tem were included. Univariate (c 2 , analysis of variance, Kaplan-Meier survival) and multivariate (Cox regression) analysis was performed as appropriate.Results: A total of 1,012,971 ESRD patients were identified, of which the majority initiated HD with HC (81%), followed by AVF (16%) and AVG (3%). During the study period (2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015), the incidence of HD using AVF increased slightly from 13.5% to 17.0%, whereas there was a decline in AVG (4.25% to 2.98%) and HC (82.25% to 80.01%; P < .001; Fig). An overall decrease in 1-year mortality from 24.64% in 2006 to 18.54% in 2015 was also observed (P < .001; Fig). Survival was higher in AVF vs AVG vs HC at 1 year (91.3% vs 86.8% vs 78.4%), 5 years (47.0% vs 40.2% vs 36.3%), and 10 years (12.6% vs 11.3% vs 12.3%), respectively (all P < .001). After adjustment for patients' demographics and comorbidities, AVF and AVG were associated with 29% (hazard ratio, 0.71; 95% confidence interval, 0.70-0.71; P < .001) and 13% (HR, 0.83; 95% confidence interval, 0.81-0.84; P < .001) lower mortality at 10 years compared with HC (Table ). Male sex, nonwhite race, obesity, hypertension, and nephrologist care were associated with lower mortality.Conclusions: Using the entire U.S. HD database, we observed a modest increase of only 3.5% in the incidence of AVF during a decade. However, compared with HC, AVF was associated with a 29% survival benefit at 10 years. Despite the current Fistula First Catheter Last goal of 50% of incident AVF access, most patients continue to initiate HD with a catheter. It is clear that this goal is difficult to attain at this rate. Further study should be dedicated to understanding the barriers to AVF creation, and major changes in the policies and clinical practices are needed. <6 months 0.99 (0.98-1.00) .04 6-12 months 0.98 (0.97-0.99) <.001 >12 months 0.91 (0.91-0.92) <.001 AVF, Arteriovenous fistula; AVG, arteriovenous graft; CI, confidence interval; ESRD, end-stage renal disease; HC, hemodialysis catheter; HD, hemodialysis; HR, hazard ratio.