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. 2017 Sep 2;18(1):279.
doi: 10.1186/s12882-017-0700-9.

A mixed-methods investigation of incident Hemodialysis access in a safety-net population

Nicole C Rich  1 , Shant M Vartanian  2 , Shimi Sharief  3 , Daniel J Freitas  4 , Delphine S Tuot  3
Affiliations

A mixed-methods investigation of incident Hemodialysis access in a safety-net population

Nicole C Rich et al. BMC Nephrol. .

Abstract

Background: Despite improved health outcomes associated with arteriovenous fistulas, 80% of Americans initiate hemodialysis using a catheter, influenced by low socioeconomic status among other factors. Risk factors for incident catheter use in safety-net populations are unknown. Our objective was to identify factors associated with incident catheter use among hemodialysis patients at one safety-net hospital, with a goal of informing fistula placement initiatives targeted at safety-net populations more generally.

Methods: We performed a retrospective review of all incident hemodialysis patients at a single urban safety-net hospital from January 1, 2010 - December 31, 2015 (n = 241), as well as semi-structured interviews with a multi-lingual convenience sample of patients (n = 10) from this cohort. The primary outcome was incident vascular access modality. Multivariable logistic regression was used to identify factors associated with incident catheter use. Interview transcripts were coded using a directed content analysis framework based on a model describing barriers to healthcare access.

Results: Subjects were 61.8% male, racially/ethnically diverse (19.5% white, 29.5% black, 28.6% Hispanic, 17.4% Asian), with a mean age of 52.4 years. Eighty-eight percent initiated hemodialysis using a catheter. In multivariable analysis, longer duration of nephrology care was associated with decreased catheter use (>12 months vs. 0-6 months: adjusted Odds Ratio [aOR] 0.07, 95% CI 0.02-0.23, p < 0.001), whereas uninsured status increased odds of catheter use (aOR 3.96, 1.23-12.76, p = 0.02). There was a decrease in catheter use after vascular surgery services became available in-hospital (OR 0.40, 95% CI 0.16-0.98, p = 0.04), however this association was not significant in multivariable analysis (aOR 0.48, 0.17-1.36, p = 0.17). During interviews, patients cited emotional responses to disease, lack of social and financial resources, and limited health knowledge as barriers to obtaining fistula surgery.

Conclusions: The rate of catheter use in this urban safety-net population is above the national average. Access to health insurance, early referrals to nephrology, and provision of in-hospital vascular surgery should be prioritized in the safety-net. Additionally, services that support patients' emotional and learning needs may decrease delays in fistula placement.

Keywords: Arteriovenous fistula; Disparities; Hemodialysis access; Safety-net; Vascular access; Vascular surgery.

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Conflict of interest statement

Ethics approval and consent to participate

The University of California, San Francisco Institutional Review Board approved all portions of this study (UCSF IRB# 15–17,918). According to IRB guidelines for the study, informed consent was waived for the retrospective review, but written informed consent was obtained from all interview participants.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Incident Vascular Access Modality 2010–2015
Fig. 2
Fig. 2
Incident Vascular Access Modality by Year
See this image and copyright information in PMC

References

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