目的:晚期初级保健提供者(PCP)或肾脏科医师对进行性肾脏疾病患者的评估可能与发病率和死亡率增加相关。在接受初始动静脉(AV)通路创建的患者中,我们旨在研究最近的PCP和肾脏科医师评估与围手术期发病率和死亡率的关系.
方法:我们对2014-2022年的患者进行了回顾性研究,这些患者在城市,安全网医院。单变量和多变量分析确定PCP和肾脏科医师评估<手术前1年和<3个月的关联,分别,通过隧道透析导管(TDC)开始血液透析,90天重新接纳,90天死亡率。
结果:在558名接受初始房室接入的患者中,平均年龄为59.7±14岁,59%是女性,60.6%是黑人。最近在386(69%)和362(65%)患者中进行了PCP和肾脏病学评估,分别。在多变量分析中,失业和无保险状态与PCP评估的可能性降低相关(失业率:OR.51,95%CI.34-.77;无保险状态:OR.05,95%CI.01-.45)和肾病学家评估(失业率:OR.63,95%CI.43-.91;无保险状态:OR.22,95%CI.06-.83)(所有P<.05)。社会支持与PCP评估的可能性增加相关(OR1.81,95%CI1.07-3.08)(所有P<0.05)。304(55%)患者用TDC开始血液透析。年龄较大(OR.98,95%CI.96-.99),肥胖(OR.38,95%CI.25-.58),和肾脏科医师评估(OR.12,95%CI.08-.19)与接受初始AV通路的患者的TDC血液透析开始减少独立相关(所有P<.05)。270例(48%)发生90天再入院。肝硬化(OR2.5,95%CI1.03-6.03,P=.04),冠状动脉疾病(OR2.31,95%CI1.5-3.57),假肢房室通路(OR1.84,95%CI1.04-3.26),步行障碍(OR1.75,95%CI1.15-2.66)与再入院增加独立相关(所有P<0.05)。年龄较大(OR.98,95%CI.97-.99),先前的TDC(OR.65,95%CI.45-.94),失业率(OR.58,95%CI.39-.86)与再入院率降低相关(所有P<.05)。1.6%的患者出现90天死亡率。PCP和肾脏科医师的评估均与再入院或死亡率无关。
结论:最近的肾脏病学评估与初始AV通路创建患者中TDC开始血液透析的减少相关。失业和无保险状态对获得肾脏病护理构成障碍。
Late primary care provider (PCP) or nephrologist evaluation of patients with progressive kidney disease may be associated with increased morbidity and mortality. Among patients undergoing initial arteriovenous (AV) access creation, we aimed to study the relationship of recent PCP and nephrologist evaluations with perioperative morbidity and mortality.
We performed a retrospective review of patients from 2014 to 2022 who underwent initial AV access creation at an urban, safety-net hospital. Univariable and multivariable analyses identified associations of PCP and nephrologist evaluations <1 year and <3 months before surgery, respectively, with hemodialysis initiation via tunneled dialysis catheters (TDCs), 90-day readmission, and 90-day mortality.
Among 558 patients receiving initial AV access, mean age was 59.7 ± 14 years, 59% were female gender, and 60.6% were Black race. Recent PCP and nephrology evaluations occurred in 386 (69%) and 362 (65%) patients, respectively. On multivariable analysis, unemployed and uninsured statuses were associated with decreased likelihood of PCP evaluation (unemployment: odds ratio [OR], 0.51; 95% confidence interval [CI], 0.34-0.77; uninsured status: OR, 0.05; 95% CI, 0.01-0.45) and nephrologist evaluation (unemployment: OR, 0.63; 95% CI, 0.43-0.91; uninsured status: OR, 0.22; 95% CI, 0.06-0.83) (all P < .05). Social support was associated with increased likelihood of PCP evaluation (OR, 1.81; 95% CI, 1.07-3.08) (all P < .05). Hemodialysis was initiated with TDCs in 304 patients (55%). Older age (OR, 0.98; 95% CI, 0.96-0.99), obesity (OR, 0.38; 95% CI, 0.25-0.58), and nephrologist evaluation (OR, 0.12; 95% CI, 0.08-0.19) were independently associated with decreased hemodialysis initiation with TDCs in patients receiving an initial AV access (all P < .05). Ninety-day readmission occurred in 270 cases (48%). Cirrhosis (OR, 2.5; 95% CI, 1.03-6.03; P = .04), coronary artery disease (OR, 2.31; 95% CI, 1.5-3.57), prosthetic AV access (OR, 1.84; 95% CI, 1.04-3.26), and impaired ambulation (OR, 1.75; 95% CI, 1.15-2.66) were independently associated with increased readmission (all P < .05). Older age (OR, 0.98; 95% CI, 0.97-0.99), prior TDC (OR, 0.65; 95% CI, 0.45-0.94), and unemployment (OR, 0.58; 95% CI, 0.39-0.86) were associated with decreased readmission (all P < .05). Ninety-day mortality occurred in 1.6% of patients. Neither PCP nor nephrologist evaluation was associated with readmission or mortality.
Recent nephrology evaluation was associated with reduced hemodialysis initiation with TDCs among patients undergoing initial AV access creation. Unemployed and uninsured statuses posed barriers to accessing nephrology care.