Assessment of Use of Arteriovenous Graft vs Arteriovenous Fistula for First-time Permanent Hemodialysis Access

Abstract

IMPORTANCE Initial hemodialysis access with arteriovenous fistula (AVF) is associated with superior clinical outcomes compared with arteriovenous graft (AVG) and should be the procedure of choice whenever possible. To address the national underuse of AVF in the United States, the Centers for Medicare & Medicaid has established an AVF goal of 66% or greater in 2009. OBJECTIVE To explore contemporary practice patterns and physician characteristics associated with high AVG use compared with AVF use. DESIGN, SETTING, AND PARTICIPANTS This review of 100% Medicare Carrier claims between January 1, 2016, and December 31, 2017, includes both inpatient and outpatient Medicare claims data. All patients undergoing initial permanent hemodialysis access placement with an AVF or AVG were included. All surgeons performing more than 10 hemodialysis access procedures during the study period were analyzed. EXPOSURES Placement of an AVF or AVG for initial permanent hemodialysis access. MAIN OUTCOMES AND MEASURES A surgeon-level AVG (vs AVF) use rate was calculated for all included surgeons. Hierarchical logistic regression modeling was used to identify patient-level and surgeon-level factors associated with AVG use. RESULTS A total of 85 320 patients (median age, 70 [range, 18-103] years; 47 370 men [55.5%]) underwent first-time hemodialysis access placement, of whom 66 489 (77.9%) had an AVF and 18 831 (22.1%) had an AVG. Among the 2397 surgeons who performed more than 10 procedures per year, the median surgeon level AVG use rate was 18.2% (range, 0.0%-96.4%). However, 498 surgeons (20.8%) had an AVG use rate greater than 34%. After accounting for patient characteristics, surgeon factors that were independently associated with AVG use included more than 30 years of clinical practice (vs 21-30 years; odds ratio, 0.85 [95% CI, 0.75-0.96]), metropolitan setting (odds ratio, 1.25 [95% CI, 1.02-1.54]), and vascular surgery specialty (vs general surgery; odds ratio, 0.77 [95% CI, 0.69-0.86]). Surgeons in the Northeast region had the lowest rate of AVG use (vs the South; odds ratio, 0.83 [95% CI, 0.73-0.96]). First-time hemodialysis access benchmarking reports for individual surgeons were created for potential distribution. CONCLUSIONS AND RELEVANCE In this study, one-fifth of surgeons had an AVG use rate above the recommended best practices guideline of 34%. Although some of these differences may be explained by patient referral practices, sharing benchmarked performance data with surgeons could be an actionable step in achieving more high-value care in hemodialysis access surgery.

Medical Adjuvant Therapy in Reducing Thrombosis With Arteriovenous Grafts and Fistulae Use: A Meta-Analysis of Randomized Controlled Trials

“…Finally, there may be a wide variation in hemodialysis access experiences by surgeons that may result in insignificant evidence of medical adjuvant therapy. 3 …”

“… 2 The type of hemodialysis access chosen for the patient has different complication rates. 3 CVCs are considered if arteriovenous communication fails to mature for dialysis or is occluded by thrombosis. 4 AVFs are preferred for hemodialysis access due to their comparatively lower morbidity and mortality than AVGs.…”

“… 4 AVFs are preferred for hemodialysis access due to their comparatively lower morbidity and mortality than AVGs. 3 Ideally, access sites need to have low rates of complications. The Fistula Breakthrough Initiative was established in 2003 by the Centers for Medicare & Medicaid Services and ESRD networks to increase the rates of AVFs, consequently improving hemodialysis access outcomes and reducing healthcare costs.…”

Efficacy of stent‐graft placement to salvage central vein stents with recalcitrant restenosis in patients with arteriovenous fistulas

“…The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (K‐DOQI) clinical practice guidelines strongly recommend the utilization of autologous arteriovenous fistula (AVF) as a superior hemodialysis access to prosthetic arteriovenous grafts (AVGs) because of their increased permanency and decreased risk of infection 2 . Inevitably, AVFs remain vulnerable and associated with significant morbidity due to multiple anatomic and physiologic short‐comings 3 . Access dysfunction is partly attributed to underlying critical central vein stenosis (CVS), which subsequently results in thrombosis and loss of dialysis access altogether 4 …”

Comparison Between Transposed Brachiobasilic Fistula and Arteriovenous Graft for Upper Limb Arteriovenous Access in Patients on Hemodialysis

“…Autologous fistulas are often better than arteriovenous grafts (AVGs) in terms of patient survival, access intervention rates, and infection rates. 1 However, creating a functioning autologous fistula is difficult among patients of advanced age and multiple comorbidities. 2 A transposed brachiobasilic fistula (BBF) or an AVG can be reportedly considered in cases when a radiocephalic or brachiocephalic fistula is not possible to create or fails.…”