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Am J Kidney Dis. 2009 Mar;53(3):475-91. doi: 10.1053/j.ajkd.2008.10.043. Epub 2009 Jan 15.

Facility hemodialysis vascular access use and mortality in countries participating in DOPPS: an instrumental variable analysis.

Author information

1
Arbor Research Collaborative for Health, Ann Arbor, MI 48103, USA. ron.pisoni@arborresearch.org

Abstract

BACKGROUND:

Previously, the Dialysis Outcomes and Practice Patterns Study (DOPPS) has shown large international variations in vascular access practice. Greater mortality risks have been seen for hemodialysis (HD) patients dialyzing with a catheter or graft versus a native arteriovenous fistula (AVF). To further understand the relationship between vascular access practice and outcomes, we have applied practice-based analyses (using an instrumental variable approach) to decrease the treatment-by-indication bias of prior patient-level analyses.

STUDY DESIGN:

A prospective observational study of HD practices.

SETTING & PARTICIPANTS:

Data collected from 1996 to 2004 from 28,196 HD patients from more than 300 dialysis units participating in the DOPPS in 12 countries.

PREDICTOR OR FACTOR:

Patient-level or case-mix-adjusted facility-level vascular access use. OUTCOMES/MEASUREMENTS: Mortality and hospitalization risks.

RESULTS:

After adjusting for demographics, comorbid conditions, and laboratory values, greater mortality risk was seen for patients using a catheter (relative risk, 1.32; 95% confidence interval, 1.22 to 1.42; P < 0.001) or graft (relative risk, 1.15; 95% confidence interval, 1.06 to 1.25; P < 0.001) versus an AVF. Every 20% greater case-mix-adjusted catheter use within a facility was associated with 20% greater mortality risk (versus facility AVF use, P < 0.001); and every 20% greater facility graft use was associated with 9% greater mortality risk (P < 0.001). Greater facility catheter and graft use were both associated with greater all-cause and infection-related hospitalization. Catheter and graft use were greater in the United States than in Japan and many European countries. More than half the 36% to 43% greater case-mix-adjusted mortality risk for HD patients in the United States versus the 5 European countries from the DOPPS I and II was attributable to differences in vascular access practice, even after adjusting for other HD practices. Vascular access practice differences accounted for nearly 30% of the greater US mortality compared with Japan.

LIMITATIONS:

Possible existence of unmeasured facility- and patient-level confounders that could impact the relationship of vascular access use with outcomes.

CONCLUSIONS:

Facility-based analyses diminish treatment-by-indication bias and suggest that less catheter and graft use improves patient survival.

PMID:
19150158
DOI:
10.1053/j.ajkd.2008.10.043
[Indexed for MEDLINE]

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