DaVita Medical Insights

An Individualized Approach to Promoting Ideal Vascular Access

The kidney care community has long recognized the importance of vascular access, with a consensus on the direct link between a patient’s vascular access type and overall clinical outcomes and costs of care. Of the most common access options—central venous catheters (CVCs) and permanent vascular access types (arteriovenous fistulas [AVFs] and arteriovenous [AV] grafts)—AVFs are typically considered the safest and longest lasting. AVFs are associated with prolonged survival, fewer infections, lower hospitalization rates, and reduced costs to both taxpayers and the overall health care system. As a matter of fact, the Centers for Medicare & Medicaid Services (CMS) estimates that complications related to synthetic accesses (AV grafts and CVCs) account for an estimated $1.5 billion in costs to Medicare.

More than 13 years ago, CMS, along with the 18 End Stage Renal Disease Networks and the Institute for Healthcare Improvement (IHI), launched a nationwide campaign called the Fistula First Breakthrough Initiative (FFBI), or the National Vascular Access Improvement Initiative (NVAII), to increase AVFs and decrease the rate of CVCs. When the initiative was launched on July 1, 2003, the AVF prevalence was 32 percent—well below the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) practice guideline of 40 percent prevalent AVF use in the United States. As of 2015, the AVF prevalence had increased to 60 percent.

Despite the proven benefits of AVFs, it should be noted that there are certain populations for which an AV graft may be the better choice. These patients may include the elderly and individuals with poor vessel anatomy, slow-progressing chronic kidney disease or a short life expectancy.  Fistulas for this subset of patients could result in failed surgical procedures, poor clinical outcomes and a reversion to CVCs—which should be considered the access type of last resort for nearly all patients. It is important to proactively determine which permanent vascular access option is most appropriate per individual patient in order to avoid CVCs and optimize vascular access success.

The following four actions can be employed across dialysis clinics to proactively determine and initiate the optimal vascular access for each individual patient—which, in turn, can help improve clinical outcomes and may reduce the financial burden for the healthcare system.

1. Educate on vascular access prior to the start of dialysis

There is a need to proactively address the quality of care prior to a patient starting dialysis treatment through kidney disease education programs. In addition to receiving information on kidney disease management, diet resources, employment and insurance, patients need to be educated on available treatment options and the proper preparation for placing a permanent vascular access or a peritoneal dialysis catheter. Patient educational resources can include:

  • Step-by-step roadmaps for converting patients from CVCs to permanent vascular access
  • Targeted education on alternatives to a CVC for patients who have chosen not to have a permanent access placed
  • Online resources, such as DaVita.com, that provide information about access choices and renal replacement therapies
  • Collaborative patient-centered forms of coaching to help elicit and strengthen patient motivation for change in the care they receive, which includes their access type
  • Identification of specific opportunities to help patients improve health through modifying their behaviors

2. Implement a catheter removal program

While avoiding the use of CVCs in the first place is an important goal, there are still a significant number of patients who start hemodialysis with a catheter. Programs that emphasize catheter removal should be designed to help this patient group move from catheters to permanent vascular access. A multidisciplinary care team—including nephrologists, surgeons and clinical teammates—can educate patients about the transition and support them through the vessel mapping; surgical evaluation; surgery, maturation and cannulation; and catheter removal.

3. Designate vascular access managers

At least one clinical teammate in each dialysis center should be assigned to serve as the primary source of vascular access information and care coordination within a center. They can collect vascular access data, educate patients on vascular access options, coordinate care for access patients within the assigned center, and communicate and collaborate with the interdisciplinary care team to improve access-related outcomes.

4. Avoid catheter reversion

Another important contributor to the use of dialysis catheters is failed permanent vascular access, which often results in reverting to a catheter. The healthcare team must proactively evaluate for failing permanent accesses and encourage any necessary reparative procedures to avoid access failure.

Patients who have their access interventions performed in free-standing-office-based access centers have better outcomes than those who are seen in the hospital outpatient department. Much of this is driven by anticipatory care (such as performing angioplasties, versus waiting until an access is clotted). Overall, the improved outcomes can be significant:

  • 11 percent lower mortality rate
  • 13 percent fewer hospitalizations
  • 38 percent fewer infections
  • $7,000 lower annual cost per patient

Ultimately, a relentless focus on avoiding catheters and identifying the proper permanent vascular access up front plays a significant role in enhanced clinical outcomes and reduced costs—and can improve patient experience and quality of life.

 

Note: Some of the content within this article has been republished with permission from Nephrology News & Issues.

Allen R. Nissenson, MD, FACP, FASN, FNKF

Allen R. Nissenson, MD, FACP, FASN, FNKF

Prolific author and renowned authority on kidney disease, Allen R. Nissenson, MD, is chief medical officer at DaVita Kidney Care and emeritus professor of medicine at the David Geffen School of Medicine at UCLA, where he has served as director of the dialysis program and associate dean. Dr. Nissenson is also co-chair of the Kidney Care Partners Quality Initiative. Dr. Nissenson served as a Robert Wood Johnson Health Policy Fellow of the Institute of Medicine from 1994–1995 and worked in the office of the late Senator Paul Wellstone. He is a former president of the Renal Physicians Association (RPA), served on the RPA Board of Directors as a special advisor to the president and is a former president of the Southern California End-Stage Renal Disease Network. He is the author of more than 700 scientific papers and the editor of two dialysis textbooks, one in its fourth edition and the other just released in its 5th edition. Dr. Nissenson earned his medical degree from Northwestern University Medical School and is the recipient of various awards, including the AAKP Medal of Excellence award, the Lifetime Achievement Award in Hemodialysis and the National Kidney Foundation “Man of the Year” award.