Clinician-Level Knowledge and Barriers to Hepatocellular Carcinoma Surveillance.

Importance: Surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is underused. Identifying potentially modifiable factors to address barriers in HCC surveillance is critical to improve patient outcomes. Objective: To evaluate clinician-level factors contributing to underuse of HCC surveillance in patients with cirrhosis. Design, Setting, and Participants: This survey study included primary care clinicians (PCCs) and gastroenterology and hepatology clinicians at 5 safety-net health systems in the US. Clinicians were surveyed from March 15 to September 15, 2023, to assess knowledge, attitudes, beliefs, perceived barriers, and COVID-19-related disruptions in HCC surveillance in patients with cirrhosis. Data were analyzed from October to November 2023. Main Outcome and Measures: HCC surveillance knowledge was assessed with 6 questions querying the respondent's ability to correctly identify appropriate use of HCC surveillance. Attitudes, perceived barriers, and beliefs regarding HCC surveillance and perceived impact of the COVID-19 pandemic-related disruptions with HCC surveillance were assessed with a series of statements using a 4-point Likert scale and compared PCCs and gastroenterology and hepatology clinicians. Results: Overall, 347 of 1362 clinicians responded to the survey (25.5% response rate), among whom 142 of 237 (59.9%) were PCCs, 48 of 237 (20.3%) gastroenterology and hepatology, 190 of 236 (80.5%) were doctors of medicine and doctors of osteopathic medicine, and 46 of 236 (19.5%) were advanced practice clinicians. On HCC knowledge assessment, 144 of 270 (53.3%) scored 5 or more of 6 questions correctly, 37 of 48 (77.1%) among gastroenterology and hepatology vs 65 of 142 (45.8%) among PCCs (P < .001). Those with higher HCC knowledge scores were less likely to report barriers to HCC surveillance. PCCs were more likely to report inadequate time to discuss HCC surveillance (37 of 139 [26.6%] vs 2 of 48 [4.2%]; P = .001), difficulty identifying patients with cirrhosis (82 of 141 [58.2%] vs 5 of 48 [10.4%]; P < .001), and were not up-to-date with HCC surveillance guidelines (87 of 139 [62.6%] vs 5 of 48 [10.4%]; P < .001) compared with gastroenterology and hepatology clinicians. While most acknowledged delays during the COVID-19 pandemic, 62 of 136 PCCs (45.6%) and 27 of 45 gastroenterology and hepatology clinicians (60.0%) reported that patients with cirrhosis could currently complete HCC surveillance without delays. Conclusions and Relevance: In this survey study, important gaps in knowledge and perceived barriers to HCC surveillance were identified. Effective delivery of HCC education to PCCs and health system-level interventions must be pursued in parallel to address the complex barriers affecting suboptimal HCC surveillance in patients with cirrhosis.

Trends in Vascular Access Among Patients Initiating Hemodialysis in the US.

This cohort study uses the US Renal Data System database to analyze trends in vascular access among more than 600 000 patients who initiated hemodialysis from 2015 to 2020.

Who Is at Risk for New Hepatitis B Infections Among People With HIV?

Hepatitis B virus (HBV) increases morbidity and mortality among people with HIV (PWH). We retrospectively analyzed HBV incidence among 5785 PWH. Fourteen had newly positive hepatitis B s antigen (mean 5.2 person-years of follow-up, 46.4/100 000 infections/year). These data show gaps in HBV vaccination and in the preventative efficacy of HBV-specific antiretroviral therapy.

Persistent low prevalence of hepatitis B vaccination among people with HIV: Time for a change?

Hepatitis B virus (HBV) infection is one of the leading causes of hepatocellular carcinoma and mortality among people living with HIV (PLWH). HBV vaccination provides protection from infection; however, vaccination rates are low. We conducted a retrospective analysis at three HIV centres in Texas to determine the proportion of PLWH who received the recommended 3 doses of hepatitis B vaccine within 1 year. Factors associated with vaccination completion were explored. In our sample of three sites in a state with high HIV transmission and high rates of liver disease from 2011 to 2021, showed low rates of hepatitis B vaccination. Among eligible PLWH, only 9% completed the 3-dose hepatitis B vaccine series in 1 year. There is an urgent need to improve HBV vaccination to reach 2030 target for hepatitis B elimination.

Chronic Liver Disease and Cirrhosis are Associated with Worse Outcomes Following SARS-CoV-2 Infection.

Background and aims: Studies evaluating the impact of SARS-CoV-2 on chronic liver disease (CLD) are limited and have focused mostly on hospitalized patients or those with cirrhosis. We aim to evaluate the impact of underlying CLD on patient outcomes following COVID-19 using a one of the largest COVID-19+CLD cohorts to date. Methods: Data from the COVID-19 Research Database (https://covid19researchdatabase.org) were evaluated from April 1, 2020, to August 31, 2021, to determine whether concurrent CLD was associated with worse outcomes within 30 day of COVID-19 diagnosis, including need for hospitalization, pneumonia, severe pneumonia, respiratory failure, and multiorgan failure. Among patients with COVID-19+CLD, risks of liver decompensation and acute on chronic liver failure (ACLF) were evaluated, stratified by presence of cirrhosis. Adjusted multivariate logistic regression models evaluated the impact of CLD on COVID-19 outcomes. Results: In total, 1,208,905 unique patients with COVID-19 were identified; 44,008 (3.6%) had concurrent CLD, among which 6515 (14.8%) had cirrhosis. Compared to patients without CLD, COVID-19+CLD patients were significantly more likely to require hospitalization (aOR 1.65, 95% CI 1.61-1.69), develop pneumonia (aOR 1.11, 95% CI 1.08-1.14), severe pneumonia (aOR 1.74, 95% CI 1.62-1.86), respiratory failure (aOR 1.14, 95% CI 1.10-1.17), and multiorgan failure (aOR 1.84, 95% CI 1.72-1.97), P < 0.0001 for all. Among COVID-19+CLD patients, underlying cirrhosis was associated with even higher risk of these poor outcomes, and higher risk of acute liver decompensation or ACLF. Conclusions: Among one of the largest studies to date evaluating patients with COVID-19 and CLD, underlying CLD is associated with significantly greater risk of poor outcomes following SARS-CoV-2 infection, particularly among cirrhotic patients.

Racial Disparities in Arteriovenous Fistula Use Among Hemodialysis Patients: The Role of Surgeon Supply.

Introduction: Factors contributing to racial disparities in arteriovenous fistula (AVF) use among hemodialysis (HD) patients remain poorly defined. We evaluated whether the Black/White race disparity in AVF use is affected by vascular access surgeon supply. Methods: Using Consolidated Renal Operations in a Web-Enabled Network (CROWNWeb) and Medicare claims data from the US Renal Data System (USRDS), competing risk analyses of all US patients initiating HD with a central venous catheter (CVC) from 2016 to 2017 (n = 100,227) were performed. The likelihood of successful AVF use was compared between Black and White patients after adjusting for vascular access surgeon supply. Results: Compared with the first (lowest) quartile of surgeon supply, higher supply levels were associated with modestly increased adjusted likelihoods of overall AVF use: 4% (95% CI 1.4%-7.2%), 4% (95% CI 1.4%-7.1%), and 3% (0.0%-6.1%) for second, third, and fourth quartiles, respectively. Although areas with lower surgeon supply had a higher proportion of Black patients, residing in areas with a greater surgeon supply was not significantly associated with a mitigation in racial disparity. Specifically, compared with White patients, Black patients were 10% (95% CI 7%-13%) and 8% (95% CI 5%-11%) less likely to have successful AVF use in lower and higher surgeon supply areas, respectively. Conclusion: Regions with lower surgeon supply had a higher proportion of Black dialysis patients. However, racial disparities in AVF use among patients initiating HD with a CVC were similar in regions with a high and low surgeon supply. Other patient, provider, and practice factors should be evaluated toward mitigating lower rates of AVF use among Black HD patients.

Implementing Advance Care Planning for dialysis patients: HIGHway project.

BACKGROUND: Patients undergoing hemodialysis have a high mortality rate and yet underutilize palliative care and hospice resources. The Shared Decision Making-Renal Supportive Care (SDM-RSC) intervention focused on goals of care conversations between patients and family members with the nephrologist and social worker. The intervention targeted deficiencies in communication, estimating prognosis, and transition planning for seriously ill dialysis patients. The intervention showed capacity to increase substantially completion of advance care directives. The HIGHway Project, adapted from the previous SDM-RSC, scale up training social workers or nurses in dialysis center in advance care planning (ACP), and then support them for a subsequent 9-month action period, to engage in ACP conversations with patients at their dialysis center regarding their preferences for end-of-life care. METHODS: We will train between 50-60 dialysis teams, led by social workers or nurses, to engage in ACP conversations with patients at their dialysis center regarding their preferences for end-of-life care. This implementation project uses the Knowledge to Action (KTA) Framework within the Consolidated Framework for Implementation Research (CFIR) to increase adoption and sustainability in the participating dialysis centers. This includes a curriculum about how to hold ACP conversation and coaching with monthly teleconferences through case discussion and mentoring. An application software will guide on the process and provide resources for holding ACP conversations. Our project will focus on implementation outcomes. Success will be determined by adoption and effective use of the ACP approach. Patient and provider outcomes will be measured by the number of ACP conversations held and documented; the quality and fidelity of ACP conversations to the HIGHway process as taught during education sessions; impact on knowledge and skills; content, relevance, and significance of ACP intervention for patients, and Supportive Kidney Care (SKC) App usage. Currently HIGHway is in the recruitment stage. DISCUSSION: Effective changes to advance care planning processes in dialysis centers can lead to institutional policy and protocol changes, providing a model for patients receiving dialysis treatment in the US. The result will be a widespread improvement in advance care planning, thereby remedying one of the current barriers to patient-centered, goal-concordant care for dialysis patients. TRIAL REGISTRATION: The George Washington University Protocol Record NCR213481, Honoring Individual Goals and Hopes: Implementing Advance Care Planning for Persons with Kidney Disease on Dialysis, is registered in ClinicalTrials.gov Identifier: NCT05324878 on April 11th, 2022.

Low Rates of Hepatitis B Virus Treatment Among Treatment-Eligible Patients in Safety-Net Health Systems.

BACKGROUND: Timely initiation of antiviral therapy in chronic hepatitis B virus (CHB) reduces risk of disease progression. We evaluate overall treatment rates and predictors of treatment among treatment-eligible safety-net CHB patients. METHODS: We retrospectively evaluated adults with CHB from 2010 to 2018 across 4 large safety-net health systems in the United States. CHB was identified with ICD-9/10 diagnosis coding and confirmed with laboratory data. Treatment eligibility was determined using American Association for the Study of Liver Diseases (AASLD) guidelines. Comparison of CHB treatment rates among treatment-eligible patients were performed using χ2 testing, Kaplan Meier methods and log-rank testing. Adjusted multivariate Cox proportional hazards models evaluated independent predictors of receiving treatment among eligible patients. RESULTS: Among 5157 CHB patients (54.7% male, 34.6% African American, 22.3% Asian), 46.8% were treatment-eligible during the study period. CHB treatment rates were 48.4% overall and 37.3% among CHB patients without human immunodeficiency virus. Significantly lower odds of treatment were observed in females versus males (odds ratio: 0.40, 95% confidence interval: 0.33-0.49, P<0.001) and patients age 65 years or above versus age below 45 years (odds ratio: 0.68, 95% confidence interval: 0.51-0.92, P=0.012). Conversely, significantly greater odds of treatment were observed in African American and Asians versus non-Hispanic whites, CHB patients with indigent care versus commercially insured patients, and non-English speaking versus English speaking patients. CONCLUSION: Among a large multicentered, safety-net cohort of CHB patients, 46.8% of treatment-eligible CHB patients overall and 37.3% of treatment-eligible CHB patients without human immunodeficiency virus received antiviral therapy. Improving CHB treatment rates among treatment-eligible patients represents "low hanging fruit," given the clear benefits of antiviral therapy in mitigating disease progression.

Antiviral Therapy Reduces Risk of Cirrhosis in Noncirrhotic HBV Patients Among 4 Urban Safety-Net Health Systems.

INTRODUCTION: To evaluate the impact of chronic hepatitis B virus infection (CHB) treatment on risk of cirrhosis, liver-related outcomes, and death among a diverse CHB cohort with a large proportion of African Americans. METHODS: Adults with noncirrhotic CHB without human immunodeficiency virus from 2010 to 2018 were retrospectively evaluated across 4 US safety-net health systems. CHB was identified with International Classification of Diseases, Ninth Revision/Tenth Revision diagnosis coding and confirmatory laboratory data. Propensity-score matching, Kaplan-Meier methods, and adjusted Cox proportional hazards models were used to evaluate impact of CHB treatment on risk of cirrhosis, hepatocellular carcinoma (HCC), death, and composite of cirrhosis, HCC, or death. RESULTS: Among 4,064 CHB patients (51.9% female, 42.0% age <45 years, 31.6% African American, 26.6% Asian, 26.7% Hispanic), 23.2% received CHB antiviral therapy and 76.8% did not. Among the propensity score-matched cohort (428 treated and 428 untreated), CHB treatment was associated with lower risk of cirrhosis (hazards ratio 0.65, 95% confidence interval 0.46-0.92, P = 0.015) and composite of cirrhosis, HCC, or death (hazards ratio 0.67, 95% confidence interval 0.49-0.94, P = 0.023). Females vs males and African Americans vs non-Hispanic whites had significantly lower risk of cirrhosis. When treatment effects were stratified by age, sex, and ethnicity, the benefits of antiviral therapies in reducing risk of cirrhosis were seen primarily in CHB patients who were females, age <45 years, and of Asian ethnicity. DISCUSSION: Our propensity score-matched cohort of noncirrhotic CHB patients demonstrated significant reductions in risk of cirrhosis due to CHB treatment.

Racial Disparities in the Arteriovenous Fistula Care Continuum in Hemodialysis Patients.

BACKGROUND AND OBJECTIVES: Arteriovenous fistulas are the optimal vascular access type for patients on hemodialysis. However, arteriovenous fistulas are used less frequently in Black than in White individuals. The arteriovenous fistula care continuum comprises a series of sequential steps. A better understanding is needed of where disparities exist along the continuum in order to mitigate racial differences in arteriovenous fistula use. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using Medicare claims data from the United States Renal Data System, longitudinal analyses of patients ≥67 years initiating hemodialysis with a central venous catheter between July 1, 2010 and June 30, 2012 were performed. Three patient cohorts were identified: patients initiating hemodialysis with a catheter (n=41,814), patients with arteriovenous fistula placement within 6 months of dialysis initiation (n=14,077), and patients whose arteriovenous fistulas were successfully used within 6 months of placement (n=7068). Three arteriovenous fistula processes of care outcomes were compared between Blacks and Whites: (1) arteriovenous fistula creation, (2) successful arteriovenous fistula use, and (3) primary arteriovenous fistula patency after successful use. RESULTS: An arteriovenous fistula was placed within 6 months of dialysis initiation in 37% of patients initiating dialysis with a catheter. Among the patients with arteriovenous fistula placement, the arteriovenous fistula was successfully used for dialysis within 6 months in 48% of patients. Among patients with successful arteriovenous fistula use, 21% maintained primary arteriovenous fistula patency at 3 years. After adjusting for competing risks, Black patients on hemodialysis were 10% less likely to undergo arteriovenous fistula placement (adjusted subdistribution hazard ratio, 0.90; 95% confidence interval, 0.87 to 0.94); 12% less likely to have successful arteriovenous fistula use after placement (adjusted subdistribution hazard ratio, 0.88; 95% confidence interval, 0.83 to 0.93); and 22% less likely to maintain primary arteriovenous fistula patency after successful use (subdistribution hazard ratio, 0.78; 95% confidence interval, 0.74 to 0.84). CONCLUSIONS: Lower arteriovenous fistula use among Blacks older than 67 years of age treated with hemodialysis was attributable to each step along the continuum of arteriovenous fistula processes of care.

Sustained Improvements in Markers of Liver Disease Severity After Hepatitis C Treatment.

BACKGROUND & AIMS: Although serological markers of disease severity improve after hepatitis C virus (HCV) treatment, it is unclear if all patients experience sustained improvement. We aim to evaluate longitudinal changes in aspartate (AST), alanine (ALT) aminotransferase, platelet count (PLT), and fibrosis-4 (FIB-4) after HCV treatment. METHODS: All adult chronic HCV patients who received antiviral therapy from January 2011 to February 2017 at four large urban hospital systems were evaluated to assess changes in AST, ALT, PLT, and FIB-4 from pre-treatment to post-treatment annually up to 4 years after HCV therapy. Comparisons used Student's t-test and analysis of variance, and were stratified by sex, race, ethnicity, age, body mass index (BMI), and diabetes mellitus. RESULTS: Among 2691 patients (62.2% men, 76.9% aged 45-65 years, 56.5% white), all markers of disease severity demonstrated sustained improvements from pre-treatment to 4 years post-treatment (AST 53 U/L to 27.5 U/L, ALT 53 U/L to 29 U/L, PLT 168 × 103 to 176 × 103, FIB-4 2.51 to 1.68). However, Hispanics and patients with BMI >30 kg/m2 experienced rebound increases in AST, ALT, and FIB-4 at 4 years post-treatment after experiencing initial improvements in these serological markers in the first-year post-treatment. Sustained improvements in PLT were observed in all groups, including Hispanics and patients with BMI >30 kg/m2. CONCLUSION: HCV treatment in a large community-based cohort demonstrated sustained improvements in AST, ALT, PLT, and FIB-4. Rebound increases in AST, ALT, and FIB-4 observed in Hispanics and those with BMI >30 kg/m2 may reflect persisting nonalcoholic fatty liver disease.

Long-Term Outcomes of Arteriovenous Fistulas with Unassisted versus Assisted Maturation: A Retrospective National Hemodialysis Cohort Study.

BACKGROUND: About half of arteriovenous fistulas (AVFs) require one or more interventions before successful dialysis use, a process called assisted maturation. Previous research suggested that AVF abandonment and interventions to maintain patency after maturation may be more frequent with assisted maturation versus unassisted maturation. METHODS: Using the US Renal Data System, we retrospectively compared patients with assisted versus unassisted AVF maturation for postmaturation AVF outcomes, including functional primary patency loss (requiring intervention after achieving AVF maturation), AVF abandonment, and frequency of interventions. RESULTS: We included 7301 patients ≥67 years who initiated hemodialysis from July 2010 to June 2012 with a catheter and no prior AVF; all had an AVF created within 6 months of starting hemodialysis and used for dialysis (matured) within 6 months of creation, with 2-year postmaturation follow-up. AVFs matured without prior intervention for 56% of the patients. Assisted AVF maturation with one, two, three, or four or more prematuration interventions occurred in 23%, 12%, 5%, and 4% of patients, respectively. Patients with prematuration interventions had significantly increased risk of functional primary patency loss compared with patients who had unassisted AVF maturation, and the risk increased with the number of interventions. Although the likelihood of AVF abandonment was not higher among patients with up to three prematuration interventions compared with patients with unassisted AVF maturation, it was significantly higher among those with four or more interventions. CONCLUSIONS: For this cohort of patients undergoing assisted AVF maturation, we observed a positive association between the number of prematuration AVF interventions and the likelihood of functional primary patency loss and frequency of postmaturation interventions.

Has Access to Hepatitis C Virus Therapy Changed for Patients With Mental Health or Substance Use Disorders in the Direct-Acting-Antiviral Period?

Direct-acting antivirals (DAA) for hepatitis C virus (HCV) became available in 2014, but the role of mental health or substance use disorders (MH/SUD) on access to treatment is unknown. The objective of this study was to examine the extent and predictors of HCV treatment in the pre-DAA and post-DAA periods in four large, diverse health care settings in the United States. We conducted a retrospective analysis of 29,544 adults with chronic HCV who did or did not receive treatment from January 1, 2011, to February 28, 2017. Kaplan-Meier curve was used to examine cumulative risk for receiving HCV treatment stratified by MH/SUD. Predictors of HCV treatment in the pre-DAA (January 1, 2011, to December 31, 2013) and post-DAA (January 1, 2014, to February 28, 2017) cohorts were analyzed using multivariate generalized estimating equations and a modified Poisson model. Overall, 21.7% (2,879/13,240) of those with chronic HCV post-DAA were treated compared with 3.5% (574/16,304) in the pre-DAA period. Compared with non-Hispanic whites, Hispanic whites (adjusted odds ratio [AOR] 0.36; 95% confidence interval [CI], 0.25, 0.52) were less likely to be treated in the post-DAA period. Those with concurrent nonalcoholic fatty liver disease (AOR 1.39; 95% CI, 1.05, 1.83), cirrhosis (AOR 2.00; 95% CI, 1.74, 2.31), and liver transplant (AOR 2.72; 95% CI, 1.87, 3.94) were more likely to be treated post-DAA. Those with MH/SUD were less likely to be treated both before (AOR 0.46; 95% CI, 0.36, 0.60) and after (AOR 0.63; 95% CI, 0.55, 0.71) DAA therapy was available. Overall, the cumulative risk for receiving HCV treatment from 2011 to 2017 among those with versus without MH/SUD was 13.6% versus 21.6%, respectively (P < 0.001). Conclusion: The volume of patients treated for HCV has increased in the post-DAA period, especially among those with liver-related comorbidities, but disparities in access to treatment continue among those with MH/SUD.

Gender Disparities in Vascular Access Surgical Outcomes in Elderly Hemodialysis Patients.

BACKGROUND: Despite national vascular access guidelines promoting the use of arteriovenous fistulas (AVF) over arteriovenous grafts (AVGs) for dialysis, AVF use is substantially lower in females. We assessed clinically relevant AVF and AVG surgical outcomes in elderly male and female patients initiating hemodialysis with a central venous catheter (CVC). METHODS: Using the United States Renal Data System standard analytic files linked with Medicare claims, we assessed incident hemodialysis patients in the United States, 9,458 elderly patients (≥67 years; 4,927 males and 4,531 females) initiating hemodialysis from July 2010 to June 2011 with a catheter and had an AVF or AVG placed within 6 months. We evaluated vascular access placement, successful use for dialysis, assisted use (requiring an intervention before successful use), abandonment after successful use, and rate of interventions after successful use. RESULTS: Females were less likely than males to receive an AVF (adjusted likelihood 0.57, 95% CI 0.52-0.63). Among patients receiving an AVF, females had higher adjusted likelihoods of unsuccessful AVF use (hazard ratio [HR] 1.46, 95% CI 1.36-1.56), assisted AVF use (OR 1.34, 95% CI 1.17-1.54), and AVF abandonment (HR 1.28, 95% CI 1.10-1.50), but similar relative rate of AVF interventions after successful use (relative risk [RR] 1.01, 95% CI 0.94-1.08). Among patients receiving an AVG, females had a lower likelihood of unsuccessful AVG use (HR 0.83, 95% CI 0.73-0.94), similar rates of assisted AVG use (OR 1.05, 95% CI 0.78-1.40) and AVG abandonment, and greater relative rate of interventions after successful AVG use (RR 1.16, 95% CI 1.01-1.33). CONCLUSIONS: While AVFs should be considered the preferred vascular access in most circumstances, clinical AVF surgical outcomes are uniformly worse in females. Clinicians should also consider AVGs as a viable alternative in elderly female patients initiating hemodialysis with a CVC to avoid extended CVC dependence.

Tradeoffs in Vascular Access Selection in Elderly Patients Initiating Hemodialysis With a Catheter.

RATIONALE & OBJECTIVE: National vascular access guidelines recommend placement of arteriovenous fistulas (AVFs) over grafts (AVGs) in hemodialysis patients, but have not been comprehensively assessed in the elderly. We evaluated clinically relevant vascular access outcomes in elderly patients receiving an AVF or AVG after hemodialysis therapy initiation. STUDY DESIGN: Retrospective cohort study using national administrative data. SETTINGS & PARTCIPANTS: Claims data from the US Renal Data System of 9,458 US patients 67 years and older who initiated hemodialysis therapy from July 1, 2010, to June 30, 2011, with a catheter and received an AVF (n=7,433) or AVG (n=2,025) within the ensuing 6 months. PREDICTOR: Arteriovenous access subtype, AVF or AVG. OUTCOMES: Successful use of vascular access, interventions to make vascular access functional, duration of catheter dependence before successful use of vascular access, frequency of interventions, and abandonment after successful use of vascular access. ANALYTICAL APPROACH: Multivariable logistic regression analysis was used to compare the need for intervention before successful use of AVFs and AVGs, and negative bionomial regression was used to calculate the frequency of intervention after successful use of vascular access. RESULTS: Unsuccessful use of vascular access within 6 months of creation was higher for AVFs versus AVGs (51% vs 45%; adjusted HR, 1.86; 95% CI, 1.73-1.99). Interventions to make vascular access functional were greater in AVFs versus AVGs (42% vs 23%; OR, 2.66; 95% CI, 2.26-3.12). AVFs had a lower 1-year abandonment rate after successful use compared with AVGs (OR, 0.71; 95% CI, 0.62-0.83) and required one-fourth fewer interventions after successful use (relative risk, 0.75; 95% CI, 0.69-0.81). Patients receiving an AVF had substantially longer catheter dependence before successful use than those receiving an AVG (median time, 3 vs 1 month; P<0.001). LIMITATIONS: Residual confounding due to vascular access choice, restriction to an elderly population, and 1-year follow-up period. CONCLUSIONS: In elderly hemodialysis patients initiating hemodialysis therapy with a catheter, the optimal vascular access selection depends on tradeoffs between shorter catheter dependence and less frequent interventions to make the vascular access (AVG) functional versus longer access patency and fewer interventions after successful use of the vascular access (AVF).

Medicare Costs Associated With Arteriovenous Fistulas Among US Hemodialysis Patients.

BACKGROUND: An arteriovenous fistula (AVF) is the recommended vascular access for hemodialysis (HD). Previous studies have not examined the resources and costs associated with creating and maintaining AVFs. STUDY DESIGN: Retrospective observational study. SETTING & PARTICIPANTS: Elderly US Medicare patients initiating hemodialysis therapy during 2010 to 2011. PREDICTOR: AVF primary and secondary patency and nonuse in the first year following AVF creation. OUTCOMES: Annualized vascular access costs per patient per year. RESULTS: Among patients with only a catheter at HD therapy initiation, only 54% of AVFs were successfully used for HD, 10% were used but experienced secondary patency loss within 1 year of creation, and 83% experienced primary patency loss within 1 year of creation. Mean vascular access costs per patient per year in the 2.5 years after AVF creation were $7,871 for AVFs that maintained primary patency in year 1, $13,282 for AVFs that experienced primary patency loss in year 1, $17,808 for AVFs that experienced secondary patency loss in year 1, and $31,630 for AVFs that were not used. Similar patterns were seen among patients with a mature AVF at HD therapy initiation and patients with a catheter and maturing AVF at HD therapy initiation. Overall, in 2013, fee-for-service Medicare paid $2.8 billion for dialysis vascular access-related services, ∼12% of all end-stage renal disease payments. LIMITATIONS: Lack of granularity with certain billing codes. CONCLUSIONS: AVF failure in the first year after creation is common and results in substantially higher health care costs. Compared with patients whose AVFs maintained primary patency, vascular access costs were 2 to 3 times higher for patients whose AVFs experienced primary or secondary patency loss and 4 times higher for patients who never used their AVFs. There is a need to improve AVF outcomes and reduce costs after AVF creation.