Maintaining Alignment in Quality Improvement

The ESRD Networks have been an integral part of the quality oversight of the ESRD program for decades now. Originally 44 such organizations, now officially 18, cover the country and have a contractual relationship with CMS based on specific performance and deliverables. The most recent iteration of Network contracts holds these organizations accountable for some specific clinical outcomes of dialysis facilities, in particular the fraction of patients with AVFs.  This focus for CMS and the Networks is part of the Fistula First Initiative, an outstanding national quality improvement program designed  to increase the number of AVFs in U.S. hemodialysis patients—an area where we lagged significantly behind other parts of the world. And who could argue with this focus? Everyone knows that AVFs are associated with fewer infections and episodes of clotting than grafts or catheters and the latter in particular lead directly to increased hospitalizations, mortality and significant increases in the costs of care.

An intense focus on AVFs, however, has some unintended consequences, including multiple surgical procedures.  Poorly constructed AVFs do not function and may lead to significant morbidity. Until permanent access is functional, catheters are required for carrying out dialysis with all of the attendant risks these convey. Judicious use of grafts is a far better alternative. Ah, but there is the rub—dialysis facilities and now Networks are not “graded” on how few catheters their patients have, but only on how many fistulas, no matter what the cost.

The misalignment this state of affairs causes was clearly illustrated to me in a recent call I had with an ESRD Network MRB chair and Executive Director. They were very concerned because their Network was getting intense pressure from CMS because the facilities in their region had among the lowest AVF rates in the country.  As it turns out, however, this Network has the lowest catheter rate. As we have been able to show in DaVita facilities, the facility can clearly impact catheter rates after patients enter the facility, with clear process approaches that drive permanent access placement and catheter removal.  It is less clear, however, how facilities impact, and can be held accountable for, whether a patient gets an AVF or a graft.  That is the domain of the attending nephrologist and the vascular surgeon, who are the ones who should be held accountable.

So, should the Network in question be viewed by CMS as a poorly functioning one because of somewhat low AVF rates or one of the best because of great catheter rates? If we return to the old adage, Do No Harm, forcing placement of AVFs where surgeons are not skilled in their construction or patients may not be suitable, seems to be far less important than focusing on minimizing the use of catheters. In the ideal circumstance, there would be great surgical support and both goals—more AVFs and fewer catheters—would be possible, few real life situations fit that description. Making tough choices is a part of the Art of Medicine, and for me, intense focus on catheter removal should clearly take priority. Penalizing Networks and facilities focusing only on AVFs, Fistula First, rather than Catheter Last is the wrong policy approach.  It creates unproductive friction between components of the care system that should be working closely together.

As articulated in Wikipedia:  “The law of unintended consequences is an…idiomatic warning that an intervention in a complex system always creates unanticipated and often undesirable outcomes.  Akin to Murphy’s law, it is commonly used as a…humorous warning against the hubristic belief that humans can fully control the world around them.”

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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