The Impact of Peripherally-inserted Central Catheters and Vascular Imaging on Hemodialysis Patients.
McGill, Rita.
2016
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Abstract: Abstract Vascular access is a critical determinant of the survival of patients receiving hemodialysis. A working fistula or a graft avoids risks of infection, hospitalization and death that are associated with central venous hemodialysis catheter access. Adequate blood vessels are required for creation of arteriovenous fistulas and grafts. Little is known about the effect of strategies t... read moreo manage and preserve veins on the ability to achieve vascular access for hemodialysis. This study defines the epidemiology of two common medical procedures that may influence the likelihood that a patient will transition to a fistula or graft: peripherally inserted central catheters, and vascular imaging procedures. We examined these exposures in Medicare beneficiaries who initiated hemodialysis with central venous catheters, and used proportional hazards models with and without time dependent covariates to determine the associations of these exposures with time to transition to first working arteriovenous fistulas or grafts and patient survival. We found that one in every eight patients had been exposed to peripherally inserted central catheters, after having initiated hemodialysis or during the two years prior. Pre-dialysis exposure to PICC was associated with a decreased likelihood of achieving a working arteriovenous fistula (HR=0.78, 95% CI=0.71, 0.85) or any fistula or graft (HR=0.85, 95% CI=0.79, 0.91). Post-dialysis exposure to PICC was independently associated with decreased achievement of working arteriovenous fistula (HR=0.81, 95% CI=0.72, 0.90) or any fistula or graft (HR=0.81, 95% CI 0.73, 0.89). Fewer than 10% of patients had diagnostic vascular imaging prior to initiating hemodialysis, despite exposure to pre-dialysis nephrology care in nearly half. Vascular imaging performed prior to dialysis initiation was associated with increased transition to arteriovenous fistulas (HR=1.36, 95% CI=1.27, 1.45) and any arteriovenous fistula or graft (HR=1.57, 95% CI=1.49, 1.66). Imaging performed after hemodialysis treatments were initiated was independently associated with increased working fistulas (HR=1.45, 95% CI=1.40, 1.51) and transition to any working fistula or graft (HR=1.63, 95% CI=1.58, 1.69). Approximately 70% of patients who have surgery achieve a fistula or graft, regardless of whether imaging is employed, suggesting that the benefits are mediated by increased performance of surgery in imaged patients. Our analyses suggest that peripherally inserted central catheters are common and associated with poor outcomes. Vascular imaging is infrequent, but associated with desireable outcomes. Decisions made regarding the use of either of these procedures represent potentially modifiable practice patterns that could influence dialysis outcomes.
Thesis (M.S.)--Tufts University, 2016.
Submitted to the Dept. of Clinical & Translational Science.
Advisor: Daniel Weiner.
Committee: Eduardo Lacson, Robin Ruthazer, Klemens Meyer, and Dana Miskulin.
Keywords: Medicine, Biostatistics, and Epidemiology.read less - ID:
- kk91fz59j
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