Surgeon Factors Have a Larger Effect on Vascular Access Type and Outcomes than Patient Factors.
Surgeon Factors Have a Larger Effect on Vascular Access Type and Outcomes than Patient Factors.
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外科医生因素对血管通路类型和结局的影响大于患者因素。
DOI：
10.1016/j.jss.2021.02.046
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发表时间：
2021-09
期刊：
影响因子：
--
通讯作者：
Woo K
中科院分区：
文献类型：
--
作者：
Copeland TP;Lawrence PF;Woo K
虽然患者因素经常与血液透析血管通路的选择和结果有关，但外科医生和外科医生专业的差异也可能起作用。本研究的目的是检查单个外科医生对血管通路类型选择、隧道式血液透析导管（THC）移除和重复血管通路的影响程度。国家索赔数据库用于识别2011年至2017年期间通过隧道血液透析导管（THC）进行血液透析的患者。采用混合效应logistic回归分析重复AVF/AVG的可能性。采用Weibull比例风险模型分析从初始动静脉瘘(AVF)/移植物（AVG）到移除THC的时间和重复AVF/AVG的时间。在所有模型中，个体外科医生标识符作为随机效应。6908例AVF/AVG符合纳入标准：5366例（78%）AVF和1542例（22%）AVG。外科医生专业仅对通路类型有显著影响，血管外科医生实施AVG的几率比普通外科医生高26% （p=0.006）。相对于其他自变量，个体外科医师标识符对准入类型的影响最大（中位优势比为2.36；95% CI为2.09-2.72）。单个外科医生标识符对THC去除的影响可能性（中位风险比，1.66;95% CI, 1.58-1.77）和第二次通路（中位风险比，1.83;95% CI, 1.66 - 2.05）的影响程度第二高，在这两种情况下，仅次于AVG的影响，AVG与THC去除的可能性较大（风险比1.91;95% CI, 1.77-2.07）和第二次通路的可能性较低（风险比0.44;95% CI, 0.38-0.52）相关。与外科医生专业和可测量的患者人口统计学/合并症相比，单个外科医生在血管通路类型和重复通路可能性方面的差异更大。未来的研究应侧重于确定哪些外科因素与预后改善有关。
Though patient factors are frequently linked to hemodialysis vascular access selection and outcomes, variability by surgeon and surgeon specialty may play a role as well. The objective of this study is to examine the extent to which individual surgeons influence selection of vascular access type, removal of tunneled hemodialysis catheter (THC), and repeat vascular access. A national claims database was used to identify patients initiating hemodialysis via a tunneled hemodialysis catheter (THC) between 2011 and 2017. Likelihood of repeat AVF/AVG was analyzed using mixed-effects logistic regression. Time from initial arteriovenous fistula (AVF)/graft (AVG) to THC removal and time to repeat AVF/AVG were analyzed using Weibull proportional hazard models. Individual surgeon identifier served as the random effect in all models. 6,908 AVF/AVG met the inclusion criteria: 5366 (78%) AVF and 1,542 (22%) AVG. Surgeon specialty only had a significant influence on access type, with vascular surgeons having 26% greater odds of performing AVG compared to general surgeons (p=0.006). Relative to the other independent variables, individual surgeon identifier had the greatest magnitude of effect on access type (median odds ratio, 2.36; 95% CI, 2.09–2.72). Individual surgeon identifier had the second greatest magnitude of effect likelihood of THC removal (median hazard ratio, 1.66; 95% CI, 1.58–1.77) and second access (median hazard ratio, 1.83; 95% CI, 1.66–2.05), in both cases second only to the effect of AVG, which was associated with greater likelihood of THC removal (hazard ratio 1.91; 95% CI, 1.77–2.07) and lower likelihood of second access (hazard ratio 0.44; 95% CI, 0.38–0.52). Individual surgeons are associated with greater variation in vascular access type and likelihood of repeat access than surgeon specialty and measurable patient demographics/co-morbidities. Future research should focus on identifying which surgeon factors are associated with improved outcomes.
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