title: Quality Improvement Targets for Regional Variation in Surgical End-Stage Renal Disease Care.
abstract: OBJECTIVE
  Arteriovenous fistula (AVF) access improves survival in patients with end-stage renal disease (ESRD) compared with other modalities when used at first hemodialysis. Use varies between locations, but, to our knowledge, no study has related this finding to mortality on a national scale.
  
  
  OBJECTIVE
  To quantify regional variation in AVF access at first hemodialysis, as well as the associated effect on mortality in the US Renal Data System.
  
  
  METHODS
  The US Renal Data System tracks all patients with ESRD in the United States. A retrospective analysis of the population from January 1, 2006, to December 31, 2010, was performed. Univariate analyses (χ² test; 2-tailed, unpaired t test; and analysis of variance) as well as multivariable logistic regressions were carried out to compare patient characteristics, incident AVF frequencies, and corrected mortality hazards between ESRD Network Programs, which comprise 18 states, commonwealths, and protectorates in which residents receive hemodialysis. Of the patients receiving hemodialysis in these networks, the data on 464,547 individuals who were beginning renal replacement therapy were analyzed. Analysis was started April 1, 2013, and ended August 3, 2014.
  
  
  METHODS
  Mortality hazard variation between ESRD Network Programs in the United States and incident AVF frequency.
  
  
  RESULTS
  Of the 464,547 patients beginning hemodialysis in this cohort, first hemodialysis with an AVF ranged from 11.1% to 22.2% depending on the ESRD Network in which they maintained residency (P < .001). Similarly, corrected mortality hazard varied by 28% (hazard ratios from 0.99 [95% CI, 0.96-1.03] to 1.27 [95% CI, 1.22-1.31]; P < .001). Logistic regression determined nephrology care to increase the odds of a patient beginning hemodialysis using an AVF by 11-fold (odds ratio, 11.42 [95% CI, 10.93-11.93]; P < .001); congestive heart failure was a negative correlatefold (odds ratio, 0.65 [95% CI, 0.64-0.67]; P < .001). No region achieved the 50% Fistula First Breakthrough Initiative (now known as Fistula First Catheter Last) target for incident AVF access.
  
  
  CONCLUSIONS
  Marked regional variation in functional incident AVF frequency and risk-adjusted ESRD mortality exists across the United States. Differences in access to preoperative nephrology care and patient comorbidities may explain some of these variations, but an opportunity to implement best-practice guidelines exists.
authors.affiliation: Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
authors.forename: Devin S
authors.initials: DS
authors.lastname: Zarkowsky
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Medical Institutes, Baltimore, Maryland.
authors.forename: Caitlin W
authors.initials: CW
authors.lastname: Hicks
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Medical Institutes, Baltimore, Maryland.
authors.forename: Isibor
authors.initials: I
authors.lastname: Arhuidese
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Medical Institutes, Baltimore, Maryland.
authors.forename: Joseph K
authors.initials: JK
authors.lastname: Canner
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Medical Institutes, Baltimore, Maryland.
authors.forename: Tammam
authors.initials: T
authors.lastname: Obeid
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Medical Institutes, Baltimore, Maryland.
authors.forename: Umair
authors.initials: U
authors.lastname: Qazi
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Medical Institutes, Baltimore, Maryland.
authors.forename: Eric
authors.initials: E
authors.lastname: Schneider
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Medical Institutes, Baltimore, Maryland.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Abularrage
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Medical Institutes, Baltimore, Maryland.
authors.forename: James H
authors.initials: JH
authors.lastname: Black
authors.affiliation: Office of the Vice Chancellor, University of California, Davis Health System, Sacramento.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Freischlag
authors.affiliation: Division of Vascular and Endovascular Therapy, Department of Surgery, The Johns Hopkins Medical Institutes, Baltimore, Maryland.
authors.forename: Mahmoud B
authors.initials: MB
authors.lastname: Malas
mesh_terms: D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000401:mortality* / Q000601:surgery* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D058996:Quality Improvement; D006435:Renal Dialysis / Q000706:statistics & numerical data; D012189:Retrospective Studies; D020379:Risk Adjustment; D014481:United States / Q000453:epidemiology