title: Impact of Poverty and Health Care Insurance on Arteriovenous Fistula Use among Incident Hemodialysis Patients.
abstract: BACKGROUND
  The impact of socioeconomic factors on arteriovenous fistula (AVF) creation in hemodialysis (HD) patients is not well understood. We assessed the association of area and individual-level indicators of poverty and health care insurance on AVF use among incident end-stage renal disease (ESRD) patients initiated on HD.
  
  
  METHODS
  In this retrospective cohort study using the United States Renal Data System database, we identified 669,206 patients initiated on maintenance HD from January 1, 2007 through December 31, 2012. We assessed the Medicare-Medicaid dual-eligibility status as an indicator of individual-level poverty and ZIP code-level median household income (MHI) data obtained from the 2010 United States Census. We conducted logistic regression of AVF use at start of dialysis as the outcome variable.
  
  
  RESULTS
  The proportions of dual-eligible and non-dual-eligible patients who initiated HD with an AVF were 12.53 and 16.17%, respectively (p<0.001). Dual eligibility was associated with significantly lower likelihood of AVF use upon initiation of HD (adjusted odds ratio (aOR) 0.91; 95% CI 0.90-0.93). Patients in the lowest area-level MHI quintile had an aOR of 0.97 (95% CI 0.95-0.99) compared to those in higher quintile levels. However, dual eligibility and area-level MHI were not significant in patients with Veterans Affairs (VA) coverage.
  
  
  CONCLUSIONS
  Individual- and area-level measures of poverty were independently associated with a lower likelihood of AVF use at the start of HD, the only exception being patients with VA health care benefits. Efforts to improve incident AVF use may require focusing on pre-ESRD care to be successful.
authors.affiliation: Nephrology, Walter Reed National Military Medical Center, Bethesda, Md., USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Nee
authors.forename: Deepti S
authors.initials: DS
authors.lastname: Moon
authors.forename: Rahul M
authors.initials: RM
authors.lastname: Jindal
authors.forename: Frank P
authors.initials: FP
authors.lastname: Hurst
authors.forename: Christina M
authors.initials: CM
authors.lastname: Yuan
authors.forename: Lawrence Y
authors.initials: LY
authors.lastname: Agodoa
authors.forename: Kevin C
authors.initials: KC
authors.lastname: Abbott
mesh_terms: D000328:Adult; D001741:Black or African American; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000706:statistics & numerical data*; D015331:Cohort Studies; D016208:Databases, Factual; D004608:Eligibility Determination / Q000706:statistics & numerical data; D005260:Female; D006630:Hispanic or Latino; D006801:Humans; D007182:Income / Q000706:statistics & numerical data*; D007348:Insurance, Health / Q000706:statistics & numerical data*; D007676:Kidney Failure, Chronic / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D006278:Medicare / Q000706:statistics & numerical data; D008875:Middle Aged; D016017:Odds Ratio; D011203:Poverty / Q000706:statistics & numerical data*; D006435:Renal Dialysis / Q000379:methods*; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014481:United States; D044465:White People