Association Of Insurance Status With Timing Of AV Fistula Placement
Andrew Lazar, MD1, Adam Johnson, MD2, Nicholas Morrissey, MD1.
1Columbia University Medical Center, New York, NY, USA, 2NewYork-Presbyterian Hospital, New York, NY, USA.
Objective:
Published guidelines promote the placement of permanent dialysis access prior to the initiation of dialysis to reduce the number of catheter days and associated morbidity. Previous research has demonstrated decreased monitoring and follow up of patients with public compared to private insurance. In this study, we aimed to examine the relationship between a patient's insurance and the timing of their permanent dialysis access placement, whether arterio-venous fistula (AVF) or arterio-venous graft (AVG).
Methods:
We queried the regional data of the Vascular Quality Initiative (VSGGNY Region), to identify patients undergoing primary placement of permanent dialysis access under the age of 65 and stratified based on primary insurance at time of dialysis access placement-- Medicare, Medicaid, and Commercial Insurance; Military/VA and non-US insured patients were excluded due to the minimal patients they included. Chi-squared analysis and multivariable regression were used to determine the association of insurance and on dialysis at the time of AVF/AVG placement.
Results:
From 2012 to 2019, there were 1,176 primary AVF/AVG performed in patients under the age of 65 in the VSGGNY VQI regional database. Of the patients, 655 (56%) had commercial insurance, 279 (24%) were on Medicare and 242 (21%) were on Medicaid. On univariable analysis and after controlling for comorbidities in multi-variable regression, patients on Medicare were significantly more likely to be on dialysis at time of surgery than their counterparts with commercial insurance (1.71, p=0.001), but no difference was seen for patients on Medicaid (0.94, p=0.721), as shown in Table 1.
Conclusion:
Health disparities have become an important issue as we better understand the difference in care between patients with different types of insurance. On multi-variable regression of patients under 65, patients were significantly more likely to present for AVF/AVG already on hemodialysis as compared to patients with Medicaid or commercial insurance. This analysis emphasizes the importance of access to care, insurance status, and the implications of public policy on quality of care for vulnerable populations.
| Dependent: Dialysis Status | Not on Dialysis | On Dialysis | OR (univariable) | OR (multivariable) | |
| Primary Insurance | Commercial | 308 (57.8) | 347 (54.0) | - | - |
| Medicare | 106 (19.9) | 173 (26.9) | 1.45 (1.09-1.93, p=0.011) | 1.71 (1.25-2.35, p=0.001) | |
| Medicaid | 119 (22.3) | 123 (19.1) | 0.92 (0.68-1.23, p=0.567) | 0.94 (0.67-1.32, p=0.721) | |
| Race | Black | 156 (29.3) | 226 (35.1) | 1.30 (0.99-1.70, p=0.055) | 1.39 (1.03-1.87, p=0.033) |
| Ethnicity | Hispanic | 101 (18.9) | 84 (13.1) | 0.64 (0.47-0.88, p=0.006) | 0.68 (0.45-1.03, p=0.068) |
| Age | Mean (SD) | 52.5 (10.2) | 51.1 (12.2) | 0.99 (0.98-1.00, p=0.035) | 0.98 (0.97-0.99, p=0.001) |
| Preop Diabetes | Non-insulin Meds | 40 (7.5) | 68 (10.6) | 1.26 (0.82-1.96, p=0.296) | 1.65 (1.02-2.68, p=0.041) |
| Insulin | 269 (50.5) | 282 (43.9) | 0.78 (0.60-1.00, p=0.053) | 0.76 (0.57-1.03, p=0.077) | |
| Prior CHF | Asymptomatic or Mild | 77 (14.4) | 142 (22.1) | 1.76 (1.30-2.41, p<0.001) | 1.76 (1.24-2.50, p=0.001) |
| Moderate/Severe | 42 (7.9) | 68 (10.6) | 1.55 (1.03-2.34, p=0.036) | 1.37 (0.87-2.16, p=0.173) | |
| Living Status | Nursing Home | 10 (1.9) | 25 (3.9) | 2.12 (1.04-4.66, p=0.048) | 1.18 (0.51-2.88, p=0.712) |
| Ambulatory Status | Amb w. assistance | 51 (9.6) | 91 (14.2) | 1.63 (1.14-2.36, p=0.009) | 1.63 (1.09-2.46, p=0.018) |
| Wheelchair/Bedridden | 21 (3.9) | 45 (7.0) | 1.96 (1.16-3.40, p=0.014) | 1.47 (0.80-2.77, p=0.220) | |
| BMI Class | Pre-Obesity | 139 (26.1) | 173 (26.9) | 0.73 (0.53-1.01, p=0.056) | 0.74 (0.52-1.05, p=0.088) |
| Obese | 280 (52.5) | 276 (42.9) | 0.58 (0.43-0.77, p<0.001) | 0.51 (0.37-0.70, p<0.001) | |
| ASA Class | Class 3 | 331 (62.5) | 304 (48.1) | 1.34 (0.78-2.33, p=0.291) | 1.60 (0.91-2.89, p=0.108) |
| Class 4 or 5 | 164 (30.9) | 304 (48.1) | 2.70 (1.56-4.75, p<0.001) | 3.30 (1.83-6.06, p<0.001) | |
| *Additional variables in the regression model that did not demonstrate significance on multi-variable analysis include: year of surgery, gender, prior CAD, preoperative smoking status, COPD status, and hypertension. | |||||
Table 1: Multi-variable regression analysis for characteristics associated with on dialysis at the time of AVF/AVG placement.
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