title: Facility hemodialysis vascular access use and mortality in countries participating in DOPPS: an instrumental variable analysis.
abstract: BACKGROUND
  Previously, the Dialysis Outcomes and Practice Patterns Study (DOPPS) has shown large international variations in vascular access practice. Greater mortality risks have been seen for hemodialysis (HD) patients dialyzing with a catheter or graft versus a native arteriovenous fistula (AVF). To further understand the relationship between vascular access practice and outcomes, we have applied practice-based analyses (using an instrumental variable approach) to decrease the treatment-by-indication bias of prior patient-level analyses.
  
  
  METHODS
  A prospective observational study of HD practices.
  
  
  METHODS
  Data collected from 1996 to 2004 from 28,196 HD patients from more than 300 dialysis units participating in the DOPPS in 12 countries.
  
  
  METHODS
  Patient-level or case-mix-adjusted facility-level vascular access use. OUTCOMES/MEASUREMENTS: Mortality and hospitalization risks.
  
  
  RESULTS
  After adjusting for demographics, comorbid conditions, and laboratory values, greater mortality risk was seen for patients using a catheter (relative risk, 1.32; 95% confidence interval, 1.22 to 1.42; P < 0.001) or graft (relative risk, 1.15; 95% confidence interval, 1.06 to 1.25; P < 0.001) versus an AVF. Every 20% greater case-mix-adjusted catheter use within a facility was associated with 20% greater mortality risk (versus facility AVF use, P < 0.001); and every 20% greater facility graft use was associated with 9% greater mortality risk (P < 0.001). Greater facility catheter and graft use were both associated with greater all-cause and infection-related hospitalization. Catheter and graft use were greater in the United States than in Japan and many European countries. More than half the 36% to 43% greater case-mix-adjusted mortality risk for HD patients in the United States versus the 5 European countries from the DOPPS I and II was attributable to differences in vascular access practice, even after adjusting for other HD practices. Vascular access practice differences accounted for nearly 30% of the greater US mortality compared with Japan.
  
  
  CONCLUSIONS
  Possible existence of unmeasured facility- and patient-level confounders that could impact the relationship of vascular access use with outcomes.
  
  
  CONCLUSIONS
  Facility-based analyses diminish treatment-by-indication bias and suggest that less catheter and graft use improves patient survival.
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, MI 48103, USA. ron.pisoni@arborresearch.org
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Pisoni
authors.forename: Charlotte J
authors.initials: CJ
authors.lastname: Arrington
authors.forename: Justin M
authors.initials: JM
authors.lastname: Albert
authors.forename: Jean
authors.initials: J
authors.lastname: Ethier
authors.forename: Naoki
authors.initials: N
authors.lastname: Kimata
authors.forename: Mahesh
authors.initials: M
authors.lastname: Krishnan
authors.forename: Hugh C
authors.initials: HC
authors.lastname: Rayner
authors.forename: Akira
authors.initials: A
authors.lastname: Saito
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Sands
authors.forename: Rajiv
authors.initials: R
authors.lastname: Saran
authors.forename: Brenda
authors.initials: B
authors.lastname: Gillespie
authors.forename: Robert A
authors.initials: RA
authors.lastname: Wolfe
authors.forename: Friedrich K
authors.initials: FK
authors.lastname: Port
mesh_terms: D001166:Arteriovenous Shunt, Surgical / Q000401:mortality* / Q000706:statistics & numerical data*; D002408:Catheters, Indwelling / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D006435:Renal Dialysis / Q000379:methods* / Q000401:mortality*