Hemodialysis Facilities, Vascular Access Surgeons, and Central Venous Catheter Use: A Retrospective Cohort Study.

RATIONALE &

objectiveReducing central venous catheter (CVC) use for hemodialysis among patients with kidney failure receiving maintenance hemodialysis is an important priority. Previous reports have suggested that partnerships between hemodialysis facilities and vascular access surgeons lead to reduced rates of CVC use. We studied whether a greater intensity of these relationships was associated with less use of CVCs. STUDY

designNational retrospective cohort study. SETTING &

participants109,293 patients with kidney failure receiving maintenance hemodialysis within 4,402 facilities. EXPOSURE: Facility-level Herfindahl-Hirschman index (HHI), an established measure of market concentration used as a proxy for closeness of the relationship between hemodialysis facilities and vascular access surgeons, with higher indices suggesting closer relationships. OUTCOME: Greater than 90 days of continuous CVC use for hemodialysis in 2018. ANALYTICAL APPROACH: Mixed-effects logistic regression model including patient-level covariates, facility-level covariates, and facility random effects. Dialysis facilities were divided into quartiles based on increasing HHI. Multiple sensitivity analyses were conducted using similar models.

resultsPatients in facilities in the highest HHI quartile were less likely to have continued catheter use for more than 90 days than those in the lowest quartile (odds ratio, 0.80; 95% confidence interval, 0.75-0.87; P < 0.001). This association was also observed in multiple sensitivity analyses. LIMITATIONS: Misclassification of the exposure, inclusion of patients insured by Medicare Fee-for-Service, unmeasured confounding.

conclusionsMore extensive partnerships between dialysis facilities and vascular access surgeons reflected by the HHI were associated with lower rates of CVC use for hemodialysis. PLAIN-LANGUAGE SUMMARY: The goal of this study was to learn if patients in dialysis facilities that partnered with surgeons (measured using a marker of market concentration) who place and maintain permanent hemodialysis vascular access grafts and fistulas experienced lower use of a temporary form of vascular access for hemodialysis, central venous catheters, which are associated with an increased risk of infection. We found that closer partnerships between hemodialysis centers and surgeons were associated with less use of catheters for the patients served by those dialysis centers. These findings may inform strategies to reduce the use of central venous catheters and improve outcomes for patients with kidney failure requiring dialysis.