A mixed-methods investigation of incident Hemodialysis access in a safety-net population

BACKGROUND: Despite improved health outcomes associated with arteriovenous fistulas, 80% of Americans initiate hemodialysis using a catheter, influenced by low socioeconomic status among other factors. Risk factors for incident catheter use in safety-net populations are unknown. Our objective was to identify factors associated with incident catheter use among hemodialysis patients at one safety-net hospital, with a goal of informing fistula placement initiatives targeted at safety-net populations more generally. METHODS: We performed a retrospective review of all incident hemodialysis patients at a single urban safety-net hospital from January 1, 2010 - December 31, 2015 (n = 241), as well as semi-structured interviews with a multi-lingual convenience sample of patients (n = 10) from this cohort. The primary outcome was incident vascular access modality. Multivariable logistic regression was used to identify factors associated with incident catheter use. Interview transcripts were coded using a directed content analysis framework based on a model describing barriers to healthcare access. RESULTS: Subjects were 61.8% male, racially/ethnically diverse (19.5% white, 29.5% black, 28.6% Hispanic, 17.4% Asian), with a mean age of 52.4 years. Eighty-eight percent initiated hemodialysis using a catheter. In multivariable analysis, longer duration of nephrology care was associated with decreased catheter use (>12 months vs. 0–6 months: adjusted Odds Ratio [aOR] 0.07, 95% CI 0.02–0.23, p < 0.001), whereas uninsured status increased odds of catheter use (aOR 3.96, 1.23–12.76, p = 0.02). There was a decrease in catheter use after vascular surgery services became available in-hospital (OR 0.40, 95% CI 0.16–0.98, p = 0.04), however this association was not significant in multivariable analysis (aOR 0.48, 0.17–1.36, p = 0.17). During interviews, patients cited emotional responses to disease, lack of social and financial resources, and limited health knowledge as barriers to obtaining fistula surgery. CONCLUSIONS: The rate of catheter use in this urban safety-net population is above the national average. Access to health insurance, early referrals to nephrology, and provision of in-hospital vascular surgery should be prioritized in the safety-net. Additionally, services that support patients’ emotional and learning needs may decrease delays in fistula placement.