Association of Medicaid Expansion with Tunneled Dialysis Catheter Use at the Time of First Arteriovenous Access Creation

High Prevalence of Adverse Social Determinants of Health in Dialysis Access Creation Patients in a Safety-Net Setting

BACKGROUND

Patients receiving dialysis access surgery are often exposed to adverse social determinants of health (SDH) that negatively impact their care. Our goal was to characterize these factors experienced by our arteriovenous dialysis access patients and identify differences in health outcomes based on their SDH.

METHODS

We performed a retrospective cohort study of all patients who underwent dialysis access creation (2017-2021) and were screened for SDH at a clinical visit (using THRIVE survey) implemented at an urban, safety-net hospital institution within 1 year of access creation. Demographics, procedural details, early postoperative outcomes, survey responses, and referral to our hospital's preventive food pantry were recorded. Univariable analysis and multivariable analyses were performed to assess for associations with key health outcomes.

RESULTS

There were 190 patients who responded to the survey within 1 year of their operation. At least 1 adverse SDH was identified in 42 (22%) patients. Normalized to number of respondents for each question, adverse SDH identified were difficulty obtaining transportation to medical appointments (18%), food insecurity (16%), difficulty affording utilities (13%), difficulty affording medication (12%), unemployed and seeking employment (9%), unstable housing (7%), difficulty caring for family/friends (6%), and desiring more education (5%). There were 71 (37%) patients who received food pantry referrals. Mean age was 60 years and 38% of patients were female and 64% were Black. More than half of patients (57%) had a tunneled dialysis catheter (TDC) at the time of access creation. Dialysis accesses created were brachiocephalic (39%), brachiobasilic (25%), radiocephalic fistulas (16%), and arteriovenous grafts (14%). Thirty-day emergency department (ED) visits, 30-day readmissions, and 90-day mortality occurred in 23%, 21%, and 2%, respectively. On univariable and multivariable analyses, any adverse SDH determined on survey and food pantry referral were not associated with preoperative dialysis through TDCs, receiving nonautogenous dialysis access, 30-day ED visits and readmissions, or 90-day mortality.

CONCLUSION

Nearly a quarter of dialysis access surgery patients at a safety-net hospital experienced adverse SDH and more than one-third received a food pantry referral. Most common difficulties experienced include difficulty obtaining transportation to medical appointments, food insecurity, and difficulty paying for utilities and medication. Although there were no differences in postoperative outcomes, the high prevalence of these adverse SDH warrants prioritization of resources in this population to ensure healthy equity and further investigation into their effects on health outcomes.

Recent evaluation by nephrologists is associated with decreased incidence of tunneled dialysis catheter being used at the time of first arteriovenous access creation

OBJECTIVE

Late primary care provider (PCP) or nephrologist evaluation of patients with progressive kidney disease may be associated with increased morbidity and mortality. Among patients undergoing initial arteriovenous (AV) access creation, we aimed to study the relationship of recent PCP and nephrologist evaluations with perioperative morbidity and mortality.

METHODS

We performed a retrospective review of patients from 2014 to 2022 who underwent initial AV access creation at an urban, safety-net hospital. Univariable and multivariable analyses identified associations of PCP and nephrologist evaluations <1 year and <3 months before surgery, respectively, with hemodialysis initiation via tunneled dialysis catheters (TDCs), 90-day readmission, and 90-day mortality.

RESULTS

Among 558 patients receiving initial AV access, mean age was 59.7 ± 14 years, 59% were female gender, and 60.6% were Black race. Recent PCP and nephrology evaluations occurred in 386 (69%) and 362 (65%) patients, respectively. On multivariable analysis, unemployed and uninsured statuses were associated with decreased likelihood of PCP evaluation (unemployment: odds ratio [OR], 0.51; 95% confidence interval [CI], 0.34-0.77; uninsured status: OR, 0.05; 95% CI, 0.01-0.45) and nephrologist evaluation (unemployment: OR, 0.63; 95% CI, 0.43-0.91; uninsured status: OR, 0.22; 95% CI, 0.06-0.83) (all P < .05). Social support was associated with increased likelihood of PCP evaluation (OR, 1.81; 95% CI, 1.07-3.08) (all P < .05). Hemodialysis was initiated with TDCs in 304 patients (55%). Older age (OR, 0.98; 95% CI, 0.96-0.99), obesity (OR, 0.38; 95% CI, 0.25-0.58), and nephrologist evaluation (OR, 0.12; 95% CI, 0.08-0.19) were independently associated with decreased hemodialysis initiation with TDCs in patients receiving an initial AV access (all P < .05). Ninety-day readmission occurred in 270 cases (48%). Cirrhosis (OR, 2.5; 95% CI, 1.03-6.03; P = .04), coronary artery disease (OR, 2.31; 95% CI, 1.5-3.57), prosthetic AV access (OR, 1.84; 95% CI, 1.04-3.26), and impaired ambulation (OR, 1.75; 95% CI, 1.15-2.66) were independently associated with increased readmission (all P < .05). Older age (OR, 0.98; 95% CI, 0.97-0.99), prior TDC (OR, 0.65; 95% CI, 0.45-0.94), and unemployment (OR, 0.58; 95% CI, 0.39-0.86) were associated with decreased readmission (all P < .05). Ninety-day mortality occurred in 1.6% of patients. Neither PCP nor nephrologist evaluation was associated with readmission or mortality.

CONCLUSIONS

Recent nephrology evaluation was associated with reduced hemodialysis initiation with TDCs among patients undergoing initial AV access creation. Unemployed and uninsured statuses posed barriers to accessing nephrology care.

Brachiocephalic and Radiocephalic Arteriovenous Fistulas in Patients with Tunneled Dialysis Catheters Have Similar Outcomes

BACKGROUND

Patients with tunneled dialysis catheters (TDCs) have a time-sensitive need for a functional permanent access due to high risk of catheter-associated morbidity. Brachiocephalic arteriovenous fistulas (BCF) have been reported to have higher maturation and patency compared to radiocephalic arteriovenous fistulas (RCF), although more distal creation is encouraged when possible. However, this may lead to a delay in establishing permanent vascular access and, ultimately, TDC removal. Our goal was to assess short-term outcomes after BCF and RCF creation for patients with concurrent TDCs to see if these patients would potentially benefit more from an initial brachiocephalic access to minimize TDC dependence.

METHODS

The Vascular Quality Initiative hemodialysis registry was analyzed from 2011 to 2018. Patient demographics, comorbidities, access type, and short-term outcomes including occlusion, reinterventions, and access being used for dialysis, were assessed.

RESULTS

There were 2,359 patients with TDC, of whom 1,389 (58.9%) underwent BCF creation and 970 (41.1%) underwent RCF creation. Average patient age was 59 years, and 62.8% were male. Compared with RCF, those with BCF were more often older, of female sex, obese, nonindependently ambulatory, have commercial insurance, diabetes, coronary artery disease, chronic obstructive pulmonary disease, be on anticoagulation, and have a cephalic vein diameter of ≥3 mm (all P < 0.05). Kaplan-Meier analysis for 1-year outcomes for BCF and RCF, respectively, showed that primary patency was 45% vs. 41.3% (P = 0.88), primary assisted patency was 86.7% vs. 86.9% (P = 0.64), freedom from reintervention was 51.1% vs. 46.3% (P = 0.44), and survival was 81.3% vs. 84.9% (P = 0.02). Multivariable analysis showed that BCF was comparable to RCF with respect to primary patency loss (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.91-1.36, P = 0.316), primary assisted patency loss (HR 1.11, 95% CI 0.72-1.29, P = 0.66), and reintervention (HR 1.01, 95% CI 0.81-1.27, P = 0.92). Access being used at 3 months was similar but trending towards RCF being used more often (odds ratio 0.7, 95% CI 0.49-1, P = 0.05).

CONCLUSIONS

BCFs do not have superior fistula maturation and patency compared to RCFs in patients with concurrent TDCs. Creation of radial access, when possible, does not prolong TDC dependence.

The impact of neighborhood social disadvantage on presentation and management of first-time hemodialysis access surgery patients

OBJECTIVES

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.