Quality improvement targets for regional variation in surgical end-stage renal disease care

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

Research output: Contribution to journalArticle

12 Citations (Scopus)

Abstract

IMPORTANCE Arteriovenous fistula (AVF) access improves survival in patients with end-stage renal disease (ESRD) compared with other modalities when used at first hemodialysis. Use varies between locations, but, to our knowledge, no study has related this finding to mortality on a national scale. OBJECTIVE To quantify regional variation in AVF access at first hemodialysis, as well as the associated effect on mortality in the US Renal Data System. DESIGN, SETTING, AND PARTICIPANTS The US Renal Data System tracks all patients with ESRD in the United States. A retrospective analysis of the population from January 1, 2006, to December 31, 2010, was performed. Univariate analyses (χ<sup>2</sup> test; 2-tailed, unpaired t test; and analysis of variance) as well as multivariable logistic regressions were carried out to compare patient characteristics, incident AVF frequencies, and corrected mortality hazards between ESRD Network Programs, which comprise 18 states, commonwealths, and protectorates in which residents receive hemodialysis. Of the patients receiving hemodialysis in these networks, the data on 464 547 individuals who were beginning renal replacement therapy were analyzed. Analysis was started April 1, 2013, and ended August 3, 2014. MAIN OUTCOMES AND MEASURES Mortality hazard variation between ESRD Network Programs in the United States and incident AVF frequency. RESULTS Of the 464 547 patients beginning hemodialysis in this cohort, first hemodialysis with an AVF ranged from 11.1%to 22.2%depending on the ESRD Network in which they maintained residency (P <.001). Similarly, corrected mortality hazard varied by 28%(hazard ratios from 0.99 [95%CI, 0.96-1.03] to 1.27 [95%CI, 1.22-1.31]; P <.001). Logistic regression determined nephrology care to increase the odds of a patient beginning hemodialysis using an AVF by 11-fold (odds ratio, 11.42 [95%CI, 10.93-11.93]; P <.001); congestive heart failure was a negative correlatefold (odds ratio, 0.65 [95%CI, 0.64-0.67]; P <.001). No region achieved the 50% Fistula First Breakthrough Initiative (now known as Fistula First Catheter Last) target for incident AVF access. CONCLUSIONS AND RELEVANCE Marked regional variation in functional incident AVF frequency and risk-adjusted ESRD mortality exists across the United States. Differences in access to preoperative nephrology care and patient comorbiditiesmay explain some of these variations, but an opportunity to implement best-practice guidelines exists.

Original languageEnglish (US)
Pages (from-to)764-770
Number of pages7
JournalJAMA Surgery
Volume150
Issue number8
DOIs
StatePublished - Aug 1 2015

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Arteriovenous Fistula
Quality Improvement
Chronic Kidney Failure
Renal Dialysis
Mortality
Nephrology
Practice Guidelines
Information Systems
Fistula
Logistic Models
Odds Ratio
Preoperative Care
Kidney
Renal Replacement Therapy
Internship and Residency
Analysis of Variance
Catheters
Heart Failure
Outcome Assessment (Health Care)
Survival

ASJC Scopus subject areas

  • Surgery

Cite this

Zarkowsky, D. S., Hicks, C. W., Arhuidese, I., Canner, J. K., Obeid, T., Qazi, U., ... Malas, M. B. (2015). Quality improvement targets for regional variation in surgical end-stage renal disease care. JAMA Surgery, 150(8), 764-770. https://doi.org/10.1001/jamasurg.2015.1126

Quality improvement targets for regional variation in surgical end-stage renal disease care. / Zarkowsky, Devin S.; Hicks, Caitlin W.; Arhuidese, Isibor; Canner, Joseph K.; Obeid, Tammam; Qazi, Umair; Schneider, Eric; Abularrage, Christopher J.; Black, James H.; Freischlag, Julie A.; Malas, Mahmoud B.

In: JAMA Surgery, Vol. 150, No. 8, 01.08.2015, p. 764-770.

Research output: Contribution to journalArticle

Zarkowsky, DS, Hicks, CW, Arhuidese, I, Canner, JK, Obeid, T, Qazi, U, Schneider, E, Abularrage, CJ, Black, JH, Freischlag, JA & Malas, MB 2015, 'Quality improvement targets for regional variation in surgical end-stage renal disease care', JAMA Surgery, vol. 150, no. 8, pp. 764-770. https://doi.org/10.1001/jamasurg.2015.1126
Zarkowsky DS, Hicks CW, Arhuidese I, Canner JK, Obeid T, Qazi U et al. Quality improvement targets for regional variation in surgical end-stage renal disease care. JAMA Surgery. 2015 Aug 1;150(8):764-770. https://doi.org/10.1001/jamasurg.2015.1126
Zarkowsky, Devin S. ; Hicks, Caitlin W. ; Arhuidese, Isibor ; Canner, Joseph K. ; Obeid, Tammam ; Qazi, Umair ; Schneider, Eric ; Abularrage, Christopher J. ; Black, James H. ; Freischlag, Julie A. ; Malas, Mahmoud B. / Quality improvement targets for regional variation in surgical end-stage renal disease care. In: JAMA Surgery. 2015 ; Vol. 150, No. 8. pp. 764-770.
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abstract = "IMPORTANCE Arteriovenous fistula (AVF) access improves survival in patients with end-stage renal disease (ESRD) compared with other modalities when used at first hemodialysis. Use varies between locations, but, to our knowledge, no study has related this finding to mortality on a national scale. OBJECTIVE To quantify regional variation in AVF access at first hemodialysis, as well as the associated effect on mortality in the US Renal Data System. DESIGN, SETTING, AND PARTICIPANTS The US Renal Data System tracks all patients with ESRD in the United States. A retrospective analysis of the population from January 1, 2006, to December 31, 2010, was performed. Univariate analyses (χ2 test; 2-tailed, unpaired t test; and analysis of variance) as well as multivariable logistic regressions were carried out to compare patient characteristics, incident AVF frequencies, and corrected mortality hazards between ESRD Network Programs, which comprise 18 states, commonwealths, and protectorates in which residents receive hemodialysis. Of the patients receiving hemodialysis in these networks, the data on 464 547 individuals who were beginning renal replacement therapy were analyzed. Analysis was started April 1, 2013, and ended August 3, 2014. MAIN OUTCOMES AND MEASURES Mortality hazard variation between ESRD Network Programs in the United States and incident AVF frequency. RESULTS Of the 464 547 patients beginning hemodialysis in this cohort, first hemodialysis with an AVF ranged from 11.1{\%}to 22.2{\%}depending on the ESRD Network in which they maintained residency (P <.001). Similarly, corrected mortality hazard varied by 28{\%}(hazard ratios from 0.99 [95{\%}CI, 0.96-1.03] to 1.27 [95{\%}CI, 1.22-1.31]; P <.001). Logistic regression determined nephrology care to increase the odds of a patient beginning hemodialysis using an AVF by 11-fold (odds ratio, 11.42 [95{\%}CI, 10.93-11.93]; P <.001); congestive heart failure was a negative correlatefold (odds ratio, 0.65 [95{\%}CI, 0.64-0.67]; P <.001). No region achieved the 50{\%} Fistula First Breakthrough Initiative (now known as Fistula First Catheter Last) target for incident AVF access. CONCLUSIONS AND RELEVANCE Marked regional variation in functional incident AVF frequency and risk-adjusted ESRD mortality exists across the United States. Differences in access to preoperative nephrology care and patient comorbiditiesmay explain some of these variations, but an opportunity to implement best-practice guidelines exists.",
author = "Zarkowsky, {Devin S.} and Hicks, {Caitlin W.} and Isibor Arhuidese and Canner, {Joseph K.} and Tammam Obeid and Umair Qazi and Eric Schneider and Abularrage, {Christopher J.} and Black, {James H.} and Freischlag, {Julie A.} and Malas, {Mahmoud B.}",
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AU - Zarkowsky, Devin S.

AU - Hicks, Caitlin W.

AU - Arhuidese, Isibor

AU - Canner, Joseph K.

AU - Obeid, Tammam

AU - Qazi, Umair

AU - Schneider, Eric

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AU - Malas, Mahmoud B.

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N2 - IMPORTANCE Arteriovenous fistula (AVF) access improves survival in patients with end-stage renal disease (ESRD) compared with other modalities when used at first hemodialysis. Use varies between locations, but, to our knowledge, no study has related this finding to mortality on a national scale. OBJECTIVE To quantify regional variation in AVF access at first hemodialysis, as well as the associated effect on mortality in the US Renal Data System. DESIGN, SETTING, AND PARTICIPANTS The US Renal Data System tracks all patients with ESRD in the United States. A retrospective analysis of the population from January 1, 2006, to December 31, 2010, was performed. Univariate analyses (χ2 test; 2-tailed, unpaired t test; and analysis of variance) as well as multivariable logistic regressions were carried out to compare patient characteristics, incident AVF frequencies, and corrected mortality hazards between ESRD Network Programs, which comprise 18 states, commonwealths, and protectorates in which residents receive hemodialysis. Of the patients receiving hemodialysis in these networks, the data on 464 547 individuals who were beginning renal replacement therapy were analyzed. Analysis was started April 1, 2013, and ended August 3, 2014. MAIN OUTCOMES AND MEASURES Mortality hazard variation between ESRD Network Programs in the United States and incident AVF frequency. RESULTS Of the 464 547 patients beginning hemodialysis in this cohort, first hemodialysis with an AVF ranged from 11.1%to 22.2%depending on the ESRD Network in which they maintained residency (P <.001). Similarly, corrected mortality hazard varied by 28%(hazard ratios from 0.99 [95%CI, 0.96-1.03] to 1.27 [95%CI, 1.22-1.31]; P <.001). Logistic regression determined nephrology care to increase the odds of a patient beginning hemodialysis using an AVF by 11-fold (odds ratio, 11.42 [95%CI, 10.93-11.93]; P <.001); congestive heart failure was a negative correlatefold (odds ratio, 0.65 [95%CI, 0.64-0.67]; P <.001). No region achieved the 50% Fistula First Breakthrough Initiative (now known as Fistula First Catheter Last) target for incident AVF access. CONCLUSIONS AND RELEVANCE Marked regional variation in functional incident AVF frequency and risk-adjusted ESRD mortality exists across the United States. Differences in access to preoperative nephrology care and patient comorbiditiesmay explain some of these variations, but an opportunity to implement best-practice guidelines exists.

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