Racial/Ethnic Disparities Associated With Initial Hemodialysis Access

Zarkowsky, Devin S.; Arhuidese, Isibor; Hicks, Caitlin W.; Canner, Joseph K.; Qazi, Umair; Obeid, Tammam; Schneider, Eric B.; Abularrage, Christopher J.; Freischlag, Julie A.; Malas, Mahmoud B.

doi:10.1001/jamasurg.2015.0287

Cited by 91 publications

(63 citation statements)

References 31 publications

(19 reference statements)

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“…Zarkowsky et al [13] reported that white patients had a 22% greater chance than did black patients of initiating hemodialysis with an AV fistula versus combined groups of AV graft and catheter. Our study modeled the use of permanent AV access (AV fistula or AV graft) compared to catheter or others; and found that blacks had 8% higher adjusted odds of using permanent access compared to whites.…”

Section: Discussionmentioning

confidence: 99%

“…Women are shown to have lower probability of receiving AV fistula than men [12]. Zarkowsky et al [13] reported that Hispanic or black patients tend to use AV fistula less frequently than white patients to initiate hemodialysis; but did not consider AV graft as one of the parameters of successful AV access [13]. Prior studies stratified by race did not look at gender differences among them, or took into account Asian and Native American patients.…”

Section: Introductionmentioning

confidence: 99%

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Gender and Racial Disparities in Initial Hemodialysis Access and Outcomes in Incident End-Stage Renal Disease Patients

Shah¹,

Leonard

Meganathan

et al. 2018

Am J Nephrol

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Background: Arteriovenous (AV) access confers survival benefits over central venous catheters (CVC) in hemodialysis patients. Although chronic kidney disease disproportionately affects women and racial minorities, disparities in the utilization of hemodialysis access across Asians, Native Americans, Hispanics, blacks, and whites among males and females after accounting for pre-dialysis health are not well studied. Methods: We evaluated 885,699 patients with end-stage renal disease who initiated hemodialysis between January 1, 2004 and December 31, 2014 using the US Renal Data System. Multivariable logistic regression models adjusted for pre-dialysis health were used to test the associations between gender and race on type of vascular access (AV access vs. CVC, and AV fistula vs. AV graft) at hemodialysis initiation as primary outcome, and on 1-year mortality as a secondary outcome. Results: Mean age was 65 ± 14 years. Females were less likely to use AV access for hemodialysis initiation than were males (OR 0.85; 95% CI 0.84–0.86). Compared to whites, adjusted odds of AV access for hemodialysis initiation were higher in blacks (OR 1.08; 95% CI 1.07–1.70), Asians (OR 1.11; 95% CI 1.07–1.14); and lower in Hispanics (OR 0.89; 95% CI 0.87–0.90). There was no significant difference in mortality between males and females. Compared to whites, 1-year adjusted mortality was lower in Asians (OR 0.55; 95% CI 0.53–0.56), blacks (OR 0.67; 95% CI 0.66–0.68), Hispanics (OR 0.62; 95% CI 0.61–0.63), and Native Americans (OR 0.62; 95% CI 0.58–0.66). Conclusion: Females had lower odds of using AV access than do males for hemodialysis initiation. As compared to whites, blacks and Asians were more likely, and Hispanics were less likely to use AV access for first outpatient hemodialysis. Further investigation of biological and process of care factors may help in developing ways to reduce these disparities.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Gender and Racial Disparities in Initial Hemodialysis Access and Outcomes in Incident End-Stage Renal Disease Patients

Shah¹,

Leonard

Meganathan

et al. 2018

Am J Nephrol

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“…For example, a recent national analysis of all patients with ESRD in the USRDS revealed the lower rates of initiating dialysis with an arteriovenous fistula for black and Hispanic patients than whites, but the analysis did not assess contextual factors jointly with the patient factors (35). The few studies that examined contextual factors found some particular aspects of residential areas associated with the lower likelihood of patients having received pre-ESRD care, including residential areas with larger proportions of black residents (23), counties with greater poverty (25), large metropolitan or rural counties (24), or states with more stringent Medicaid coverage (36).…”

Section: Discussionmentioning

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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“…Similarly, Arce et al [29] demonstrated that Hispanics were significantly less likely to use an arteriovenous access for the first outpatient HD treatment compared with non-Hispanics (prevalence ratio 0.94). More recently, in a USRDS cohort of 396,075 patients initiating dialysis between 2006 and 2010, Zarkowsky et al [30] reported that white patients were significantly more likely to initiate HD with an AVF than AA (aOR 1.22) and Hispanic (aOR 1.32) patients. Key differences between that study and the current study are that we assessed measures of poverty in our model and ours is a larger cohort.…”

Section: Discussionmentioning

confidence: 99%

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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Racial/Ethnic Disparities Associated With Initial Hemodialysis Access

Cited by 91 publications

References 31 publications

Gender and Racial Disparities in Initial Hemodialysis Access and Outcomes in Incident End-Stage Renal Disease Patients

Gender and Racial Disparities in Initial Hemodialysis Access and Outcomes in Incident End-Stage Renal Disease Patients

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

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

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