Provider Visits and Early Vascular Access Placement in Maintenance Hemodialysis (original) (raw)
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Provider visit frequency and vascular access interventions in hemodialysis
Clinical journal of the American Society of Nephrology : CJASN, 2015
Medicare reimbursement policy encourages frequent provider visits to patients with ESRD undergoing hemodialysis. This study sought to determine whether more frequent face-to-face provider (physician and advanced practitioner) visits lead to more procedures and therapeutic interventions aimed at preserving arteriovenous fistulas and grafts, improved vascular access outcomes, and fewer related hospitalizations. Multivariable regression was used to evaluate the association between provider (physician and advanced practitioner) visit frequency and interventions aimed at preserving vascular access, vascular access survival, hospitalization for vascular access infection, and outpatient antibiotic use in a cohort of 63,488 Medicare beneficiaries receiving hemodialysis in the United States. Medicare claims were used to identify the type of vascular access used, access-related events, and vascular access failure. One additional provider (physician and advanced practitioner) visit per month w...
American Journal of Kidney Diseases, 2011
Background-The Centers for Medicare & Medicaid Services (CMS) established a national goal of 66% arterio-venous fistula (AVF) use among prevalent hemodialysis (HD) patients for the current Fistula First Breakthrough Initiative (FFBI). The feasibility of achieving the goal has been debated. We examined contemporary patterns of AVF use among prevalent patients to assess the potential for attaining the goal by dialysis facilities and their associated end-stage renal disease (ESRD) Networks in the United States (US).
National Profile of Practice Patterns for Hemodialysis Vascular Access in the United States
Journal of the American Society of Nephrology, 2002
The Centers for Medicare & Medicaid Service's (CMS), national End-Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project is a data collection initiative to identify opportunities for improvement of care to adult, Medicare maintenance dialysis beneficiaries. This analysis of 1999 CPM data characterizes the profile of hemodialysis vascular access in the United States and identifies determinants of vascular access type 2 yr after the translation of vascular access clinical practice guideline statements into national CPMs. CPM data were collected during October to December 1999 and stratified by the 18 regional ESRD networks. Univariate and multivariable analyses were conducted to examine associations of access type with demographic, laboratory, and geographic variables. Multivariable logistic regression analyses were performed to identify independent variables associated with access type. A total of 8154 hemodialysis patients were sampled; 17% (n ϭ 1399) were incident. Twenty-eight percent were dialyzed through an autologous arteriovenous fistula (AVF), 49% through a prosthetic graft
Barriers to timely arteriovenous fistula creation: A study of providers and patients
2011
Background: Current clinical practice guidelines recommend a native arteriovenous fistula (AVF) as the vascular access of first choice. Despite this, most patients in western countries start hemodialysis therapy using a catheter. Little is known regarding specific physician and system characteristics that may be responsible for delays in permanent access creation.
Annals of vascular surgery, 2008
The aims of this study were to determine whether National Kidney Foundation (NKF) guidelines for native arteriovenous fistula (AVF) creation (at least 50% of all new end-stage renal disease [ESRD] patients and 40% of prevalent hemodialysis patients) could be met in an underserved population who presented in late stages of ESRD. We also sought to determine 1-year AVF patency rates and factors associated with early thrombosis. One hundred seventy-six patients underwent hemodialysis access surgery during the period 2003-2005 with a mean age of 51 years. Sixty-two percent were male, and 48% had diabetes mellitus. Ultrasound vein mapping was performed in only 37%. Temporary central venous access was necessary in 109 patients (62%) due to late presentation. Of the 160 patients who were first-time access, 137 (86%) received a native AVF and 23 (14%) had an arteriovenous graft. There was a higher rate of AVF creation in males (91% vs. 75% for females, p = 0.005). The 1-year primary patency ...
Timing of nephrologist referral and arteriovenous access use: The CHOICE Study
American Journal of Kidney Diseases, 2001
• Recent clinical practice guidelines recommend the creation of an arteriovenous (AV) vascular access (ie, native fistula or synthetic graft) before the start of chronic hemodialysis therapy to prevent the need for complicationprone dialysis catheters. We report on the association of referral to a nephrologist with duration of dialysis-catheter use and type of vascular access used in the first 6 months of hemodialysis therapy. The study population is a representative cohort of 356 patients with questionnaire, laboratory, and medical record data collected as part of the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease Center Study. Patients who reported being seen by a nephrologist at least 1 month before starting hemodialysis therapy (75%) were more likely than those referred later to use an AV access at initiation (39% versus 10%; P < 0.001) and 6 months after starting hemodialysis therapy (74% versus 56%; P < 0.01). Patients referred within 1 month of initiating hemodialysis therapy used a dialysis catheter for a median of 202 days compared with 64, 67, and 19 days for patients referred 1 to 4, 4 to 12, and greater than 12 months before initiating hemodialysis therapy, respectively (P trend < 0.001). Patients referred at least 4 months before initiating hemodialysis therapy were more likely than patients referred later to use an AV fistula, rather than a synthetic graft, as their first AV access (45% versus 31%; P < 0.01). These associations remained after adjustment for age, sex, race, marital status, education, insurance coverage, comorbid disease status, albumin level, body mass index, and underlying renal diagnosis. These data show that late referral to a nephrologist substantially increases the likelihood of dialysis-catheter use at the initiation of hemodialysis therapy and is associated with prolonged catheter use. Regardless of the time of referral, only a minority of patients used an AV access at the initiation of treatment, and greater than 25% had not used an AV access 6 months after initiation. Thus, further efforts to improve both referral patterns and preparation for dialysis after referral are needed.
American Journal of Nephrology, 2019
Background: Patients with advanced chronic kidney disease frequently undergo arteriovenous fistula creation prior to reaching end-stage renal disease (ESRD), but some initiate hemodialysis with a central vein catheter, if their fistula is not yet usable. The clinical consequences of the delay in fistula use have not been quantified in such patients. We compared patients with pre-ESRD fistula surgery who initiated dialysis with a catheter versus a fistula in terms of the frequency of post-dialysis vascular access procedures and complications and their economic impact. Methods: We identified 205 patients with predialysis fistula creation from 2006 to 2012 at a large dialysis center who started hemodialysis within the ensuing 2 years. Of these, 91 (44%) initiated dialysis with a catheter and 114 (56%) with a fistula. We compared these 2 groups in terms of their annual frequency of percutaneous vascular access procedures, surgical access procedures, total access procedures, hospitalizations due to catheter-related bacteremia, and overall cost of vascular access management. Results: The 2 groups were similar in demographics, comorbidities, and fistula type. As compared to patients initiating dialysis with a fistula, those initiating with a catheter had a significantly greater annual frequency of percutaneous access procedures (1.
Nephron Clinical Practice, 2013
Background: Vascular access (VA) guidelines recommend the native arteriovenous fistula (AVF) as VA of first choice for chronic hemodialysis patients. AVF management is important in hemodialysis patient care. AVF survival is associated with various physical factors, but the effects of dialysis treatment factors upon AVF survival are still not clear. Methods: Study patients were treated at 498 dialysis facilities participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS) 2 or 3 (2002-2007). Analyses included 1,183 incident hemodialysis patients (on dialysis ≤7 days and using an AVF at study entry) and 949 prevalent patients (on dialysis >7 days at DOPPS entry and using a new AVF created during study observation). AVF survival was modeled from the study entry date for incident patients and date of first AVF use for prevalent patients. Predictors of primary and final AVF survival were compared across Japan, North America and Europe/Australia/New Zealand (EUR/ANZ) with...
Vascular Access Creation before Hemodialysis Initiation and Use: A Population-Based Cohort Study
Clinical journal of the American Society of Nephrology : CJASN, 2015
In Canada, approximately 17% of patients use an arteriovenous access (fistula or arteriovenous graft) at commencement of hemodialysis, despite guideline recommendations promoting its timely creation and use. It is unclear if this low pattern of use is attributable to the lack of surgical creation or a high nonuse rate. Using large health care databases in Ontario, Canada, a population-based cohort of adult patients (≥18 years old) who initiated hemodialysis as their first form of RRT between 2001 and 2010 was studied. The aims were to (1) estimate the proportion of patients who had an arteriovenous access created before starting hemodialysis and the proportion who successfully used it at hemodialysis start, (2) test for secular trends in arteriovenous access creation, and (3) estimate the effect of late nephrology referral and patient characteristics on arteriovenous access creation. There were 17,183 patients on incident hemodialysis. The mean age was 65.8 years, 60% were men, and ...
Hemodialysis International, 2017
Background: Gender disparities had been noted in the care of women with end stage renal disease (ESRD) in the early 2000's, including less frequent initiation of hemodialysis utilizing a fistula but more recent data have not been examined and underlying factors have not been extensively studied. Study design: Data from the United States Renal Data System (USRDS) were examined, including 202,999 hemodialysis patients. Only those who had received prior nephrology care were included. Multiple logistic regression was used, adjusted for possible confounders, including age, race, cause of ESRD, BMI, height, history of alcohol or drug abuse, medical comorbidities, ability to ambulate, time of nephrology care, type of insurance, and ESRD network. Results: The odds of arteriovenous fistula (AVF) use at initiation of hemodialysis were significantly lower in women compared to men (OR 5 0.69, 95% CI 0.67-0.71, P < 0.0001). The gender gap in AVF use at initiation was highest in New York and the upper Midwest (networks 2 and12) and smallest for Southern California and the Pacific Northwest and Alaska (18 and 16). Gender disparity was more pronounced for black women, with odds ratios for AVF use at initiation of dialysis (OR 5 0.66, 95% CI 0.62-0.69), P < 0.0001 as compared to non-black (OR 0.70, 95% CI 0.68-0.73), P 0.0001. Limitations: Limitations include use of USRDS data. Data misclassification or errors in data reporting may exist and certain comorbid conditions may be underreported. Data regarding rate of primary fistula non-function are also not available. Conclusion: Adjusted odds ratio for AVF use was significantly lower in women compared to men, independent of time of nephrology care and other predictors. The gender disparity was most pronounced for black women and also varied from 20% to 46% lower odds for AVF use in women for different ESRD networks, after controlling for possible confounding variables, suggesting that practice based factors may be of importance in explaining this important finding.