Education Challenges in Patients with End Stage Renal Disease Requiring Hemodialysis

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Education Challenges in Patients with End Stage Renal Disease Requiring Hemodialysis
*Nyah Patel MPH¹, *Anna Schneider ¹, *Thomas Cheng ², *Andrea Alonso MD¹, *Thomas Mcnamara BS¹, *Elizabeth King MD¹, Alik Farber ¹, Jeffrey Siracuse MD, MBA¹
¹Surgery, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA; ²Dartmouth-Hitchcock Medical Center, Lebanon, NH

Background: Higher education level has historically been associated with improved health outcomes and life expectancy, yet its impacts on outcomes for patients with end stage renal disease (ESRD) undergoing hemodialysis are not well understood. Our goal was to characterize patient factors and outcomes associated with initial arteriovenous (AV) access creation by education level. Study Design: We performed a single-center retrospective review of patients who underwent initial AV access creation from 2014-2021. Education levels were defined as primary (elementary school), secondary (middle/high school equivalent), and tertiary (college/higher). Univariable, multivariable, and Kaplan-Meier analyses were performed. Results: We identified 480 upper extremity AV access creations performed on patients with primary (20.2%), secondary (54.6%), or tertiary education (25.2%). Access types included brachiocephalic (43.6%), brachiobasilic (24%), radiocephalic (17.8%) AV fistulas, and prosthetic grafts (11.1%). The mean age of this cohort was 58.7 years, 60.2% of patients were male, 24.8% were White, 66.2% were Black, 9% were another race, and 24.2% reported Hispanic ethnicity. Patients who completed only primary education were more often of Hispanic ethnicity (58.8% primary vs. 17.9% secondary vs. 9.9% tertiary, P<.0001) and more often were uninsured (62.9% primary vs. 46.2% secondary vs. 39.7% tertiary, P<.001). In similar group order, those with only primary education less commonly spoke English as a primary language (27.1% vs. 79.4% vs. 77.5%, P<.001), were male (53.6% vs. 58% vs. 70.3%, P=.025), or identified as a race other than Black/White (20.8% vs 5.7% vs. 8.6%, P=.009). There were no significant differences between education levels for access-related steal or 30-day readmission. On multivariable analysis, 30-day index readmission was not significantly associated with education level (Table). Loss of primary patency was also not significantly associated with secondary or tertiary education (Table). Kaplan-Meier analysis showed that 2-year survival was similar between education level (72% for primary, 70.5% for secondary, and 79% for tertiary, P=.41). Maturation at 180 days was 86.6%, 82.8%, and 81.8% for those with primary, secondary, and tertiary education, respectively (P=.56). Conclusions: Although education level was not associated with outcomes in patients with ESRD and undergoing hemodialysis, education level was low with many only having primary school education. Earlier attempts at improving health care literacy, especially in our identified vulnerable patients, and preventative care should be examined prior to deterioration of kidney function.
Table I: Multivariable analyses for 30-day index readmission and any primary patency loss during the study period
30-day Index Readmission Any Loss of Primary Patency
Covariates OR 95% CI P Value OR 95% CI P Value
Education Level
Primary or less Ref Ref Ref Ref
Secondary 1.04 0.50-1.26 .90 1.17 0.60-2.28 .55
Tertiary or more 1.02 0.45-2.31 .99 1.01 0.48-2.12 .81
Male Sex 0.80 0.48-1.32 .37 0.77 0.47-1.25 .29
Race
White Ref Ref Ref Ref
Black 0.91 0.55-1.62 .72 1.21 0.68-2.15 .29
Other 0.65 0.23-1.83 .44 0.79 0.34-1.82 .40
Hispanic 0.96 0.43-2.14 .93 0.76 0.37-1.53 .44
COPD 0.93 0.46-1.90 .84 1.57 0.70-3.54 .28
Smoking status
Never Ref Ref Ref Ref
Current 2.10 0.99-4.46 .10 1.17 0.54-2.54 .81
Former 1.49 0.82-2.68 .92 1.16 0.67-2.01 .78
Insurance
Private Ref Ref Ref Ref
Medicare 1.12 0.52-2.43 .82 0.71 0.34-1.47 .20
Other 1.11 0.51-2.40 .87 1.01 0.49-2.08 .50
English Speaking 0.83 0.40-1.74 .63 1.51 0.79-2.88 .22
Immigrant 0.87 0.46-1.62 .66 1.01 0.57-1.81 .96
Employment Status
Unemployed Ref Ref Ref Ref
Employed 1.21 0.58-2.51 .87 0.71 0.36-1.38 .41
Retired 1.30 0.76-2.23 .55 0.85 0.50-1.45 .95

Abbreviations: CI � confidence interval, COPD- chronic obstructive pulmonary disease, OR � odds ratio

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	30-day Index Readmission			Any Loss of Primary Patency
Covariates	OR	95% CI	P Value	OR	95% CI	P Value
Education Level
Primary or less	Ref	Ref		Ref	Ref
Secondary	1.04	0.50-1.26	.90	1.17	0.60-2.28	.55
Tertiary or more	1.02	0.45-2.31	.99	1.01	0.48-2.12	.81
Male Sex	0.80	0.48-1.32	.37	0.77	0.47-1.25	.29
Race
White	Ref	Ref		Ref	Ref
Black	0.91	0.55-1.62	.72	1.21	0.68-2.15	.29
Other	0.65	0.23-1.83	.44	0.79	0.34-1.82	.40
Hispanic	0.96	0.43-2.14	.93	0.76	0.37-1.53	.44
COPD	0.93	0.46-1.90	.84	1.57	0.70-3.54	.28
Smoking status
Never	Ref	Ref		Ref	Ref
Current	2.10	0.99-4.46	.10	1.17	0.54-2.54	.81
Former	1.49	0.82-2.68	.92	1.16	0.67-2.01	.78
Insurance
Private	Ref	Ref		Ref	Ref
Medicare	1.12	0.52-2.43	.82	0.71	0.34-1.47	.20
Other	1.11	0.51-2.40	.87	1.01	0.49-2.08	.50
English Speaking	0.83	0.40-1.74	.63	1.51	0.79-2.88	.22
Immigrant	0.87	0.46-1.62	.66	1.01	0.57-1.81	.96
Employment Status
Unemployed	Ref	Ref		Ref	Ref
Employed	1.21	0.58-2.51	.87	0.71	0.36-1.38	.41
Retired	1.30	0.76-2.23	.55	0.85	0.50-1.45	.95