Background: The impact of socioeconomic factors on arteriovenous fistula (AVF) creation in hemodialysis (HD) patients is not well understood. We assessed the association of area and individual-level indicators of poverty and health care insurance on AVF use among incident end-stage renal disease (ESRD) patients initiated on HD. Methods: In this retrospective cohort study using the United States Renal Data System database, we identified 669,206 patients initiated on maintenance HD from January 1, 2007 through December 31, 2012. We assessed the Medicare-Medicaid dual-eligibility status as an indicator of individual-level poverty and ZIP code-level median household income (MHI) data obtained from the 2010 United States Census. We conducted logistic regression of AVF use at start of dialysis as the outcome variable. Results: The proportions of dual-eligible and non-dual-eligible patients who initiated HD with an AVF were 12.53 and 16.17%, respectively (p < 0.001). Dual eligibility was associated with significantly lower likelihood of AVF use upon initiation of HD (adjusted odds ratio (aOR) 0.91; 95% CI 0.90-0.93). Patients in the lowest area-level MHI quintile had an aOR of 0.97 (95% CI 0.95-0.99) compared to those in higher quintile levels. However, dual eligibility and area-level MHI were not significant in patients with Veterans Affairs (VA) coverage. Conclusions: Individual- and area-level measures of poverty were independently associated with a lower likelihood of AVF use at the start of HD, the only exception being patients with VA health care benefits. Efforts to improve incident AVF use may require focusing on pre-ESRD care to be successful.

1.
Centers for Medicare & Medicaid Services: ESRD Quality Incentive Program. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/index.html (accessed May 5, 2015).
2.
United States Renal Data System: 2014 Annual Data Report. http://www.usrds.org/2014/view/v2_03.aspx (accessed May 5, 2015).
3.
Pisoni RL, Zepel L, Port FK, Robinson BM: Trends in US vascular access use, patient preferences, and related practices: an update from the US DOPPS practice monitor with international comparisons. Am J Kidney Dis 2015;65:905-915.
4.
Vachharajani N, Wise P, Klingensmith M, Jaques D, Shenoy S: Vascular access creation and maintenance in the USA. J Vasc Access 2015;16(suppl 9):S1-S4.
5.
Ishani A, Gilbertson DT, Kim D, Bradbury BD, Collins AJ: Predialysis care and dialysis outcomes in hemodialysis patients with a functioning fistula. Am J Nephrol 2014;39:238-247.
6.
Hurst FP, Abbott KC, Raj D, Krishnan M, Palant CE, Agodoa LY, Jindal RM: Arteriovenous fistulas among incident hemodialysis patients in department of defense and veterans affairs facilities. J Am Soc Nephrol 2010;21:1571-1577.
7.
Hanko J, Romann A, Taylor P, Copland M, Beaulieu M: Optimizing AVF creation prior to dialysis start: the role of predialysis renal replacement therapy choices. Nephrol Dial Transplant 2012;27:4205-4210.
8.
Stoumpos S, Stevens KK, Aitken E, Kingsmore DB, Clancy MJ, Fox JG, Geddes CC: Predictors of sustained arteriovenous access use for haemodialysis. Am J Nephrol 2014;39:491-498.
9.
Dageforde LA, Harms KA, Feurer ID, Shaffer D: Increased minimum vein diameter on preoperative mapping with duplex ultrasound is associated with arteriovenous fistula maturation and secondary patency. J Vasc Surg 2015;61:170-176.
10.
Patibandla BK, Narra A, Desilva R, Chawla V, Vin Y, Brown RS, Goldfarb-Rumyantzev AS: Disparities in arteriovenous fistula placement in older hemodialysis patients. Hemodial Int 2014;18:118-126.
11.
Yan G, Cheung AK, Ma JZ, Yu AJ, Greene T, Oliver MN, Yu W, Norris KC: The associations between race and geographic area and quality-of-care indicators in patients approaching ESRD. Clin J Am Soc Nephrol 2013;8:610-618.
12.
McClellan WM, Wasse H, McClellan AC, Holt J, Krisher J, Waller LA: Geographic concentration of poverty and arteriovenous fistula use among ESRD patients. J Am Soc Nephrol 2010;21:1776-1782.
13.
McMillan A, Pine PL, Gornick M, Prihoda R: A study of the ‘crossover population': aged persons entitled to both Medicare and Medicaid. Health Care Financ Rev 1983;4:19-46.
14.
Hagland M: Medicaid/Medicare dual eligibles. Healthplan 1997;38:52-56, 58, 60-61.
15.
Nemore P: Dual eligibles. Issue Brief Cent Medicare Educ 2004;5:1-6.
16.
Centers for Medicare & Medicaid Services: Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/Medicare_Beneficiaries_Dual_Eligibles_At_a_Glance.pdf (accessed May 5, 2015).
17.
Solid CA, Collins AJ, Ebben JP, Chen SC, Faravardeh A, Foley RN, Ishani A: Agreement of reported vascular access on the medical evidence report and on Medicare claims at hemodialysis initiation. BMC Nephrol 2014;15:30.
18.
United States Renal Data System: 2014 Annual Data Report. http://www.usrds.org/2014/view/v2_01.aspx (accessed May 5, 2015).
19.
United States Census Bureau: Poverty. http://www.census.gov/hhes/www/poverty/methods/definitions.html (accessed July 9, 2015).
20.
Gaylin DS, Held PJ, Port FK, Hunsicker LG, Wolfe RA, Kahan BD, Jones CA, Agodoa LY: The impact of comorbid and sociodemographic factors on access to renal transplantation. JAMA 1993;269:603-608.
21.
Kasiske BL, London W, Ellison MD: Race and socioeconomic factors influencing early placement on the kidney transplant waiting list. J Am Soc Nephrol 1998;9:2142-2147.
22.
Paul P, Pennell ML, Lemeshow S: Standardizing the power of the Hosmer-Lemeshow goodness of fit test in large data sets. Stat Med 2013;32:67-80.
23.
Congressional Budget Office: Dual-Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care Spending, and Evolving Policies. https://www.cbo.gov/publication/44308 (accessed May 18, 2015).
24.
Allen SM, Piette ER, Mor V: The adverse consequences of unmet need among older persons living in the community: dual-eligible versus Medicare-only beneficiaries. J Gerontol B Psychol Sci Soc Sci 2014;69(suppl 1):S51-S58.
25.
Parikh DS, Inrig JK, Kipp A, Szczech LA, McClellan W, Patel UD: Veterans more likely to start hemodialysis with an arteriovenous fistula. Semin Dial 2011;24:570-575.
26.
Nicholas SB, Kalantar-Zadeh K, Norris KC: Socioeconomic disparities in chronic kidney disease. Adv Chronic Kidney Dis 2015;22:6-15.
27.
Hall YN, Choi AI, Chertow GM, Bindman AB: Chronic kidney disease in the urban poor. Clin J Am Soc Nephrol 2010;5:828-835.
28.
Hossain MP, Goyder EC, Rigby JE, El Nahas M: CKD and poverty: a growing global challenge. Am J Kidney Dis 2009;53:166-174.
29.
Arce CM, Mitani AA, Goldstein BA, Winkelmayer WC: Hispanic ethnicity and vascular access use in patients initiating hemodialysis in the United States. Clin J Am Soc Nephrol 2012;7:289-296.
30.
Zarkowsky DS, Arhuidese IJ, Hicks CW, Canner JK, Qazi U, Obeid T, Schneider E, Abularrage CJ, Freischlag JA, Malas MB: Racial/ethnic disparities associated with initial hemodialysis access. JAMA Surg 2015;150:529-536.
31.
Kurella-Tamura M, Goldstein BA, Hall YN, Mitani AA, Winkelmayer WC: State Medicaid coverage, ESRD incidence, and access to care. J Am Soc Nephrol 2014;25:1321-1329.
32.
Marinovich S, Lavorato C, Rosa-Diez G, Bisigniano L, Fernández V, Hansen-Krogh D: The lack of income is associated with reduced survival in chronic haemodialysis. Nefrologia 2012;32:79-88.
33.
Plantinga LC, Kim M, Goetz M, Kleinbaum DG, McClellan W, Patzer RE: Pre-end-stage renal disease care not associated with dialysis facility neighborhood poverty in the United States. Am J Nephrol 2014;39:50-58.
34.
Malas MB, Canner JK, Hicks CW, Arhuidese IJ, Zarkowsky DS, Qazi U, Schneider EB, Black JH 3rd, Segev DL, Freischlag JA: Trends in incident hemodialysis access and mortality. JAMA Surg 2015;150:441-448.
35.
Oliver MJ, Rothwell DM, Fung K, Hux JE, Lok CE: Late creation of vascular access for hemodialysis and increased risk of sepsis. J Am Soc Nephrol 2004;15:1936-1942.
36.
Polkinghorne KR, McDonald SP, Atkins RC, Kerr PG: Vascular access and all-cause mortality: a propensity score analysis. J Am Soc Nephrol 2004;15:477-486.
37.
Lee T, Thamer M, Zhang Y, Zhang Q, Allon M: Outcomes of elderly patients after predialysis vascular access creation. J Am Soc Nephrol 2015;pii:ASN.2014090938.
38.
Allon M, Dinwiddie L, Lacson E Jr, Latos DL, Lok CE, Steinman T, Weiner DE: Medicare reimbursement policies and hemodialysis vascular access outcomes: a need for change. J Am Soc Nephrol 2011;22:426-430.
39.
Hanley GE, Morgan S: On the validity of area-based income measures to proxy household income. BMC Health Serv Res 2008;8:79.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.