Racial Disparity In The Application Of The "Fistula First" Guideline
Elizabeth H. Weissler, MD1, Kevin Southerland, MD1, Leila Mureebe, MD, MPH1, Emily Malgor, MD2, Mark Nehler, MD2, Chandler Long, MD1.
1Duke University, Durham, NC, USA, 2University of Colorado, Denver, CO, USA.
Introduction: The United States Renal Data System reports demonstrate lower arteriovenous fistula (AVF) placement at hemodialysis (HD) initiation and reduced AVF prevalent usage over time in African Americans and women. The cause of these disparities is not clear: Plausible explanations include differences in available venous conduit, access to care, or bias. Access to nephrology care has been implicated in the USRDS and CMS datasets, but the contribution of anatomy has not been explored at a national scale.
Methods: We queried the Vascular Quality Initiative database from 2011 to 2019 for patients undergoing HD access. Patients who died were excluded from analysis of HD access utility. Patient, venous anatomy, procedural characteristics, and outcomes were compared using Pearson Χ2 tests for categorical variables and Wilcoxon rank-sum tests for continuous variables.
Results: 41,455 white and 34,495 black patients underwent HD access placement, of whom 46% overall were female. Fewer black patients than white patients underwent fistula creation (75.0% vs. 80.2%, p<0.001). Black patients were significantly more likely to have a fistula placed while they were already on dialysis (70.3% vs 61.0%, p<0.001). Slightly more white patients had pre-access venous mapping than black patients (84.1% vs 81.0%, p<0.001). There was no difference in vein adequacy (>3mm) between races (86.9% in black patients versus 86.6% in white patients, p=0.225). Though mean vein diameters varied in a statistically significant fashion, they did not vary in a clinically meaningful way (minimum 3.81mm in black women, maximum 3.99mm in white men).
More white patients died over the course of follow-up (24.9% vs 19.8%, p<0.001). More white patients than black patients remained dialysis-independent over the course of follow-up (39% vs 29.7%, p<0.001). Long-term fistula utility in black patients was 39.9% versus 32.4% in white patients (p<0.001). Black men had a 43.0% fistula utility rate, white men a 38.2% utility rate, black women a 41.0% utility rate and white women a 33.3% utility rate.
Conclusions:
This VQI analysis shows that black patients have greater utility from fistula placement than white patients, but they are less likely to undergo fistula creation and more likely to undergo access creation after already starting dialysis. This is not due to differences in vein diameters and suggests that “fistula first” guidelines may not be equally applied to black patients.
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