Racial/ethnic disparities associated with initial hemodialysis access

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

Research output: Contribution to journalArticle

40 Citations (Scopus)

Abstract

IMPORTANCE: Superior outcomes have been established with the use of an arteriovenous fistula (AVF) at first hemodialysis. However, considering the influence of comorbidities, medical insurance, and specialist care, racial/ethnic differences in the patterns of utilization of AVFs are unknown and deserve evaluation. OBJECTIVE: To assess national trends in initial hemodialysis access with respect to race/ethnicity stratified by comorbid disease, nephrology care, and medical insurance status within the US Renal Data System. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis of all patients with end-stage renal disease in the US Renal Data System who initiated hemodialysis between January 1, 2006, and December 31, 2010. Univariable statistics (Χ<sup>2</sup> test and analysis of variance) and logistic regression were used to compare racial/ethnic groups (white vs black vs Hispanic). Multivariable logistic regression and propensity score-matching techniques were used to evaluate hemodialysis access rates between patients of different races/ethnicities with comparable characteristics. MAINOUTCOMESAND MEASURES Utilization rates of AVF, arteriovenous graft, and intravascular hemodialysis catheter. RESULTS: In this cohort of 396 075 patients, more white patients initiated hemodialysis with an AVF than black patients or Hispanic patients (18.3% vs 15.5% and 14.6%, respectively; P <.001). Black patients and Hispanic patients initiated hemodialysis with an AVF less frequently despite being younger and having less coronary artery disease, chronic obstructive pulmonary disease, and cancer than white patients with an AVF. When stratified by medical insurance status, black patients (odds ratios, 0.90 [95% CI, 0.82-0.98] for uninsured and 0.85 [95% CI, 0.84-0.87] for insured) and Hispanic patients (odds ratios, 0.72 [95% CI, 0.65-0.81] for uninsured and 0.81 [95% CI, 0.79-0.84] for insured) persistently initiated hemodialysis with an AVF less frequently than white patients (P <.05 for all). Arteriovenous fistula utilization at initial hemodialysis was lower among black patients (odds ratio, 0.81 [95% CI, 0.78-0.84]) and Hispanic patients (odds ratio, 0.86 [95% CI, 0.82-0.90]) compared with white patients within the category of patients who had nephrology care for longer than 1 year (P <.001 for all). CONCLUSIONS AND RELEVANCE: Black patients and Hispanic patients tend to initiate hemodialysis with an AVF less frequently than white patients despite being younger and having fewer comorbidities. These disparities persisted independent of factors that drive health access for fistula placement, such as medical insurance status and nephrology care. The sociocultural underpinnings of these disparities deserve investigation and redress to maximize the benefits of initiating hemodialysis via fistula in patients with end-stage renal disease irrespective of race/ethnicity.

Original languageEnglish (US)
Pages (from-to)529-536
Number of pages8
JournalJAMA Surgery
Volume150
Issue number6
DOIs
StatePublished - Jun 1 2015

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Renal Dialysis
Arteriovenous Fistula
Hispanic Americans
Insurance Coverage
Nephrology
Odds Ratio
Information Systems
Chronic Kidney Failure
Fistula
Comorbidity
Logistic Models
Kidney
Propensity Score
Insurance
Ethnic Groups
Chronic Obstructive Pulmonary Disease

ASJC Scopus subject areas

  • Surgery

Cite this

Zarkowsky, D. S., Arhuidese, I. J., Hicks, C. W., Canner, J. K., Qazi, U., Obeid, T., ... Malas, M. B. (2015). Racial/ethnic disparities associated with initial hemodialysis access. JAMA Surgery, 150(6), 529-536. https://doi.org/10.1001/jamasurg.2015.0287

Racial/ethnic disparities associated with initial hemodialysis access. / Zarkowsky, Devin S.; Arhuidese, Isibor J.; Hicks, Caitlin W.; Canner, Joseph K.; Qazi, Umair; Obeid, Tammam; Schneider, Eric; Abularrage, Christopher J.; Freischlag, Julie A.; Malas, Mahmoud B.

In: JAMA Surgery, Vol. 150, No. 6, 01.06.2015, p. 529-536.

Research output: Contribution to journalArticle

Zarkowsky, DS, Arhuidese, IJ, Hicks, CW, Canner, JK, Qazi, U, Obeid, T, Schneider, E, Abularrage, CJ, Freischlag, JA & Malas, MB 2015, 'Racial/ethnic disparities associated with initial hemodialysis access', JAMA Surgery, vol. 150, no. 6, pp. 529-536. https://doi.org/10.1001/jamasurg.2015.0287
Zarkowsky DS, Arhuidese IJ, Hicks CW, Canner JK, Qazi U, Obeid T et al. Racial/ethnic disparities associated with initial hemodialysis access. JAMA Surgery. 2015 Jun 1;150(6):529-536. https://doi.org/10.1001/jamasurg.2015.0287
Zarkowsky, Devin S. ; Arhuidese, Isibor J. ; Hicks, Caitlin W. ; Canner, Joseph K. ; Qazi, Umair ; Obeid, Tammam ; Schneider, Eric ; Abularrage, Christopher J. ; Freischlag, Julie A. ; Malas, Mahmoud B. / Racial/ethnic disparities associated with initial hemodialysis access. In: JAMA Surgery. 2015 ; Vol. 150, No. 6. pp. 529-536.
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abstract = "IMPORTANCE: Superior outcomes have been established with the use of an arteriovenous fistula (AVF) at first hemodialysis. However, considering the influence of comorbidities, medical insurance, and specialist care, racial/ethnic differences in the patterns of utilization of AVFs are unknown and deserve evaluation. OBJECTIVE: To assess national trends in initial hemodialysis access with respect to race/ethnicity stratified by comorbid disease, nephrology care, and medical insurance status within the US Renal Data System. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis of all patients with end-stage renal disease in the US Renal Data System who initiated hemodialysis between January 1, 2006, and December 31, 2010. Univariable statistics (Χ2 test and analysis of variance) and logistic regression were used to compare racial/ethnic groups (white vs black vs Hispanic). Multivariable logistic regression and propensity score-matching techniques were used to evaluate hemodialysis access rates between patients of different races/ethnicities with comparable characteristics. MAINOUTCOMESAND MEASURES Utilization rates of AVF, arteriovenous graft, and intravascular hemodialysis catheter. RESULTS: In this cohort of 396 075 patients, more white patients initiated hemodialysis with an AVF than black patients or Hispanic patients (18.3{\%} vs 15.5{\%} and 14.6{\%}, respectively; P <.001). Black patients and Hispanic patients initiated hemodialysis with an AVF less frequently despite being younger and having less coronary artery disease, chronic obstructive pulmonary disease, and cancer than white patients with an AVF. When stratified by medical insurance status, black patients (odds ratios, 0.90 [95{\%} CI, 0.82-0.98] for uninsured and 0.85 [95{\%} CI, 0.84-0.87] for insured) and Hispanic patients (odds ratios, 0.72 [95{\%} CI, 0.65-0.81] for uninsured and 0.81 [95{\%} CI, 0.79-0.84] for insured) persistently initiated hemodialysis with an AVF less frequently than white patients (P <.05 for all). Arteriovenous fistula utilization at initial hemodialysis was lower among black patients (odds ratio, 0.81 [95{\%} CI, 0.78-0.84]) and Hispanic patients (odds ratio, 0.86 [95{\%} CI, 0.82-0.90]) compared with white patients within the category of patients who had nephrology care for longer than 1 year (P <.001 for all). CONCLUSIONS AND RELEVANCE: Black patients and Hispanic patients tend to initiate hemodialysis with an AVF less frequently than white patients despite being younger and having fewer comorbidities. These disparities persisted independent of factors that drive health access for fistula placement, such as medical insurance status and nephrology care. The sociocultural underpinnings of these disparities deserve investigation and redress to maximize the benefits of initiating hemodialysis via fistula in patients with end-stage renal disease irrespective of race/ethnicity.",
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T1 - Racial/ethnic disparities associated with initial hemodialysis access

AU - Zarkowsky, Devin S.

AU - Arhuidese, Isibor J.

AU - Hicks, Caitlin W.

AU - Canner, Joseph K.

AU - Qazi, Umair

AU - Obeid, Tammam

AU - Schneider, Eric

AU - Abularrage, Christopher J.

AU - Freischlag, Julie A.

AU - Malas, Mahmoud B.

PY - 2015/6/1

Y1 - 2015/6/1

N2 - IMPORTANCE: Superior outcomes have been established with the use of an arteriovenous fistula (AVF) at first hemodialysis. However, considering the influence of comorbidities, medical insurance, and specialist care, racial/ethnic differences in the patterns of utilization of AVFs are unknown and deserve evaluation. OBJECTIVE: To assess national trends in initial hemodialysis access with respect to race/ethnicity stratified by comorbid disease, nephrology care, and medical insurance status within the US Renal Data System. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis of all patients with end-stage renal disease in the US Renal Data System who initiated hemodialysis between January 1, 2006, and December 31, 2010. Univariable statistics (Χ2 test and analysis of variance) and logistic regression were used to compare racial/ethnic groups (white vs black vs Hispanic). Multivariable logistic regression and propensity score-matching techniques were used to evaluate hemodialysis access rates between patients of different races/ethnicities with comparable characteristics. MAINOUTCOMESAND MEASURES Utilization rates of AVF, arteriovenous graft, and intravascular hemodialysis catheter. RESULTS: In this cohort of 396 075 patients, more white patients initiated hemodialysis with an AVF than black patients or Hispanic patients (18.3% vs 15.5% and 14.6%, respectively; P <.001). Black patients and Hispanic patients initiated hemodialysis with an AVF less frequently despite being younger and having less coronary artery disease, chronic obstructive pulmonary disease, and cancer than white patients with an AVF. When stratified by medical insurance status, black patients (odds ratios, 0.90 [95% CI, 0.82-0.98] for uninsured and 0.85 [95% CI, 0.84-0.87] for insured) and Hispanic patients (odds ratios, 0.72 [95% CI, 0.65-0.81] for uninsured and 0.81 [95% CI, 0.79-0.84] for insured) persistently initiated hemodialysis with an AVF less frequently than white patients (P <.05 for all). Arteriovenous fistula utilization at initial hemodialysis was lower among black patients (odds ratio, 0.81 [95% CI, 0.78-0.84]) and Hispanic patients (odds ratio, 0.86 [95% CI, 0.82-0.90]) compared with white patients within the category of patients who had nephrology care for longer than 1 year (P <.001 for all). CONCLUSIONS AND RELEVANCE: Black patients and Hispanic patients tend to initiate hemodialysis with an AVF less frequently than white patients despite being younger and having fewer comorbidities. These disparities persisted independent of factors that drive health access for fistula placement, such as medical insurance status and nephrology care. The sociocultural underpinnings of these disparities deserve investigation and redress to maximize the benefits of initiating hemodialysis via fistula in patients with end-stage renal disease irrespective of race/ethnicity.

AB - IMPORTANCE: Superior outcomes have been established with the use of an arteriovenous fistula (AVF) at first hemodialysis. However, considering the influence of comorbidities, medical insurance, and specialist care, racial/ethnic differences in the patterns of utilization of AVFs are unknown and deserve evaluation. OBJECTIVE: To assess national trends in initial hemodialysis access with respect to race/ethnicity stratified by comorbid disease, nephrology care, and medical insurance status within the US Renal Data System. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis of all patients with end-stage renal disease in the US Renal Data System who initiated hemodialysis between January 1, 2006, and December 31, 2010. Univariable statistics (Χ2 test and analysis of variance) and logistic regression were used to compare racial/ethnic groups (white vs black vs Hispanic). Multivariable logistic regression and propensity score-matching techniques were used to evaluate hemodialysis access rates between patients of different races/ethnicities with comparable characteristics. MAINOUTCOMESAND MEASURES Utilization rates of AVF, arteriovenous graft, and intravascular hemodialysis catheter. RESULTS: In this cohort of 396 075 patients, more white patients initiated hemodialysis with an AVF than black patients or Hispanic patients (18.3% vs 15.5% and 14.6%, respectively; P <.001). Black patients and Hispanic patients initiated hemodialysis with an AVF less frequently despite being younger and having less coronary artery disease, chronic obstructive pulmonary disease, and cancer than white patients with an AVF. When stratified by medical insurance status, black patients (odds ratios, 0.90 [95% CI, 0.82-0.98] for uninsured and 0.85 [95% CI, 0.84-0.87] for insured) and Hispanic patients (odds ratios, 0.72 [95% CI, 0.65-0.81] for uninsured and 0.81 [95% CI, 0.79-0.84] for insured) persistently initiated hemodialysis with an AVF less frequently than white patients (P <.05 for all). Arteriovenous fistula utilization at initial hemodialysis was lower among black patients (odds ratio, 0.81 [95% CI, 0.78-0.84]) and Hispanic patients (odds ratio, 0.86 [95% CI, 0.82-0.90]) compared with white patients within the category of patients who had nephrology care for longer than 1 year (P <.001 for all). CONCLUSIONS AND RELEVANCE: Black patients and Hispanic patients tend to initiate hemodialysis with an AVF less frequently than white patients despite being younger and having fewer comorbidities. These disparities persisted independent of factors that drive health access for fistula placement, such as medical insurance status and nephrology care. The sociocultural underpinnings of these disparities deserve investigation and redress to maximize the benefits of initiating hemodialysis via fistula in patients with end-stage renal disease irrespective of race/ethnicity.

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