Association of insurance status with timing of hemodialysis access placement.

OBJECTIVE: Patients without adequate outpatient follow-up often present requiring emergency hemodialysis and then undergo permanent dialysis access placement at a later time. We sought to examine the relationship between type of insurance and whether a patient was already on dialysis at time of surgery. METHODS: The Vascular Quality Initiative Hemodialysis Access registry was queried for all adult patients undergoing first time permanent hemodialysis access between January 2015 and September 2019. Patient and procedural characteristics were examined in patients split by private insurance-Medicare more than 65 years of age, Medicare less than 65 years of age, and Medicaid. The primary outcome was whether patients were on dialysis at the time of surgery. RESULTS: There were 19,307 adult patients that underwent first time placement of an arteriovenous fistula or graft. Of these patients, 9729 (50%) had Medicare, 7179 (37%) had private insurance, and 2399 (12%) had Medicaid. The patients with Medicare were subgrouped by age with 2968 (31%) being less than 65 years of age and 6761 (69%) being more than 65 years of age. Patients with Medicare and less than 65 were the most likely to be on dialysis at the time of surgical access placement at 67%, whereas 59% of Medicaid patients were on dialysis, and 53% each group of patients with Medicare and more than 65 years of age and private insurance were on dialysis. After adjustment for patient characteristics, patients with Medicare who were less than 65 and more than 65 years of age were both significantly more likely to be on dialysis at time of surgery compared with private insurance with odds ratio (OR) of 1.64 (95% confidence interval [CI], 1.49-1.80; P < .001) and an OR of 1.11 (95% CI, 1.03-1.20; P = .007), respectively. After adjustment, patients with Medicaid were no longer significantly more likely to be on dialysis. Secondary outcomes demonstrated, after adjustment, no difference in the association between a surgical fistula vs graft in any insurance groups; however, patients with Medicare and who were less than 65 years of age were more likely to have a nonradial artery used for anastomosis with an OR of 1.18 (95% CI, 1.04-1.34; P = .011). CONCLUSIONS: Certain types of insurance are correlated with being on dialysis at the time of access placement. Although associations were seen between insurance type and surgical access characteristics, these were associations predominantly insignificant when patient demographics and status of dialysis were controlled for. These potential gaps in care represent an area for improvement that deserves further exploration.

Managing central venous access during a health care crisis.

OBJECTIVE: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic. METHODS: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19. RESULTS: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). CONCLUSIONS: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.