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Inpatient Arteriovenous Fistula Creation Is Associated With Worse 30-Day Outcomes
Muhammad Saad Hafeez, MBBS, Othman A. Abdul-Malak, MD MS, Catherine Go, MD, Mohammad H. Eslami, MD MPH, Rabih A. Chaer, MD MS, Theodore H. Yuo, MD MS.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

OBJECTIVES:
Arteriovenous fistula (AVF) creation during an inpatient hospitalization is often performed for patient convenience and to ensure compliance. We sought to evaluate whether this approach has comparable outcomes to planned outpatient AVF creation.
METHODS:
We identified patients undergoing index AVF creation after initiation of dialysis from the United States Renal Data System (USRDS) dataset (2012-2017). Patients were grouped into outpatient (OP) and inpatient (IP) groups. IP included only patients that had claims for an inpatient visit in the days prior to access creation. OP included patients that were operated on either in outpatient setting, ambulatory surgical center or were admitted inpatient on the day of AVF creation. Patient characteristics were compared between groups using standard statistical methods. Multiple safety outcomes were compared between groups using unadjusted and adjusted logistic regression methods. One-year maturation rates were compared using competing risks regression methods. Additionally, outcomes were compared after 1:1 propensity score matching for relevant variables.
RESULTS:
We identified 68,869 patients undergoing AVF creation, 4,854 (7.1%) of which were created during inpatient hospitalization. Patients in the IP group were older (65.213.8 vs 65.813.8, p=0.002), more likely to be Black race (28.1% vs 26.8%, p=0.018), have cardiovascular comorbidities (congestive heart failure 37.9% vs 34.6%; peripheral vascular disease 13.6% vs 11.6%; cerebrovascular disease 11.3% vs 9.4%; all p<0.01). IP were more likely to be dialyzed at for-profit (88.1% vs 85.9%, p<0.01) and freestanding (94.8% vs 92.9%, p<0.01) dialysis centers, compared with OP. On both unadjusted and adjusted analysis, IP were more likely to experience 30-day adverse events such as pneumonia, COPD exacerbation, stroke, myocardial infarction, any complication, and all-cause mortality (Table). On competing risks analysis, successful two-needle cannulation at one year was significantly less likely in the IP group (53.0% vs 68.6%, p<0.01; sHR=0.67[0.65-0.70],p<0.01). These trends were robust on 1:1 propensity matching with 4,806 patients in each group.
CONCLUSIONS:
Carrying out AVF creation procedures on hospitalized patients is associated with worse outcomes compared with those performed on an outpatient basis. A temporary delay for stabilization, medical optimization and outpatient referral may be associated with improved outcomes.

Association of inpatient AVF creation with 30-day adverse events
30-day outcomeOutpatient AVF (%)Inpatient AVF (%)Adjusted Odds Ratio95 % confidence intervalP-value
Pneumonia2.279.154.193.75 - 4.69<0.001
COPD exacerbation0.652.253.402.73 - 4.23<0.001
Myocardial infarction0.912.763.012.48 - 3.65<0.001
Stroke1.133.322.862.40 - 3.41<0.001
Any complication4.5715.433.703.39 - 4.04<0.001
Mortality1.565.093.192.76 - 3.69<0.001


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