Surgical site infection rates in dialysis patients undergoing endovascular procedures.

A surgical site infection (SSI) is an infection related to surgery that develops within 30 days after an operation or within 1 year of implant placement. Postoperative SSIs are the most common health-care-associated infections, occurring in up to 5% of surgical patients. Endovascular surgical procedures related to vascular access are common in the dialysis population and may cause SSIs. A large outpatient vascular access system developed and implemented a surveillance program to measure and monitor SSIs in their population. The health-care surveillance system extended to 76 ambulatory care centers across the United States and Puerto Rico. Based on a recorded 92,880 patient encounters, the surveillance system tabulated 12,541 valid patient survey responses documenting self-reported symptoms of infection within a 30-day postoperative period. The SSI rate was tabulated based on the presence of two or more specified indicators of infection: antibiotics, pus, dehiscence, pain, warmth, and swelling. Patients undergoing interventional procedures received surveys at discharge. Data were collected and analyzed using SPSS software. Survey analysis indicated a less than 3% superficial incisional SSI rate in hemodialysis patients undergoing endovascular procedures. The SSI rate for clean wound procedures is generally 2% or less. These data indicate that dialysis patients undergoing interventional procedures in vascular access centers may have a slightly greater risk of developing SSIs due to the presence of additional risk factors including obesity, diabetes, and age. This study was limited by a set of loose diagnostic criteria self-reported by patients, which may have overestimated the prevalence of infection. SSIs are a serious medical problem associated with increased morbidity and mortality and increased medical care costs. All providers should consider an active surveillance program following endovascular procedures given the comorbidities associated with the dialysis population.

Clinical and economic value of performing dialysis vascular access procedures in a freestanding office-based center as compared with the hospital outpatient department among Medicare ESRD beneficiaries.

Dialysis vascular access (DVA) care is being increasingly provided in freestanding office-based centers (FOC). Small-scale studies have suggested that DVA care in a FOC results in favorable patient outcomes and lower costs. To further evaluate this issue, data were drawn from incident and prevalent ESRD patients within a 4-year sample (2006-2009) of Medicare claims (USRDS) on cases who receive at least 80% of their DVA care in a FOC or a hospital outpatient department (HOPD). Using propensity score matching techniques, cases with a similar clinical and demographic profile from these two sites of service were matched. Medicare utilization, payments, and patient outcomes were compared across the matched cohorts (n = 27,613). Patients treated in the FOC had significantly better outcomes (p < 0.001), including fewer related or unrelated hospitalizations (3.8 vs. 4.4), vascular access-related infections (0.18 vs. 0.29), and septicemia-related hospitalizations (0.15 vs. 0.18). Mortality rate was lower (47.9% vs. 53.5%) as were PMPM payments ($4,982 vs. $5,566). This study shows that DVA management provided in a FOC has multiple advantages over that provided in a HOPD.

Interventional nephrology: When should you consider a graft?

The patient's vascular access is critical in ensuring that hemodialysis is successful, effective, relatively uncomplicated, and consistently reproducible from one treatment to another. The choice of vascular access is dictated by a multitude of factors, some of which are generalizable to a larger system, and others of which are flavored by local experience and expertise; an important fraction is specific to the patient presenting to the clinician at a particular point in time. Some of these factors, such as patient age and sex, are not modifiable; others, like comorbidity, vessel size and urgency of presentation to the renal provider, are manageable and sometimes modifiable. The role of the autologous arteriovenous fistula as the ideal conduit for hemodialysis treatments is well established. The role of the prosthetic graft warrants discussion and investigation to most optimally apply to patients this important alternative within the armamentarium of vascular access.