title: Geographic disparities in arteriovenous fistula placement in patients approaching hemodialysis in the United States.
abstract: Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis (HD). Several factors associated with AVF placement have been identified (e.g., age, sex, race, comorbidities). We hypothesized that geographic location of patient residence might be associated with the probability of AVF placement as the initial access. We used the data from the United States Renal Data System (USRDS) database (2005-2008) linked to Medicare claims (2003-2008). Logistic regression was used to estimate specific characteristics of population associated with the AVF as first access placed or attempted for HD initiation. Our primary variable of interest was the geographic location, and the multivariate model was adjusted for age, sex, race, body mass index, primary cause of end-stage renal disease (ESRD), duration of pre-ESRD nephrology care, comorbidities, employment status, substance abuse, and income. Geographic location was determined using the data collected by the RUCA project and divided population into metropolitan, micropolitan, and rural categories. Patients (n = 111,953) identified from the USRDS database with linked Medicare claims were examined. Rates of fistula placement in the metropolitan, micropolitan, and rural population were 18.5%, 22.4%, and 21.6%, respectively. In comparison, patients who received catheter as the first access were 81.5%, 77.6% and 78.4%, respectively. The odds ratio of AVF placement as a first HD access in the rural and metropolitan population compared with the micropolitan population were 0.96 (0.90-1.03; P = 0.26) and 0.80 (0.76-0.84; P < 0.001), respectively. Our results indicate the presence of geographic disparities in AVF placement with decreased rates of AVF as the first access created in the metropolitan (but not rural) populations compared with the micropolitan communities.
authors: Division of Nephrology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Transplant Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
authors: Alexander S
authors: AS
authors: Goldfarb-Rumyantzev
authors: Wajih
authors: W
authors: Syed
authors: Bhanu K
authors: BK
authors: Patibandla
authors: Akshita
authors: A
authors: Narra
authors: Ranil
authors: R
authors: Desilva
authors: Varun
authors: V
authors: Chawla
authors: Tammy
authors: T
authors: Hod
authors: Yael
authors: Y
authors: Vin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001164:Arteriovenous Fistula / Q000453:epidemiology* / Q000473:pathology / Q000628:therapy*; D015331:Cohort Studies; D005260:Female; D005843:Geography; D006801:Humans; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000379:methods / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
keywords: Geographic disparities; access; arteriovenous fistula; hemodialysis; outcome