This Article  • References  • Full text PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Social Bookmarking   What's this?

Richard A. Hirth, PhD; Marc N. Turenne; John D. Woods, MB MRCP; Eric W. Young, MD, MS; Friedrich K. Port, MD, MS; Mark V. Pauly, PhD; Philip J. Held, PhD

JAMA. 1996;276(16):1303-1308.

Abstract
Objective.
—Complications from vascular access account for 15% of hospital admissions among US hemodialysis patients. Complications are less frequent with arteriovenous fistulas than with synthetic grafts. We assessed clinical and nonclinical predictors of whether patients with end-stage renal disease (ESRD) starting hemodialysis receive a fistula or graft. We also investigated changes in practice between 1986-1987 and 1990.

Design.
—Cross-sectional study.

Setting.
—United States hemodialysis population.

Patients.
—Random, national samples of ESRD patients who started hemodialysis in 1986-1987 (n=2741) or 1990 (n=1409) from United States Renal Data System Special Studies.

Main Outcome Measure.
—Type of permanent vascular access (arteriovenous fistula vs synthetic graft), analyzed using multivariate logistic regression.

Results.
—Clinical and demographic factors as well as socioeconomic status, region of residence, and year starting hemodialysis predicted the type of vascular access. Overall, 56% of patients had grafts 30 days after starting dialysis, but graft use increased from 51% in 1986-1987 to 65% in 1990 (adjusted odds ratio [AOR], 1.67for 1990 vs 1986-1987; 95% confidence interval [CI], 1.43-1.95; P<.001). Graft use (relative to fistula) varied by region of residence (ranging from AOR, 0.20; 95% CI, 0.14-0.28; P<.001 [New England], to AOR, 2.69; 95% CI, 2.03-3.58; P<.001 [East South Central]; both relative to the national average).

Concclusions.
—This national study documents large variations in the relative use of fistulas and grafts and a trend away from fistulas. The prevalence of comorbid conditions fails to explain these findings. Presentation and referral of patients early in the process of their ESRD, teaching surgeons to place fistulas, and training dialysis nurses to access fistulas may increase their use.

Author Affiliations
From the Departments of Health Management and Policy (Drs Hirth and Held), Economics (Dr Hirth), Internal Medicine (Mr Turenne and Drs Woods, Young, Port, and Held), and Epidemiology (Dr Port), University of Michigan, Ann Arbor; the Veterans Affairs Medical Center, Ann Arbor (Drs Young and Port); and the Department of Health Care Systems, University of Pennsylvania, Philadelphia (Dr Pauly).

Footnotes
Reprints: Richard A. Hirth, PhD, Department of Health Management and Policy, University of Michigan School of Public Health, 109 S Observatory, Ann Arbor, Ml 48109-2029.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Effect of demographic characteristics and timing of vascular access maturation on patency in Chinese incident haemodialysis patients
Ng et al.
Nephrol Dial Transplant 2009;0:gfp269v1-gfp269.
ABSTRACT | FULL TEXT  

Regional Variation in Kidney Transplant Outcomes: Trends Over Time
Chakkera et al.
CJASN 2009;4:152-159.
ABSTRACT | FULL TEXT  

Factors influencing the prevalence of central venous catheter use in a Canadian haemodialysis centre
Graham et al.
Nephrol Dial Transplant 2008;23:3585-3591.
ABSTRACT | FULL TEXT  

Increased Hemodialysis Catheter Use in Canada and Associated Mortality Risk: Data from the Canadian Organ Replacement Registry 2001-2004
Moist et al.
CJASN 2008;3:1726-1732.
ABSTRACT | FULL TEXT  

Comorbidities Do not Influence Primary Fistula Success in Incident Hemodialysis Patients: A Prospective Study
Wang et al.
CJASN 2008;3:78-84.
ABSTRACT | FULL TEXT  

Subdural Hematomas in Chronic Dialysis Patients: Significant and Increasing
Sood et al.
CJASN 2007;2:956-959.
ABSTRACT | FULL TEXT  

Current Management of Vascular Access
Allon
CJASN 2007;2:786-800.
ABSTRACT | FULL TEXT  

Geography Matters: Relationships among Urban Residential Segregation, Dialysis Facilities, and Patient Outcomes
Rodriguez et al.
ANN INTERN MED 2007;146:493-501.
ABSTRACT | FULL TEXT  

Associations between Demographic Factors and Provider Structures on Cost and Length of Stay for Hemodialysis Patients with Vascular Access Failure
Brenner et al.
CJASN 2006;1:455-461.
ABSTRACT | FULL TEXT  

Design of the Dialysis Access Consortium (DAC) clopidogrel prevention of early AV fistula thrombosis trial
Dember et al.
Clin Trials 2005;2:413-422.
ABSTRACT  

Variability in quality of care among dialysis units in western Switzerland
Saudan et al.
Nephrol Dial Transplant 2005;20:1854-1863.
ABSTRACT | FULL TEXT  

Hemodialysis Arteriovenous Fistula Maturity: US Evaluation
Robbin et al.
Radiology 2002;225:59-64.
ABSTRACT | FULL TEXT  

National Profile of Practice Patterns for Hemodialysis Vascular Access in the United States
Reddan et al.
J. Am. Soc. Nephrol. 2002;13:2117-2124.
ABSTRACT | FULL TEXT  

Hospital Utilization among Chronic Dialysis Patients
ARORA et al.
J. Am. Soc. Nephrol. 2000;11:740-746.
ABSTRACT | FULL TEXT  

Haemodialysis vascular access and fistula surveillance methods in The Netherlands
Ezzahiri et al.
Nephrol Dial Transplant 1999;14:2110-2115.
ABSTRACT | FULL TEXT  

Prevalence of and Factors Associated with Suboptimal Care before Initiation of Dialysis in the United States
OBRADOR et al.
J. Am. Soc. Nephrol. 1999;10:1793-1800.
ABSTRACT | FULL TEXT  

Comparing Generalist and Specialty Care: Discrepancies, Deficiencies, and Excesses
Donohoe
Arch Intern Med 1998;158:1596-1608.
ABSTRACT | FULL TEXT  

Vascular Access in Patients Receiving Hemodialysis
Qureshi
JAMA 1997;277:455-455.
ABSTRACT  

Vascular Access in Patients Receiving Hemodialysis
Tokars and Miller
JAMA 1997;277:455-455.
ABSTRACT  

Vascular Access in Patients Receiving Hemodialysis
Tesi and O'Donovan
JAMA 1997;277:455-456.
ABSTRACT  

Grafts vs Fistulas for Hemodialysis Patients: Equal Access for All?
Chertow
JAMA 1996;276:1343-1344.
ABSTRACT