Abstract：
OBJECTIVE: The optimal timing of vascular access (VA) creation for hemodialysis (HD) and whether this timing affects mortality and health-care utilization after HD initiation remain unclear. Thus, we conducted a population-based study to explore their association.
METHODS: We used Taiwan\'s National Health Insurance Research Database to analyze health-care outcomes and utilization in a cohort initiating HD during 2003-2013. We stratified patients by the following VA creation time points: >180, 91-180, 31-90, and ≤30 days before and ≤30 days after HD initiation and examined all-cause mortality, ambulatory care utilization/costs, hospital admission/costs, and total expenditure within 2 years after HD. Cox regression, Poisson regression, and general linear regression were used to analyze mortality, health-care utilization, and costs respectively.
RESULTS: We identified 77,205 patients who started HD during 2003-2013. Compared with the patients undergoing VA surgery >180 days before HD initiation, those undergoing VA surgery ≤30 days before HD initiation had the highest mortality-15.92 deaths per 100-person-years, crude hazard ratio (HR) 1.56, and adjusted HR 1.28, the highest hospital admissions rates- 2.72 admission per person-year, crude rate ratio (RR) 1.48 and adjusted RR 1.32, and thus the highest health-care costs- US$31,390 per person-year, 7% increase of costs and 6% increase with adjustment within the 2-year follow-up after HD initiation.
CONCLUSIONS: Late VA creation for HD can increase all-cause mortality, hospitalization, and health-care costs within 2 years after HD initiation. Early preparation of VA has the potential to reduce post-HD mortality and healthcare expenses for the ESKD patients.
METHODS: We used Taiwan\'s National Health Insurance Research Database to analyze health-care outcomes and utilization in a cohort initiating HD during 2003-2013. We stratified patients by the following VA creation time points: >180, 91-180, 31-90, and ≤30 days before and ≤30 days after HD initiation and examined all-cause mortality, ambulatory care utilization/costs, hospital admission/costs, and total expenditure within 2 years after HD. Cox regression, Poisson regression, and general linear regression were used to analyze mortality, health-care utilization, and costs respectively.
RESULTS: We identified 77,205 patients who started HD during 2003-2013. Compared with the patients undergoing VA surgery >180 days before HD initiation, those undergoing VA surgery ≤30 days before HD initiation had the highest mortality-15.92 deaths per 100-person-years, crude hazard ratio (HR) 1.56, and adjusted HR 1.28, the highest hospital admissions rates- 2.72 admission per person-year, crude rate ratio (RR) 1.48 and adjusted RR 1.32, and thus the highest health-care costs- US$31,390 per person-year, 7% increase of costs and 6% increase with adjustment within the 2-year follow-up after HD initiation.
CONCLUSIONS: Late VA creation for HD can increase all-cause mortality, hospitalization, and health-care costs within 2 years after HD initiation. Early preparation of VA has the potential to reduce post-HD mortality and healthcare expenses for the ESKD patients.
摘要：
目的：目前尚不清楚血液透析（HD）血管通路（VA）建立的最佳时机以及该时机是否会影响HD开始后的死亡率和医疗保健利用率。因此，我们进行了一项以人群为基础的研究,以探讨它们之间的关联.
方法：我们使用台湾的国家健康保险研究数据库来分析2003-2013年期间启动HD的队列中的医疗保健结果和利用情况。我们通过以下VA创建时间点对患者进行分层：>180、91-180、31-90和HD开始前30天和≤30天后，并检查了全因死亡率。门诊护理利用率/费用，住院/费用，以及HD后2年内的总支出。Cox回归,泊松回归，和一般线性回归分析死亡率，医疗保健利用，和成本分别。
结果：我们确定了在2003-2013年期间发生HD的77,205例患者。与开始HD前>180天接受VA手术的患者相比，那些在HD开始前≤30天接受VA手术的人的死亡率最高-每100人年15.92例死亡，粗危险比(HR)1.56，调整后的HR1.28，最高的住院率-每人每年2.72入院率，粗利率比率(RR)1.48和调整后的RR1.32，因此是最高的医疗保健成本-每人每年31,390美元，在开始HD后的2年随访中，费用增加了7％，随着调整增加了6％。
结论：HD的晚期VA创建可以增加全因死亡率，住院治疗,以及开始HD后2年内的医疗保健费用。早期准备VA有可能降低ESKD患者的HD后死亡率和医疗保健费用。
方法：我们使用台湾的国家健康保险研究数据库来分析2003-2013年期间启动HD的队列中的医疗保健结果和利用情况。我们通过以下VA创建时间点对患者进行分层：>180、91-180、31-90和HD开始前30天和≤30天后，并检查了全因死亡率。门诊护理利用率/费用，住院/费用，以及HD后2年内的总支出。Cox回归,泊松回归，和一般线性回归分析死亡率，医疗保健利用，和成本分别。
结果：我们确定了在2003-2013年期间发生HD的77,205例患者。与开始HD前>180天接受VA手术的患者相比，那些在HD开始前≤30天接受VA手术的人的死亡率最高-每100人年15.92例死亡，粗危险比(HR)1.56，调整后的HR1.28，最高的住院率-每人每年2.72入院率，粗利率比率(RR)1.48和调整后的RR1.32，因此是最高的医疗保健成本-每人每年31,390美元，在开始HD后的2年随访中，费用增加了7％，随着调整增加了6％。
结论：HD的晚期VA创建可以增加全因死亡率，住院治疗,以及开始HD后2年内的医疗保健费用。早期准备VA有可能降低ESKD患者的HD后死亡率和医疗保健费用。
