The Impact of Neighborhood Social Disadvantage on Presentation and Management of Hemodialysis Access Surgery Patients

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The impact of social determinants of health on the presentation, management, and outcomes of patients requiring hemodialysis (HD) access surgery have not been well characterized. The Area Deprivation Index (ADI) is a validated measure of aggregate community-level social determinants of health disparities experienced by members within a community. Herein, we examined the effect of ADI on health outcomes for first-time HD access patients. We identified patients who underwent first-time HD access surgery in the Vascular Quality Initiative between August 2011 and May 2022. Patient zip codes were correlated with an ADI quintile (Q1-Q5, least to most disadvantaged). Patients without ADI were excluded. Perioperative and long-term outcomes considering ADI were analyzed. There were 43,292 patients analyzed. The average age was 63 years, 43% were female, 60% were of White race, 10% were of Hispanic ethnicity, and 85% received autogenous arteriovenous (AV) access. Patient distribution by ADI quintile (Q) was as follows: Q1 (16%), Q2 (18%), Q3 (21%), Q4 (23%), and Q5 (22%). On multivariable analysis, the most disadvantaged quintile (Q5) was associated with decreased autogenous access creations (odds ratio [OR], 0.85; 95% confidence interval [CI], 0.77-0.94; P = .002), fewer preoperative vein imaging (OR, 0.62; 95% CI, 0.50-0.77; P < .001), lower access maturation (OR, 0.82; 95% CI, 0.71-0.94; P = .005), and lower 1-year survival (OR, 0.80; 95% CI, 0.71-0.90; P < .001) compared to Q1. Q5 was not associated with significantly higher 1-year intervention rates (Table). The most socially disadvantaged (Q5) AV access creation patients were more likely to experience disparities at the time of preoperative AV access creation, access type, as well as well as at 1-year outcomes. Improvement in preoperative planning and long-term follow-up may be an opportunity for advancing health equity in this population.TableUnivariate and multivariable analysis of outcomes of interest stratified by Area Deprivation Index (ADI) quintileADIAV fistulaVein imaging obtainedAccess matured at last follow-up1-Year intervention1-Year survivalUniMultiUniMultiUniMultiUniMultiUniMultiQ16138 (87)(ref)2413 (91)(ref)2695 (86)(ref)798 (31)(ref)6483 (92)(ref)Q26771 (85)0.84 [0.75-0.93]2254 (91)1.01 [0.80-1.26]2840 (83)0.83 [0.72-0.97]961 (32)0.98 [0.86-1.11]7121 (89)0.82 [0.72-0.93]Q37717 (85)0.81 [0.73-0.89]2575 (94)1.50 [1.18-1.90]3253 (83)0.82 [0.71-0.95]1089 (31)0.93 [0.82-1.05]8122 (89)0.80 [0.71-0.90]Q48211 (84)0.76 [0.69-0.84]2619 (91)0.96 [0.78-1.19]3529 (84)0.91 [0.78-1.05]1268 (32)0.94 [0.83-1.06]8844 (90)0.88 [0.79-0.99]Q57838 (84)0.85- [0.77-0.94]2018 (88)0.62 [0.50-0.77]3694 (82)0.82 [0.71-0.94]1433 (34)0.99 [0.88-1.12]8370 (90)0.80 [0.71-0.90]P value<.001-<.001-<.001-.047-<.001-Multi, multivariable analysis; Uni, univariate analysis.Univariate results represented as number (%). Multivariable results represented as adjusted odds ratio. Brackets in multivariable analysis indicated the 95% confidence interval. Bold indicated statistically significant results. Of patients with long-term follow-up data, the average length of last long-term follow-up data was 383 ± 240 days. Open table in a new tab