv
authors.initials: R
authors.lastname: Saran
authors.forename: Stacey J
authors.initials: SJ
authors.lastname: Elder
authors.forename: David A
authors.initials: DA
authors.lastname: Goodkin
authors.forename: Takashi
authors.initials: T
authors.lastname: Akiba
authors.forename: Jean
authors.initials: J
authors.lastname: Ethier
authors.forename: Hugh C
authors.initials: HC
authors.lastname: Rayner
authors.forename: Akira
authors.initials: A
authors.lastname: Saito
authors.forename: Eric W
authors.initials: EW
authors.lastname: Young
authors.forename: Brenda W
authors.initials: BW
authors.lastname: Gillespie
authors.forename: Robert M
authors.initials: RM
authors.lastname: Merion
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Pisoni
mesh_terms: D001166:Arteriovenous Shunt, Surgical / Q000193:education*; D001315:Australia; D002408:Catheters, Indwelling; D002983:Clinical Competence; D015331:Cohort Studies; D005060:Europe; D013502:General Surgery / Q000193:education*; D006801:Humans; D007564:Japan; D009656:North America; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D006435:Renal Dialysis; D051437:Renal Insufficiency / Q000628:therapy*; D016896:Treatment Outcome; D014654:Vascular Patency