Veterans More Likely to Start Hemodialysis with an Arteriovenous Fistula

Abstract

Hemodialysis via arteriovenous fistulas (AVFs) is associated with reduced morbidity and mortality when compared to alternative vascular accesses, yet few patients in the United States start dialysis with AVFs. Recent studies have demonstrated higher quality of care for many conditions in Veterans Affairs' Medical Centers (VAMC); however, differences in quality of vascular access care are unknown. We used patient-level data (6/05-5/06) from Medicare claims (n = 25,912) to compare the proportions of AVF among incident patients at VAMC-affiliated (n = 20) and unaffiliated dialysis (n = 1631) facilities. Multivariate logistic regression was used to determine whether associations of access type with facility type were independent. Compared to non-VAMC patients, a larger proportion of VAMC patients started dialysis with AVFs (20.9% versus 11.6% in non-VAMC patients; OR 1.99, [95% CI 1.55-2.56]). Although attenuated, this finding persisted in models adjusted for demographics (OR 1.65 [95% CI 1.28-2.13]) and demographics with comorbidities (OR 1.70 [95% CI 1.31-2.20]). However, after accounting for pre end-stage renal disease (ESRD) care, similar proportions of VAMC and non-VAMC patients started hemodialysis with an AVF (OR 1.28 [95% CI 0.98-1.66]). In conclusion, patients receiving care at VAMC-associated facilities were more likely to start hemodialysis with AVFs, perhaps because of better pre-ESRD care. Nonetheless, AVF rates remain suboptimal, indicating a need for ongoing vascular access evaluation and improvement.