Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.
Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
J Vasc Surg. 2023 Oct;78(4):1041-1047.e1. doi: 10.1016/j.jvs.2023.05.044. Epub 2023 Jun 16.
The impact of social determinants of health on the presentation, management, and outcomes of patients requiring hemodialysis (HD) arteriovenous (AV) access creation have not been well-characterized. The Area Deprivation Index (ADI) is a validated measure of aggregate community-level social determinants of health disparities experienced by members living within a community. Our goal was to examine the effect of ADI on health outcomes for first-time AV access patients.
We identified patients who underwent first-time HD access surgery in the Vascular Quality Initiative between July 2011 to May 2022. Patient zip codes were correlated with an ADI quintile, defined as quintile 1 (Q1) to quintile 5 (Q5) from least to most disadvantaged. Patients without ADI were excluded. Preoperative, perioperative, and postoperative outcomes considering ADI were analyzed.
There were 43,292 patients analyzed. The average age was 63 years, 43% were female, 60% were of White race, 34% were of Black race, 10% were of Hispanic ethnicity, and 85% received autogenous AV access. Patient distribution by ADI quintile was as follows: Q1 (16%), Q2 (18%), Q3 (21%), Q4 (23%), and Q5 (22%). On multivariable analysis, the most disadvantaged quintile (Q5) was associated with lower rates of autogenous AV access creation (OR, 0.82; 95% confidence interval [CI], 0.74-0.90; P < .001), preoperative vein mapping (OR, 0.57; 95% CI, 0.45-0.71; P < .001), access maturation (OR, 0.82; 95% CI, 0.71-0.95; P = .007), and 1-year survival (OR, 0.81; 95% CI, 0.71-0.91; P = .001) compared with Q1. Q5 was associated with higher 1-year intervention rates than Q1 on univariable analysis, but not on multivariable analysis.
The patients undergoing AV access creation who were most socially disadvantaged (Q5) were more likely to experience lower rates of autogenous access creation, obtaining vein mapping, access maturation, and 1-year survival compared with the most socially advantaged (Q1). Improvement in preoperative planning and long-term follow-up may be an opportunity for advancing health equity in this population.
社会决定因素对需要血液透析（HD）动静脉（AV）通路创建的患者的表现、管理和结局的影响尚未得到很好的描述。区域贫困指数（ADI）是一种经过验证的衡量社区成员所经历的社区层面社会决定因素健康差异的综合指标。我们的目标是研究 ADI 对首次 AV 通路患者健康结果的影响。
我们在 2011 年 7 月至 2022 年 5 月期间在血管质量倡议中确定了接受首次 HD 通路手术的患者。将患者的邮政编码与 ADI 五分位数相关联，定义为五分位数 1（Q1）至五分位数 5（Q5），从最不利到最有利。排除没有 ADI 的患者。分析了考虑 ADI 的术前、围手术期和术后结果。
共分析了 43292 名患者。平均年龄为 63 岁，43%为女性，60%为白人，34%为黑人，10%为西班牙裔，85%接受自体 AV 通路。ADl 五分位数的患者分布如下：Q1（16%）、Q2（18%）、Q3（21%）、Q4（23%）和 Q5（22%）。多变量分析显示，最贫困的五分位数（Q5）与自体 AV 通路创建率较低相关（OR，0.82；95%置信区间[CI]，0.74-0.90；P<.001）、术前静脉绘图（OR，0.57；95%CI，0.45-0.71；P<.001）、通路成熟（OR，0.82；95%CI，0.71-0.95；P=.007）和 1 年生存率（OR，0.81；95%CI，0.71-0.91；P=.001），与 Q1 相比。Q5 与 Q1 相比，1 年干预率较高，但多变量分析结果并非如此。
与社会地位最高的（Q1）相比，接受 AV 通路创建的社会地位最低的（Q5）患者更有可能出现自体通路创建、获得静脉绘图、通路成熟和 1 年生存率较低的情况。改进术前计划和长期随访可能是提高该人群健康公平性的机会。
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