Enhanced training in vascular access creation predicts arteriovenous fistula placement and patency in hemodialysis patients: results from the Dialysis Outcomes and Practice Patterns Study

Rajiv Saran, Stacey J Elder, David A Goodkin, Takashi Akiba, Jean Ethier, Hugh C Rayner, Akira Saito, Eric W Young, Brenda W Gillespie, Robert M Merion, Ronald L Pisoni
Annals of Surgery 2008, 247 (5): 885-91

OBJECTIVE: To investigate whether intensity of surgical training influences type of vascular access placed and fistula survival.

SUMMARY BACKGROUND DATA: Wide variations in fistula placement and survival occur internationally. Underlying explanations are not well understood.

METHODS: Prospective data from 12 countries in the Dialysis Outcomes and Practice Patterns Study were analyzed; outcomes of interest were type of vascular access in use (fistula vs. graft) in hemodialysis patients at study entry and time from placement until primary and secondary access failures, as predicted by surgical training. Logistic and Cox regression models were adjusted for patient characteristics and time on hemodialysis.

RESULTS: During training, US surgeons created fewer fistulae (US mean = 16 vs. 39-426 in other countries) and noted less emphasis on vascular access placement compared with surgeons elsewhere. Significant predictors of fistula versus graft placement in hemodialysis patients included number of fistulae placed during training (adjusted odds ratio [AOR] = 2.2 for fistula placement, per 2 times greater number of fistulae placed during training, P < 0.0001) and degree of emphasis on vascular access creation during training (AOR = 2.4 for fistula placement, for much-to-extreme emphasis vs. no emphasis, P = 0.0008). Risk of primary fistula failure was 34% lower (relative risk = 0.66, P = 0.002) when placed by surgeons who created > or = 25 (vs. < 25) fistulae during training.

CONCLUSIONS: Surgical training is key to both fistula placement and survival, yet US surgical programs seem to place less emphasis on fistula creation than those in other countries. Enhancing surgical training in fistula creation would help meet targets of the Fistula First Initiative.

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