Vascular access practice patterns for dialysis vary based on specific surgeon characteristics
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For dialysis access, the likelihood of arteriovenous fistula placement and subsequent maturation varied based on specific surgeon characteristics, according to this study.
“A native arteriovenous (AV) fistula (AVF) is the access of choice for most patients because it is associated with the lowest risks for infection and overall mortality compared with AV grafts (AVGs) and, in particular, central venous catheters,” Vahakn B. Shahinian, MD, of the Kidney Epidemiology and Cost Center at the University of Michigan, and colleagues wrote. “Clinical practice guidelines and national quality improvement initiatives have promoted the use of AVFs, with a subsequent increase in their use among prevalent hemodialysis patients from 32% in 2003 to 63% in 2015, although there appears to be a plateau since 2013.”
The researchers proposed that this plateau could, in part, be due to the frequency with which AVFs fail to mature (occurring in 20% to 60% of cases). Noting that previous studies have found patient factors to be associated with AVF failure, “wide variations in AVF use and success across facilities even after robust adjustment for a host of patient factors suggest that there are other important contributors.”
To determine if surgeon characteristics play a role, they included 4,959 surgeons who placed at least 10 vascular accesses from 2009 to 2015 (total of 467,827 placements in 312,919 patients).
During the study period, the median rate of AVF placement was 71%, while the maturation rate was 59%.
The researchers found that surgeons who graduated from medical school more recently had higher odds for AVF placement. Further, specializing in general surgery, as opposed to vascular, cardiothoracic or transplantation surgery, was associated with higher odds for AVF placement.
More recent year of medical school graduation was also associated with higher odds for maturation, though specialty was not.
Finally, it was determined that surgeons who had greater prior volume of AVF placement were more likely to achieve AVF maturation (OR = 1.46 for >85 AVF placements in 2 years vs. < 14).
In a related editorial, Thomas S. Huber, MD, PhD, of the department of surgery at University of Florida College of Medicine, argued that it is important to remember “neither the AVF creation nor maturation rate should be used as a quality metric.” He wrote that if too much emphasis is placed on AVF creation, there may be a higher number of AVF procedures that won’t necessarily yield higher rates of maturation or, even more crucially, functional access. Citing the upcoming KDOQI guideline on vascular access (“the right access, in the right patient, at the right time, for the right reasons”), he contended that an AVF might not be the best option in all situations and that surgeons need to widen their focus from hemodialysis access to “a lifetime plan for kidney replacement therapy.” – by Melissa J. Webb
Disclosures: The authors report no relevant financial disclosures.
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