Variation in fistula use across dialysis facilities: Is it explained by case-mix?

Navdeep Tangri, Ranjani Moorthi, Hocine Tighiouhart, Klemens B. Meyer, Dana C. Miskulin

Research output: Contribution to journalArticle

19 Scopus citations


Background and objectives: Arteriovenous fistulas (AVFs) remain the preferred vascular access for hemodialysis patients. Dialysis facilities that fail to meet Centers for Medicare & Medicaid Services goals cite patient case-mix as a reason for low AVF prevalence. This study aimed to determine the magnitude of the variability in AVF usage across dialysis facilities and the extent to which patient case-mix explains it. Design, setting, participants, & measurements: The vascular access used in 10,112 patients dialyzed at 173 Dialysis Clinic Inc. facilities from October 1 to December 31, 2004, was evaluated. The access in use was considered to be an AVF if it was used for >70% of hemodialysis treatments. Mixed-effects models with a random intercept for dialysis facilities evaluated the effect of facilities on AVF usage. Sequentially adjusted multivariate models measured the extent to which patient factors (case-mix) explain variation across facilities in AVF rates. Results: 3787 patients (38%) were dialyzed using AVFs. There was a significant facility effect: 7.6% of variation in AVF use was attributable to facility. This was reduced to 7.1% after case-mix adjustment. There were no identified specific facility-level factors that explained the interfacility variation. Conclusions: AVF usage varies across dialysis facilities, and patient case-mix did not reduce this variation. In this study, 92% of the total variation in AVF usage was due to patient factors, but most were not measurable. A combination of patient factors and process indicators should be considered in adjudicating facility performance for this quality indicator.

Original languageEnglish (US)
Pages (from-to)307-313
Number of pages7
JournalClinical Journal of the American Society of Nephrology
Issue number2
StatePublished - 2010

ASJC Scopus subject areas

  • Epidemiology
  • Critical Care and Intensive Care Medicine
  • Nephrology
  • Transplantation

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