Regional and center-based variation in arteriovenous fistula placement as a first-time hemodialysis access.

Abstract

Forearm arteriovenous fistulas (AVFs) are the preferred initial hemodialysis access for patients with end-stage kidney disease, yet limited data exist regarding the use of forearm AVFs across different clinical practices. Therefore, we sought to explore regional and center-based variation in access creation in the United States. We conducted a retrospective cross-sectional study (2012-2022) using the Vascular Quality Initiative (VQI) database. All patients undergoing first-time upper extremity surgical hemodialysis access creation were included. Primary analysis examined variation in type of access created across VQI regions and centers. Secondary analyses consisted of constructing mixed effects logistic regression models to determine patient factors associated with forearm AVF placement and exploring the effect of centers and surgeons on variation. Finally, a subgroup analysis was performed in upper arm AVFs to understand center and surgeon-level variation in the use of brachial vs proximal radial artery for access inflow. A total of 51,508 accesses were included. Among 19 VQI regions, proportion of first-time forearm AVFs ranged from 10.8% to 54.2%, with two regions placing >50% forearm AVFs. Across 132 centers, proportion of forearm AVFs ranged from 2.4% to 66.7% with a median of 24.2% (interquartile range, 15.8%-33.4%). Characteristics negatively associated with forearm AVF placement were male sex, age >65 years, Black race, and diabetes, and a positive association included use of regional anesthesia. Overall, 23% of the variance in forearm AVF placement was explained by the grouping structure at the center and surgeon levels. In a subgroup analysis of upper arm AVFs by brachial vs radial inflow, the variance explained by center and surgeon increased to 38%. There is considerable regional and center-based variation in the creation of forearm and upper arm AVFs. Part of this variation is explained by patient factors, and approximately one-quarter of this variance is due to the center and surgeon. A greater understanding of the drivers of this variation is necessary to ensure optimal access creation in patients with end-stage kidney disease.