Action Points

Using an arteriovenous fistula (AVF) rather than a catheter at first hemodialysis is associated with better outcomes, but black and Hispanic patients get AVF less frequently than do white patients, a study found.

In the retrospective analysis of nearly 400,000 patients with end stage renal disease (ESRD), 18.3% of the white patients used AVF, compared with 15.5% of black patients and 14.6% of Hispanic patients, despite the minority patients being younger with fewer comorbidities (P<0.001), according to Devin Zarkowsky, MD, in the department of surgery at Dartmouth-Hitchcock Medical Center in New Hampshire, and colleagues.

The study was published on April 29 in JAMA Surgery.

"Racial/ethnic disparities related to hemodialysis access (a key survival determinant among patients with end-stage renal disease) are both a cause for alarm and a call to action, but these findings are hardly surprising," wrote Laura Peterson, MD, and Matthew Corriere, MD, both at Wake Forest University School of Medicine, in an accompanying editorial.

"In fact, race/ethnicity and sex-based outcomes disparities are so commonly identified in surgical outcomes research that their absence from an area of clinical evidence should prompt suspicion of inadequate investigation," they added.

White patients were 22% more likely than African-American patients (odds ratio 1.22, 95% CI 1.20-1.24) and 32% more likely than Hispanic patients (OR 1.32, 95% CI 1.28-1.35) to start dialysis with AVF. These disparities were seen even when factors that affect access to fistula placement, like insurance status and nephrology care, were controlled for, wrote the authors.

"The racial/ethnic disparities in incident AVF access that we describe deserve elucidation," wrote Zarkowsky and colleagues. "The high rates of catheter use despite national programs to reverse this trend is unacceptable."

All of the patients in the study had first dialysis at some point from 2006 to 2010 and were included in the US Renal Data System, which looks at trends of nephrology care. Data on demographics, insurance status, nephrology care, and ESRD network were also collected.

More than half, 55.4%, of the patients were white, 30.3% were African American, and 14.3% were Hispanic. The majority of patients (78.9%) received a catheter at first dialysis. The most common causes of the patient's ESRD were diabetic nephropathy (43.2%) and hypertension (29.4%).

Mean age of white patients was 67.0 years, but it was much lower for black patients, at 58.8 years, and for Hispanic patients, at 58.9 years. White patients had significantly more comorbidities, including cancer, congestive heart failure, coronary artery disease, peripheral arterial disease, and chronic obstructive pulmonary disease (P<0.001).

Black and Hispanic patients received nephrology care less frequently than did white patients (57.9% and 54.0% versus 63.2%, respectively; P<0.001). Medicare was the most common insurance status across all of the groups, but black patients and Hispanic patients were much more likely to be uninsured or to have Medicaid.

The most significant factor affecting whether or not a patient initiates dialysis with an AVF is nephrology care, said the researchers -- management by a nephrologist increased a patient's odds of using AVF nearly 11-fold.

The authors noted that it's possible that black and Hispanic patients are progressing too quickly to ESRD, making an AVF a poor option. "Consistent with this notion, both black patients and Hispanic patients appear to be younger than white patients at the time of dialysis initiation," they wrote. "Certain comorbidities may also exert an influence on perceived operative risk or fistula maturation."

But in the editorial, Peterson and Corriere said that they suspected the disparities in AVF access are due to larger, structural issues. "Although one might hypothesize that the disparities related to incident hemodialysis access ... may result from anatomic, physiological, or risk factors, the omnipresence of disparities across diseases and populations may instead reflect broader systems issues related to access, health literacy, and socioeconomics," they wrote.

The authors of the study also hypothesized that a potential language barrier may be limiting access to quality care for Hispanic patients.

Limitations of the study included its reliance on the Medicare and Medicaid insurance forms, which can vary by practitioner. Race and ethnicity were self-reported, and overlap between the three groups was possible. In addition, regional variations exist for dialysis care, and it's possible that nephrologists and surgeons made their choices based on factors not considered by the researchers.

Researchers disclosed no relevant relationships with industry.

Peterson and Corriere also disclosed no relevant relationships with industry.

• Reviewed by Henry A. Solomon, MD, FACP, FACC Clinical Associate Professor, Weill Cornell Medical College and Dorothy Caputo, MA, BSN, RN, Nurse Planner

last updated 05.03.2015

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