Hispanic Ethnicity and Vascular Access Use in Patients Initiating Hemodialysis in the United States

Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA.
Clinical Journal of the American Society of Nephrology (Impact Factor: 4.61). 11/2011; 7(2):289-96. DOI: 10.2215/CJN.08370811
Source: PubMed


Hispanics are the largest minority in the United States (comprising 16.3% of the US population) and have 1.5 times the age-, sex-, and race-adjusted incidence of ESRD compared with non-Hispanics. Poor health care access and low-quality care generally received by Hispanics are well documented. However, little is known regarding dialysis preparation of Hispanic patients with progressive CKD.
Using data from Medical Evidence Report form CMS-2728-U3, 321,996 adult patients of white or black race were identified who initiated hemodialysis (HD) between July 1, 2005 and December 31, 2008. The form captures Hispanic ethnicity, vascular access use at first outpatient HD, sociodemographic characteristics, and comorbidities. This study also examined whether use of an arteriovenous fistula (AVF) or graft (AVG) was reported.
AVF/AVG use was reported in 14.5% of Hispanics and 17.6% in non-Hispanics (P<0.001). The unadjusted prevalence ratio (PR) was 0.85 (95% confidence interval [95% CI], 0.83-0.88), indicating that Hispanics were 15% less likely to use AVG/AVF for their first outpatient HD. Adjustment for age, sex, and race, as well as a large number of comorbidities and frailty indicators, did not change this association (PR, 0.85; 95% CI, 0.83-0.88). Further adjustment for timing of first predialysis nephrology care, however, attenuated the PR by two-thirds (PR, 0.94; 95% CI, 0.92-0.97).
Hispanics are less likely to use arteriovenous access for first outpatient HD compared with non-Hispanics, which seems to be explained by variation in the access to predialysis nephrology care.

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    • "In 2005, the Centers for Medicare & Medicaid Services (CMS) revised the end-stage renal disease (ESRD) Medical Evidence Report (form CMS-2728) to collect information regarding the type of access used at the first outpatient dialysis session for incident patients. While some studies have used the vascular access data from form CMS-2728, lack of validation of those data is cited as a limitation by several authors [27-30]. Previous studies have attempted to validate other data from form CMS-2728, resulting in varying levels of validity and reliability [31-33]. "
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    ABSTRACT: The choice of vascular access type is an important aspect of care for incident hemodialysis patients. However, data from the Centers for Medicare & Medicaid Services (CMS) Medical Evidence Report (form CMS-2728) identifying the first access for incident patients have not previously been validated. Medicare began requiring that vascular access type be reported on claims in July 2010. We aimed to determine the agreement between the reported vascular access at initiation from form CMS-2728 and from Medicare claims. This retrospective study used a cohort of 9777 patients who initiated dialysis in the latter half of 2010 and were eligible for Medicare at the start of renal replacement therapy to compare the vascular access type reported on form CMS-2728 with the type reported on Medicare outpatient dialysis claims for the same patients. For each patient, the reported access from each data source was compiled; the percent agreement represented the percent of patients for whom the access was the same. Multivariate logistic analysis was performed to identify characteristics associated with the agreement of reported access. The two data sources agreed for 94% of patients, with a Kappa statistic of 0.83, indicating an excellent level of agreement. Further, we found no evidence to suggest that agreement was associated with the patient characteristics of age, sex, race, or primary cause of renal failure. These results suggest that vascular access data as reported on form CMS-2728 are valid and reliable for use in research studies.
    BMC Nephrology 02/2014; 15(1):30. DOI:10.1186/1471-2369-15-30 · 1.69 Impact Factor
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    Clinical Journal of the American Society of Nephrology 02/2012; 7(2):196-8. DOI:10.2215/CJN.13021211 · 4.61 Impact Factor
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    ABSTRACT: The number of elderly (≥65 years) end-stage renal disease (ESRD) patients on hemodialysis is rapidly increasing. Vascular access outcomes remain contradictory and understudied across different elderly populations. We hypothesized age might influence primary autogenous fistula use and outcomes in a predominantly diabetic multiethnic Asian ESRD population. Demographic and clinical factors affecting fistula patency and maturation were retrospectively compared among patients with incident ESRD aged <65 and ≥65 years at a single center. Fistula patency was estimated by Kaplan-Meier curves with log-rank test comparison. We analyzed 280 primary fistulas (59% radiocephalic, 33% brachiocephalic, and 8% brachiobasilic) in this cohort consisting of 31.8% aged ≥65 years, 50% Chinese, 39% Malay, 42% women, and 70% diabetic. One- and 2-year primary and secondary patency in patients aged <65 vs ≥65 years were comparable: 41.3% vs 36.7% and 28.7% vs 24.4% (P = .547) and 57.7% vs 56.8% and 47.1% vs 47.2% (P = .990). On multivariate analysis, only non-Chinese, dialysis initiation with tunneled catheters, and surgical/endovascular interventions affected fistula survival hazard ratios (HR): 0.622 (95% confidence interval [CI], 0.43-1.00), 0.549 (95% CI, 0.297-0.841), and 2.503 (95% CI, 1.695-3.697), respectively. Nonmaturation and intervention rates were also similar at 56.7% vs 61.8% and 34% vs 32.2% at 3 and 6 months and 0.31 vs 0.36 per access year, respectively (P > .05). Females and tunneled catheters were the only risk factors for nonmaturation (HR, 1.568; 95% CI, 1.148-1.608, and HR, 1.623; 95% CI, 1.400-1.881, respectively). A primary fistula strategy in incident elderly ESRD is feasible and does not result in inferior outcomes. Age should therefore not be a determinant for primary fistula creation.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 05/2012; 56(2):433-9. DOI:10.1016/j.jvs.2012.01.063 · 3.02 Impact Factor
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