Geographic Concentration of Poverty and Arteriovenous Fistula Use among ESRD Patients

McClellan, William M.; Wasse, Haimanot; McClellan, Ann C.; Holt, James B.; Krisher, Jenna; Waller, Lance A.

doi:10.1681/asn.2009121235

Cited by 22 publications

(20 citation statements)

References 27 publications

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“…One recent study reported that patients living in residential areas with a larger proportion of black residents were less likely than those in other areas to have received nephrologist care (26). Another study found that county poverty is associated with the decreased likelihood of AVF use (33). To our knowledge, our study is the first to examine combined urbanization/rurality and racial/ethnic variations in pre-ESRD care at a national level.…”

Section: Discussionmentioning

confidence: 79%

The Associations between Race and Geographic Area and Quality-of-Care Indicators in Patients Approaching ESRD

Gao¹,

Cheung

Jennie³

et al. 2013

Clinical Journal of the American Society of Nephrology

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Background and objectives Pre-ESRD care is an important predictor of outcomes in patients undergoing longterm dialysis. This study examined the extent of variation in receiving pre-ESRD care and black-white disparities across urban and rural counties.Design, setting, participants, & measurements Participants were 404,622 non-Hispanic white and black patients aged .18 years who began dialysis between 2005 and 2010 and resided in 3076 counties from the U.S. Renal Data System. The counties were grouped into large metropolitan, medium/small metropolitan, suburban, and rural counties. Pre-ESRD care indicators included receipt of nephrologist care at least 6 or 12 months before ESRD, dietitian care, use of arteriovenous fistula at first outpatient dialysis session, and use of erythropoiesis-stimulating agents (ESAs) in patients with hemoglobin level , 10 g/dl.Results Large metropolitan and rural counties had lower percentages of patients who received pre-ESRD nephrologist care (25.7% and 26.9% for nephrologist care . 12 months), compared with the higher percentage in medium/small metropolitan counties (31.6%; both P,0.001). For both races, nonmetropolitan patients had poorer access to dietitian care and lower ESA use than metropolitan patients. Consistently in all four geographic areas, black patients received less care than their white counterparts. The unadjusted odds ratios of black versus white patients in receiving nephrologist care for .12 months before ESRD were 0.66 (95% confidence interval [CI], 0.61-0.72) in large metropolitan counties and 0.79 (95% CI, 0.69-0.90) in rural counties. The patterns remained, albeit attenuated, after adjustment for patient factors.Conclusions The receipt of pre-ESRD care, with blacks receiving less care, varies among geographic areas defined by urban/rural characteristics.

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Section: Discussionmentioning

confidence: 79%

The Associations between Race and Geographic Area and Quality-of-Care Indicators in Patients Approaching ESRD

Gao¹,

Cheung

Jennie³

et al. 2013

Clinical Journal of the American Society of Nephrology

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“…Because AVF require several weeks to mature and approximately 40% of created AVF never mature [4] , AVF creation is reliant on predialysis care, especially predialysis nephrology referral [5][6][7] . While studies of the development and maturation of AVF have focused on clinical factors [8][9][10][11] , the role of socioeconomic factors, particularly individual-level poverty, has not been reported in a recent national cohort of dialysis patients, although a previous study reported that county-level poverty was inversely associated with incident AVF use, but not with subsequent improvement in AVF use in prevalent patients [12] . We have previously reported that AVF use in new HD patients is significantly higher among patients in the federal health system (e.g.…”

Section: Impact Of Poverty and Healthmentioning

confidence: 98%

Impact of Poverty and Health Care Insurance on Arteriovenous Fistula Use among Incident Hemodialysis Patients

et al. 2015

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Background: The impact of socioeconomic factors on arteriovenous fistula (AVF) creation in hemodialysis (HD) patients is not well understood. We assessed the association of area and individual-level indicators of poverty and health care insurance on AVF use among incident end-stage renal disease (ESRD) patients initiated on HD. Methods: In this retrospective cohort study using the United States Renal Data System database, we identified 669,206 patients initiated on maintenance HD from January 1, 2007 through December 31, 2012. We assessed the Medicare-Medicaid dual-eligibility status as an indicator of individual-level poverty and ZIP code-level median household income (MHI) data obtained from the 2010 United States Census. We conducted logistic regression of AVF use at start of dialysis as the outcome variable. Results: The proportions of dual-eligible and non-dual-eligible patients who initiated HD with an AVF were 12.53 and 16.17%, respectively (p < 0.001). Dual eligibility was associated with significantly lower likelihood of AVF use upon initiation of HD (adjusted odds ratio (aOR) 0.91; 95% CI 0.90-0.93). Patients in the lowest area-level MHI quintile had an aOR of 0.97 (95% CI 0.95-0.99) compared to those in higher quintile levels. However, dual eligibility and area-level MHI were not significant in patients with Veterans Affairs (VA) coverage. Conclusions: Individual- and area-level measures of poverty were independently associated with a lower likelihood of AVF use at the start of HD, the only exception being patients with VA health care benefits. Efforts to improve incident AVF use may require focusing on pre-ESRD care to be successful.

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“…Although the receipt of nephrologist care is influenced by individual as well as contextual factors such as those related to residence, prior studies have mostly examined individual factors (12,(19)(20)(21), or the few studies that examined contextual factors have generally examined them separately (22)(23)(24) or were limited to certain regional areas (15,25). An important knowledge gap exists regarding broad regional (e.g., state-level) differences in the utilization of nephrologist care among patients with CKD stages 4-5.…”

Section: Introductionmentioning

confidence: 99%

Interstate Variation in Receipt of Nephrologist Care in US Patients Approaching ESRD

Gao

Cheung

Greene

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives Although multiple factors influence access to nephrologist care in patients with CKD stages 4-5, the geographic determinants within the United States are incompletely understood. In this study, we examined interstate differences in nephrologist care among patients approaching ESRD.Design, setting, participants, & measurements This national, population-based analysis included 373,986 adult patients from the US Renal Data System, who initiated maintenance dialysis between 2005 and 2009. Multilevel logistic regression was used to examine interstate variation in nephrologist care ($12 months before ESRD) for overall and four race-age subpopulations (black or white and older or younger than 65 years). ResultsThe average state-level probability of having received nephrologist care in all states combined was 28.8% (95% confidence interval, 25.2% to 32.7%) overall and was lowest (24.3%) in the younger black subpopulation. Even at these lower levels, state-level probabilities varied considerably across states in overall and subpopulations (all P,0.001). Overall, excluding the states in the upper and lower five percentiles, the remaining states had a probability of receiving care that varied from 18.5% to 41.9%. The lower probability of receiving nephrologist care for blacks than whites among younger patients noted in most states was attenuated in older patients. Geographically, all New England states and most Midwest states had higher than average probability, whereas most Middle Atlantic and Southern states had lower than average probability. After controlling for patient factors, three state-characteristic categories, including general healthcare access measured by percentage of uninsured persons and Medicaid program performance scores, preventive care measured by percentage of receiving recommended preventive care, and socioeconomic status, contributed 55%-66% of interstate variation.Conclusions Patients living in states with better health service and socioeconomic characteristics were more likely to receive predialysis nephrologist care. The reported national black-white difference in nephrologist care was primarily driven by younger black patients being the least likely to receive care.

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Geographic Concentration of Poverty and Arteriovenous Fistula Use among ESRD Patients

Cited by 22 publications

References 27 publications

The Associations between Race and Geographic Area and Quality-of-Care Indicators in Patients Approaching ESRD

The Associations between Race and Geographic Area and Quality-of-Care Indicators in Patients Approaching ESRD

Impact of Poverty and Health Care Insurance on Arteriovenous Fistula Use among Incident Hemodialysis Patients

Interstate Variation in Receipt of Nephrologist Care in US Patients Approaching ESRD

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