WASHINGTON—Kidney disease patients insured by some federally sponsored national healthcare organizations are more likely to receive a fistula for vascular access during dialysis than patients with other types of insurance, according to a study appearing online Aug. 12 in the Journal of the American Society Nephrology (JASN).
The results may provide insights into ways to improve kidney-related care for patients before they go on dialysis, according to the study’s authors.
Experts recommend creating an arteriovenous fistula (AVF), to connect a vein and artery and allow access to the vascular system during dialysis. An AVF provides a long-lasting site through which blood can be removed and returned during the dialysis procedure, which patients must undergo three to four times per week.
While AVF use for hemodialysis access is safe, cost-effective, and associated with improved survival in kidney disease patients, only a minority of U.S. patients start hemodialysis with an AVF (13.7 percent in 2008), according to the study.
To understand predialysis AVF placement better, Frank Hurst, MD, of the Walter Reed Army Medical Center and F. Edward Hebert School of Medicine, and his colleagues evaluated the use of AVFs in federally sponsored national healthcare organizations such as the Departments of Veterans Affairs (DVA) and Department of Defense (DoD).
Hurst and his team searched the United States Renal Data System (USRDS) database to identify patients who initiated hemodialysis between 2005 and 2006. They found that patients who received predialysis kidney care were 10 times as likely to begin dialysis with an AVF compared with patients who did not receive such care.
Patients with DVA/DoD insurance were 40 percent more likely to initiate dialysis with an AVF compared with patients with other types of insurance. Specifically, 27.2 percent of patients with DVA/DoD insurance initiated hemodialysis with an AVF, compared with 18.5 percent of patients reporting employer-group insurance, 16.7 percent of patients with “Other” insurance, 15.6 percent of patients with Medicare, 13 percent of patients with Medicaid, and 8.2 percent of patients who reported no insurance. The analysis also revealed that patients who initiated hemodialysis at a DoD facility were twice as likely to use an AVF.
Experts are attempting to increase the use of AVFs through initiatives such as the Fistula First Breakthrough Coalition, whereby the Centers for Medicare & Medicaid Services, End-Stage Renal Disease Networks, and the entire kidney community are working together to ensure that every suitable patient will receive the most optimal form of vascular access. Hurst’s findings show that despite these efforts, AVF use is still highly dependent upon a patient’s type of health insurance prior to the initiation of dialysis.
“Further study of these federal systems may identify practices that could improve processes of care across healthcare systems to increase the number of patients who initiate hemodialysis with an AVF,” the authors wrote. They added that while AVF use is more frequent in DVA/DoD patients, the proportion of these patients who initiate hemodialysis with an AVF is still far too low.
