Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI.
Department of Biostatistics, University of Michigan, Ann Arbor, MI.
Am J Kidney Dis. 2020 Jun;75(6):879-886. doi: 10.1053/j.ajkd.2019.08.023. Epub 2019 Nov 22.
RATIONALE & OBJECTIVE: Patients with multiple comorbid conditions are less likely to use an arteriovenous fistula (AVF) for hemodialysis vascular access. Some dialysis facilities have high rates of AVF placement despite having patients with many comorbid conditions. This study describes variation in facility-level use of AVFs across the facility-level burden of patient comorbid conditions.
Retrospective cohort study.
SETTING & PARTICIPANTS: Medicare patients receiving hemodialysis for 1 year or more in US dialysis facilities.
Facility-level burden of patient comorbid conditions; patient characteristics.
Odds of AVFs versus other access types; facility-level use of AVFs.
Facility-level comorbidity burden was calculated by summing individual comorbid conditions, determining the average per patient, then defining 11 groups based on facility percentile ranking. Generalized estimating equations with a logit link were used to estimate the odds of AVF placement at the patient level. For the facility-level analysis, a generalized estimating equation model with the identity link was fit to characterize the percentage of AVF use at each facility.
Overall, AVF use was 65.8% in 315,919 prevalent hemodialysis patients among 5,813 facilities. After adjustment for patient characteristics, AVF use was 0.27, 0.30, 1.05, and 1.74 percentage points lower than the median among facilities in the 61st to 70th, 71st to 80th, 81st to 90th, and 91st to 99th percentiles of comorbidity, respectively, and 0.42, 0.63, 1.34, and 1.90 percentage points higher than the median among facilities in the 31st to 40th, 21st to 30th, 11th to 20th, and 1st to 10th percentiles of comorbidity, respectively. Facilities in the greater than 99th percentile of comorbidity burden had AVF use that was 3.47 percentage points lower than the median. Facilities in the less than 1st percentile of comorbidity burden had AVF use that was 2.64 percentage points greater than the median.
Limited to Medicare dialysis-dependent patients treated for 1 year or more.
After adjustment for patient characteristics, we found small differences in facility rates of AVF use except in the extremes of high or low levels of comorbidity burden. Our study demonstrates that dialysis facilities with a relatively high patient comorbidity burden can achieve similar fistula rates as facilities with healthier patients. Although high comorbidity burden does not explain low facility AVF use, additional study is needed to understand differences in AVF use rates between facilities with similar comorbidity burdens.
患有多种合并症的患者更不可能使用动静脉瘘（AVF）作为血液透析血管通路。尽管有些透析中心的患者合并症较多，但仍有很高的 AVF 植入率。本研究描述了在患者合并症负担程度不同的情况下，设施层面 AVF 使用的变化情况。
回顾性队列研究。
在美国透析中心接受血液透析治疗 1 年或以上的医疗保险患者。
设施层面患者合并症负担；患者特征。
在 5813 家透析中心的 315919 名接受血液透析的患者中，AVF 的总体使用率为 65.8%。在调整了患者特征后，设施层面的 AVF 使用率在第 61-70%、71-80%、81-90%和 91-99%百分位的设施中分别比中位数低 0.27、0.30、1.05 和 1.74 个百分点，而在第 31-40%、21-30%、11-20%和 1-10%百分位的设施中则分别比中位数高 0.42、0.63、1.34 和 1.90 个百分点。合并症负担大于 99%百分位的设施中，AVF 的使用率比中位数低 3.47 个百分点。合并症负担小于 1%百分位的设施中，AVF 的使用率比中位数高 2.64 个百分点。
仅局限于医疗保险透析依赖患者，治疗时间为 1 年或以上。
在调整了患者特征后，我们发现设施层面 AVF 使用率的差异很小，除了在合并症负担极高或极低的极端情况下。我们的研究表明，合并症负担相对较高的透析中心可以达到与合并症较轻患者相似的瘘管率。虽然高合并症负担并不能解释低设施 AVF 使用，但需要进一步研究来了解具有相似合并症负担的设施之间 AVF 使用率的差异。
