(taken from abstract) Complications related to hemodialysis access are a major cause of morbidity and mortality among chronic hemodialysis patients. Arteriovenous fistulas are superior to synthetic grafts because they have a lower rate of infection, thrombosis, and stenosis. Recently the National Kidney Foundation recommended an aggressive approach to AVF placement with AVG's reserved only for those patients in whom AVF placement is not possible. Despite these recommendations intended to improve the quality of access for hemodialysis patients, AVG's continue to be the most popular form of permanent access nationally. The reasons for this preference are not well understood. It is known there are wide geographic variations in the relative percentages of AVF's and AVG's in the US. This is not due entirely to variations in patient characteristics and probably also reflects variations in surgical practice between centers. The role of surgical practice variation in choice and survival of hemodialysis access is not known. This is most likely because data on surgical procedures are not readily available through the commonly used dialysis database and hospital discharge databases. This study will use the VA National Patient Care Database to examine variations among VA Medical Centers and the type of permanent hemodialysis access placed and to evaluate the effect of center and surgeon characteristics on access survival. The NPCD contains information on all inpatient and outpatient encounters at VA Medical centers. Using NPCD data, the investigators will identify a national cohort of all patients who underwent placement of permanent hemodialysis access in the VA system during the years 1998-2000. The investigators will then identify patient related, medical center related, and surgeon related variables that affect the probability of receiving an AVF versus AVG and those that affect access survival. Results of this analysis may prove helpful in the development and implementation of policies to increase the percentage of AVF's placed in the US.
