Jeffrey J. Siracuse, Adi Wollstein, Yuriy Kotsurovskyy, Diana Catz, Irene Epelboym, In-Kyong Kim, Heather L. Gill, Nicholas J. Morrissey
New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY.
OBJECTIVES: Insurance status and race are potential barriers to health care maintenance. We assessed their contribution to upper extremity vascular access outcomes in our population.
METHODS: We retrospectively reviewed outcomes of 601 vascular access patients from 2004-2012 at our institution. We recorded patient demographics, comorbidities and complications. Primary outcomes were reintervention, long-term mortality and kidney transplantation.
RESULTS: Arteriovenous fistulas (AVF) accounted for majority (66%) of operations. Median age was 62; 58% were male. Race, a self-reported variable, was 50% Hispanic, 22% white and 19% black. Most had Medicare only (42%), while 31% had private insurance and 27% had Medicaid. Black patients were less likely to get an AVF compared to whites and Hispanics (p<0.05). White patients were significantly older than either Hispanics or blacks (68 vs. 61 vs. 58 p<0.05). Overall freedom from reintervention at 5 years was 55%, with infection (HR 2.0 95% CI 1.3-3.0), stenosis (HR 3.2 95% CI 2.3-4.3), thrombosis (HR 1.7 95% CI 1.2-2.4) and nerve injury (HR 4.1 95% CI 1.5-11.5) being independent predictors of reintervention. Mortality at 5 years was 35%, predicted by AV graft placement (HR 1.9 95% CI 1.4-2.7), low albumin (HR 0.7 95% CI 0.6-0.9), white race (HR 1.9 95% CI 1.3-2.8), and not receiving a kidney transplant (HR 0.3 95% CI 0.2-0.6). Transplantation rate was 31% at 5 years and predicted by high albumin (HR 1.9 95% CI 1.4-2.6), AVF (HR 1.6 95% 1.1-2.6), and no CAD (HR 0.6 95% CI 0.4-0.9). Race and insurance status did not affect reintervention or transplantation rate.
CONCLUSIONS: Controlling for patient and clinical factors, insurance status did not have a significant effect on long-term vascular access outcomes in our population. Race was not significantly associated with reintervention or transplantation; however, more black patients had less suitable vasculature for AVF, and white patients had a lower long-term survival, possibly due to more advanced age.
AUTHOR DISCLOSURES: D. Catz: Nothing to disclose; I. Epelboym: Nothing to disclose; H. L. Gill: Nothing to disclose; I. Kim: Nothing to disclose; Y. Kotsurovskyy: Nothing to disclose; N. J. Morrissey: Nothing to disclose; J. J. Siracuse: Nothing to disclose; A. Wollstein: Nothing to disclose.
Posted April 2013