Background Information

Background

In July 2003, the End Stage Renal Disease Network of Texas, Inc. began a multi-year quality improvement project to increase arterio-venous fistula (AVF) use. This project, referred to as the Fistula First Project, is part of a national effort sponsored by the Centers for Medicare & Medicaid Services (CMS), the 18 regional ESRD Network organizations, the Institute for Healthcare Quality Improvement (IHI), the large provider organizations and other professional and specialty societies.

Purpose

An (AVF) has long been the preferred vascular access for hemodialysis (HD) patients because of longer primary patency rates and fewer complications, as compared to grafts and central line catheters.

Today, vascular access procedures and complications account for over 20% of hospitalizations of dialysis patients and annually cost the Medicare ESRD program nearly $1 billion dollars.

In 1997, a National Kidney Foundation Dialysis Outcomes Quality Initiative (K/DOQI) Vascular Access Workgroup developed clinical practice guidelines recommending the AVF be considered the first choice for permanent access placement. These guidelines, which were revised in 2006, recommend the following goals:

  • Creation of appropriate AVF in 50% of all new HD patients.
  • Utilization of AVFs in at least 65% of prevalent patients.
  • Less than 10% of patients should be utilizing a cuffed catheter as their dialysis access for 90 days or longer.

In 2002, only about 31% of prevalent HD patients in the U.S. and 25% in Texas were using fistulas. In November 2006, four years after the start of this national QI project, 44.8% of prevalent HD patients in the U.S. and 43.7% in Texas were using fistulas.

Barriers to Increasing AVF Rates

  • Missed opportunities for AVF placement in CKD patients.
  • Underutilization of preoperative venous mapping (important for appropriate fistula site selection).
  • Inadequate communication between surgeons and nephrologists about vascular access preferences.
  • Lack of training for vascular surgeons on evaluation and placement of AVFs.
  • Failure to recognize and refer patients for evaluation and repair of non-maturing AVFs.
  • Lack of dialysis staff training on assessment and cannulation of AVFs.
  • Missed opportunities to create a secondary AVF in patients with an AV graft, either proactively or following graft failure.
  • Financial disincentives for surgical placement of an AVF as compared to other access types.
  • Lack of understanding on the patient's part about the benefits of AVF, complicated by his/her desire to avoid needle sticks.

Project Goals

Fulfill the AVF goals recommended by K/DOQI by collaborating with the nephrology and surgical community to develop organizational changes to improve AVF prevalence through the implementation of proven clinical, quality management and educational strategies.

To be added to our mailing list or to learn more about the project, contact Bobbie Knotek, RN, BSN, CNN, CPHQ or Angie Wieler, RN, BSN, Quality Management Coordinators at the ESRD Network.

Page Updated/Reviewed on 01/18/07

Related Information

The following links further explain the background of the Fistula First project.

Logo for Fistula First, the National Vascular Access Improvement Initiative