RATIONALE & OBJECTIVE Patients with multiple comorbid conditions are less likely to use an arteriovenous fistula (AVF) for hemodialysis vascular access. Some dialysis facilities have high rates of AVF placement despite having patients with many comorbid conditions. This study describes variation in facility-level use of AVFs across the facility-level burden of patient comorbid conditions. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Medicare patients receiving hemodialysis for 1 year or more in US dialysis facilities. PREDICTORS Facility-level burden of patient comorbid conditions; patient characteristics. OUTCOMES Odds of AVFs versus other access types; facility-level use of AVFs. ANALYTICAL APPROACH Facility-level comorbidity burden was calculated by summing individual comorbid conditions, determining the average per patient, then defining 11 groups based on facility percentile ranking. Generalized estimating equations with a logit link were used to estimate the odds of AVF placement at the patient level. For the facility-level analysis, a generalized estimating equation model with the identity link was fit to characterize the percentage of AVF use at each facility. RESULTS Overall, AVF use was 65.8% in 315,919 prevalent hemodialysis patients among 5,813 facilities. After adjustment for patient characteristics, AVF use was 0.27, 0.30, 1.05, and 1.74 percentage points lower than the median among facilities in the 61st to 70th, 71st to 80th, 81st to 90th, and 91st to 99th percentiles of comorbidity, respectively, and 0.42, 0.63, 1.34, and 1.90 percentage points higher than the median among facilities in the 31st to 40th, 21st to 30th, 11th to 20th, and 1st to 10th percentiles of comorbidity, respectively. Facilities in the greater than 99th percentile of comorbidity burden had AVF use that was 3.47 percentage points lower than the median. Facilities in the less than 1st percentile of comorbidity burden had AVF use that was 2.64 percentage points greater than the median. LIMITATIONS Limited to Medicare dialysis-dependent patients treated for 1 year or more. CONCLUSIONS After adjustment for patient characteristics, we found small differences in facility rates of AVF use except in the extremes of high or low levels of comorbidity burden. Our study demonstrates that dialysis facilities with a relatively high patient comorbidity burden can achieve similar fistula rates as facilities with healthier patients. Although high comorbidity burden does not explain low facility AVF use, additional study is needed to understand differences in AVF use rates between facilities with similar comorbidity burdens.

中文翻译：

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在美国动静脉瘘的使用和透析设施水平的合并症负担。

理由和目的具有多种合并症的患者不太可能使用动静脉瘘（AVF）进行血液透析血管通路。尽管有许多合并症患者，但某些透析设施的AVF放置率很高。这项研究描述了AVF在不同级别患者共病情况下在设施级别使用的差异。研究设计回顾性队列研究。背景与参与者Medicare在美国透析机构接受血液透析1年以上的患者。预测者患者合并疾病的设施级负担；患者特征。结果AVF与其他访问类型的赔率；设施级别的AVF的使用。分析方法通过合并各个合并症条件来计算设施级合并症负担，确定每位患者的平均值，然后根据设施百分等级对11个组进行定义。使用具有logit链接的广义估计方程式来估计AVF在患者水平上的位置几率。对于设施级别的分析，带有身份链接的广义估计方程模型适用于描述每个设施使用AVF的百分比。结果总体上，在5,813家医疗机构中，有315,919名流行性血液透析患者使用了AVF，占65.8％。调整患者特征后，AVF的使用率分别比第61至70、71至80、81至90和91至99％百分位数的设施中位数低0.27、0.30、1.05和1.74个百分点，并且在第31至第40位的设施中，其设施中位值分别比中位数高0.42、0.63、1.34和1.90个百分点，第21至30、11至20和1至10个百分位数。合并症负担大于99％的机构的AVF使用率比中位数低3.47个百分点。合并症负担低于1％的机构的AVF使用率比中位数高2.64个百分点。局限性限于治疗1年或以上的Medicare透析依赖性患者。结论调整患者特征后，我们发现AVF的使用率存在细微差异，除了合并症负担高或低的极端情况外。我们的研究表明，患者合并症负担相对较高的透析设施可以达到与健康患者的设施相似的瘘管发生率。