Association of Insurance Status with Timing of Hemodialysis Access Placement.

Abstract

OBJECTIVE\nPatients without adequate outpatient follow-up often present requiring emergency hemodialysis and then undergo permanent dialysis access placement at a later time. We sought to examine the relationship between type of insurance and whether a patient was already on dialysis at time of surgery.\n\n\nMETHODS\nThe Vascular Quality Initiative Hemodialysis Access registry was queried for all adult patients undergoing first time permanent hemodialysis access between January 2015 and September 2019. Patient and procedural characteristics were examined in patients split by private insurance, Medicare over 65 years, Medicare under 65 years, and Medicaid. Primary Outcome was whether patients were on dialysis at time of surgery.\n\n\nRESULTS\nThere were 19,307 adult patients that underwent first time placement of an arterio-venous fistula or graft. Of these patients, 9,729 (50%) had Medicare, 7,179 (37%) had private insurance, and 2,399 (12%) had Medicaid. The patients with Medicare were sub-grouped by age with 2,968 (31%) being under the age of 65 and 6,761 (69%) being over the age of 65. Patients with Medicare and under 65 were the most likely to be on dialysis at the time of surgical access placement at 67%, while 59% of Medicaid patients were on dialysis, and 53% each group of patients with Medicare and over 65 and private insurance were on dialysis. Following adjustment for patient characteristics, patients with Medicare under 65 and over 65 were both significantly more likely to be on dialysis at time of surgery compared to private insurance with odds ratio of 1.64 (95% confidence interval 1.49-1.80, p <0.001) and odds ratio of 1.11 (95% confidence interval 1.03-1.20, p = 0.007), respectively. After adjustment, patients with Medicaid were no longer significantly more likely to be on dialysis. Secondary outcomes demonstrated, after adjustment, no difference in association with surgical fistula versus graft in any insurance groups, however patients with Medicare and under 65 were more likely to have a non-radial artery used for anastomosis with an odds ratio of 1.18 (95% confidence interval 1.04-1.34, p = 0.011).\n\n\nCONCLUSIONS\nCertain types of insurance are correlated with being on dialysis at the time of access placement. Although associations were seen between insurance type and surgical access characteristics, these were predominantly insignificant when patient demographics and status of dialysis were controlled for. These potential gaps in care represent an area for improvement that deserves further exploration.