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American Journal of Kidney Diseases

Surgeon Characteristics and Dialysis Vascular Access Outcomes in the United States: A Retrospective Cohort Study

  • Vahakn B. Shahinian
    Affiliations
    Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI

    Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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  • Xiaosong Zhang
    Affiliations
    Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI

    Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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  • Anca M. Tilea
    Affiliations
    Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI

    Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI

    Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
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  • Kevin He
    Affiliations
    Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI

    Department of Biostatistics, University of Michigan, University of Michigan, Ann Arbor, MI
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  • Douglas E. Schaubel
    Affiliations
    Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI

    Department of Biostatistics, University of Michigan, University of Michigan, Ann Arbor, MI
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  • Wenbo Wu
    Affiliations
    Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI

    Department of Biostatistics, University of Michigan, University of Michigan, Ann Arbor, MI
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  • Ronald Pisoni
    Affiliations
    Arbor Research Collaborative for Health, Ann Arbor, MI
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  • Bruce Robinson
    Affiliations
    Arbor Research Collaborative for Health, Ann Arbor, MI
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  • Rajiv Saran
    Correspondence
    Address for Correspondence: Rajiv Saran, MBBS, MD, MRCP, MS, Division of Nephrology, Department of Internal Medicine, Kidney Epidemiology Cost Center, 1415 Washington Heights, 3645 School of Public Health I, University of Michigan, Ann Arbor, MI 48109-2029.
    Affiliations
    Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI

    Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI

    Department of Epidemiology, University of Michigan, Ann Arbor, MI
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  • Kenneth J. Woodside
    Affiliations
    Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI

    Department of Surgery, University of Michigan, Ann Arbor, MI
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Published:October 01, 2019DOI:https://doi.org/10.1053/j.ajkd.2019.08.001

      Rationale & Objective

      An arteriovenous fistula (AVF) is the preferred access for most patients receiving maintenance hemodialysis, but maturation failure remains a challenge. Surgeon characteristics have been proposed as contributors to AVF success. We examined variation in AVF placement and AVF outcomes by surgeon and surgeon characteristics.

      Study Design

      Retrospective cohort study.

      Setting & Participants

      National Medicare claims and web-based data submitted by dialysis facilities on maintenance hemodialysis patients from 2009 through 2015.

      Exposures

      Patient characteristics, including demographics and comorbid conditions; surgeon characteristics, including specialty, prior volume of AVF placements, and years since medical school graduation.

      Outcomes

      Percent of access placements that were an AVF from 2009 to 2015 (designated AVF placement), and percent of AVFs with successful use within 6 months of placement (maturation) from 2013 to 2014.

      Analytical Approach

      Multilevel logistic regression models examining the association of surgeon characteristics with the outcomes, adjusted for patient characteristics and dialysis facilities as random effects.

      Results

      Among 4,959 surgeons placing 467,827 accesses, median AVF placement was 71% (IQR, 59%-84%). More recent year of medical school graduation and general surgery specialty (vs vascular, cardiothoracic, or transplantation surgery) were associated with higher odds of AVF placement. Among 2,770 surgeons placing 49,826 AVFs, the median AVF maturation rate was 59% (IQR, 44%-71%). More recent year of medical school graduation, but not surgical specialty, was associated with higher odds of AVF maturation. Greater prior volume of AVF placement was associated with higher odds of AVF maturation: OR of 1.46 (95% CI, 1.37-1.57) for highest (>84 AVF placements in 2 years) versus lowest (<14) volume quintile.

      Limitations

      The study relied on administrative data, limiting capture of some factors affecting access outcomes.

      Conclusions

      There is substantial surgeon-level variation in AVF placements and AVF maturation. Surgeons’ prior volume of AVF placements is strongly associated with AVF maturation.

      Index Words

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      Linked Article

      • Surgeon Characteristics and Arteriovenous Fistula Maturation Success
        American Journal of Kidney DiseasesVol. 75Issue 2
        • Preview
          In this issue of AJKD, Shahinian et al1 report findings from a study analyzing the impact of surgeon characteristics on the incidence of autogenous arteriovenous hemodialysis access (AVF) creation and maturation among prevalent dialysis patients in the United States. Using data from the US Renal Data System encompassing almost 5,000 surgeons and 50,000 procedures, the authors reported that the median placement rate of AVFs (vs arteriovenous grafts) was 71% (interquartile range, 59%-84%) while the maturation rate was 59% (interquartile range, 44%-71%).
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