Quality Improvement Targets for Regional Variation in Surgical End-Stage Renal Disease Care

JAMA Surg. 2015 Aug;150(8):764-70. doi: 10.1001/jamasurg.2015.1126.


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 comorbidities may explain some of these variations, but an opportunity to implement best-practice guidelines exists.

MeSH terms

  • Aged
  • Arteriovenous Shunt, Surgical / statistics & numerical data*
  • Female
  • Humans
  • Incidence
  • Kidney Failure, Chronic / epidemiology
  • Kidney Failure, Chronic / mortality*
  • Kidney Failure, Chronic / surgery*
  • Kidney Failure, Chronic / therapy
  • Male
  • Middle Aged
  • Quality Improvement*
  • Renal Dialysis / statistics & numerical data
  • Retrospective Studies
  • Risk Adjustment
  • United States / epidemiology