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5 Ways to Address Rising Central Venous Catheter Rates as a Medical Director

Historically, in-center dialysis facilities in the U.S. have had declining rates of prevalent central venous catheter (CVC) utilization. This positive trend directly impacts patient health, resulting in fewer blood stream infections and higher-quality dialysis in general. According to the United States Renal Data System, prevalent CVC utilization has declined from approximately 27 percent in 2004 to near 19 percent in 2016. Much of this trend is related to the Fistula First initiative, which has also led to a doubling of Arteriovenous fistula (AVF) utilization from approximately 30 percent to more than 60 percent in the same 12-year span.

Unfortunately, inconsistencies in patient education, shared decision making and system-based processes has led to high variability with CVC and fistula utilization rates. This variation exists not only regionally, but also locally with dialysis facilities in close proximity to one another—and sometimes even among patients cared for by separate practitioners in one given dialysis facility.

Additionally, over the past year, the renal community has seen a slight uptick in CVC utilization and declining fistula rates. As medical directors, we may find that this negative drift directly impacts the clinics we oversee and the patients for whom we care.

If your facility is experiencing rising CVC rates or highly variable rates among providers, consider these five steps that can help identify the root cause(s) and may help you and your care team develop solutions.

  1. Determine your incident patient CVC rate. Across the U.S., approximately 60 percent of patients initiate dialysis with a CVC only, while another 20 percent begin with a CVC and other, maturing dialysis access AVF, arteriovenous graft (AVG) or peritoneal dialysis (PD) catheter).[i] Examining these rates over time may help you identify whether or not your facility’s rising prevalent CVC rates are related to greater numbers of patients initiating dialysis with a CVC. If this is the case, consider working with your own practice or group to examine the most recent 100 patients who started dialysis. By reviewing these patients’ pre-dialysis medical records, you can categorize each patient into one of five groups, which are:
    1. Patients who started dialysis optimally (with a working AVF, AVG or PD)
    2. Patients who started dialysis near-optimally (with a CVC and a maturing AVF, AVG or PD catheter)
    3. Patients who started with a CVC only, had been under your group’s care for chronic kidney disease (CKD) stage 4 or 5, had been seen in the 12 months before initiating dialysis and had received formal CKD and modality education
    4. Patients who started with a CVC only, had been under your group’s care for CKD stage 4 or 5, had been seen in the 12 months prior to initiating dialysis and did not receive formal CKD and modality education
    5. Patients who had not previously been under your group’s care in the past 12 months for CKD stage 4 or 5

In the U.S., patients in group e (fifth bucket) account for about 35 percent of dialysis admissions. Unfortunately, the fourth group (group d) may account for a larger percentage of patients than we typically recognize. Anecdotally, these patients often represent a cohort of “stable CKD 4” patients with relatively unchanging eGFR. Their stability may lull us and them into a false sense of security. However, a major illness can lead to a rapid decline in renal function and a subsequent dialysis start without optimal preparation.

  1. Review your acute kidney injury patients. Since January 2017, The Centers for Medicare & Medicaid Services has reimbursed dialysis facilities and physicians for the care of patients with acute kidney injury (AKI). Currently, approximately 20 percent of all incident dialysis patients begin outpatient treatment with the AKI designation. Of that group, approximately 60 percent will eventually transition to ESRD status.[ii] Patients who are older, those with underlying CKD and those with a history of congestive heart failure are at even greater risk of transitioning to ESRD. Currently, this group of patients has higher CVC rates 90 days after transitioning to ESRD status than patients who begin dialysis with ESRD. Certainly, there are several reasonable hypotheses for why this paradox may occur. Greater education early in the AKI time period may help this vulnerable group of patients participate in shared decision making and alleviate the misconception that access planning is less important for this group of individuals.
  1. Find the bottleneck. DaVita has designed a tracking tool that attributes seven steps to the process of removing a CVC and beginning dialysis with a permanent access. These steps involve patient education; vessel mapping; pre-op evaluation for AVF; fistula surgery, maturation, and cannulation; and CVC removal. The tracking tool includes average time allotments for each “stop” along the path. Evaluation of your facility’s average times can help identify areas of opportunity within your center or your community. As an example, if your facility is experiencing greater than average time from vascular access surgery to cannulation, there may be opportunities to work with local surgeons to evaluate the delay. Are surgeons in your area reticent to allow cannulation at six weeks? Are your surgeons more likely to place AVFs in patients with small vessels, thus requiring secondary interventions? Or is your facility culture leading to delays in cannulation? Identifying bottlenecks along the process is a valuable exercise and can help your team deploy resources strategically.
  1. Evaluate physician-level discrepancies. We each have our own practice patterns, and autonomy is a major driver of physician satisfaction and fulfillment. Practice variations may play a role in large variations in CVC rates by physician, even within a given facility and presumably with a homogenous patient population. High variation in vascular access types is unlikely to be entirely related to patient-specific factors. Whether physicians with patients who have higher CVC rates are your partners or your competitors, discussions can be awkward and identifying culpability may be difficult. However, our role as medical directors is to ensure that all patients receive the highest-quality, safest care possible. At an increasing frequency, state surveyors are questioning medical directors regarding their role in ensuring that every patient has a plan for permanent vascular access. Identifying outliers, counseling our colleagues and holding those who round in our facilities accountable is well within the responsibilities of the medical director.
  1. Identify other extenuating circumstances. Certainly, we all have experience with patients who have extremely limited resources, suboptimal understanding of the risks associated with CVCs and general distrust for the health care system. These burdens in some patient populations may lead to higher CVC rates and fewer opportunities for true shared decision making. Other dialysis patient populations have very high PD penetration, which, by altering both the numerator and denominator, may skew the CVC rates in the remaining hemodialysis population. Alternatively, lack of access to the majority of vascular surgeons and/or inability to receive care in an ambulatory surgical center (e.g., Medical) may impact CVC rates. These extenuating circumstances are important to identify and may explain, in some cases, above-average CVC rates. It is, however, our duty as physicians to overcome these issues when possible. Through creative problem solving, family involvement, determination by the interdisciplinary care team and trust building with patients, there are now regions of the country with historically “difficult” patient populations that routinely have CVC rates below 10 percent.

The trilogy of identifying root causes, developing solutions and deploying appropriate resources is not unique to dialysis access. It is simply a means of employing continuous process improvement and can serve as an ideal roadmap for improving patient outcomes. In spite of average U.S. CVC rates near 19 percent, some facilities routinely report rates below 5 percent. Using these five steps to determine the underlying reason(s) for your facility’s vascular access composite can greatly streamline the task and help you as the clinical leader guide your care team in their endeavor for continuous improvement.

[i] DaVita data, 2018.

[ii] DaVita data, 2017-2018.

Jeffrey Giullian, MD, MBA

Jeffrey Giullian, MD, MBA

Jeffrey Giullian, MD, serves as chief medical officer for DaVita Kidney Care. Dr. Giullian leads the transformation of kidney care through his commitment to providing holistic, integrated care that addresses the clinical and psychosocial needs of patients. Dr. Giullian is focused on pushing the boundaries on exemplary clinical care through innovation and expanding what is possible for patients living with kidney disease. Since joining DaVita in 2016, Dr. Giullian previously served as chief medical officer of hospital services, vice president of medical affairs and national group medical director at DaVita Kidney Care. Dr. Giullian relies on his past experiences in private practice and hospital leadership to advocate for patients, physicians and medical directors. He is active with the Renal Physicians Association (RPA) as a member of the Board of Directors, chairman of the Healthcare Payment Committee and member of the RPA’s team of advisors to the American Medical Association Relative Value Units Utilization Committee. Dr. Giullian trained in nephrology and transplantation at Vanderbilt University and received his MBA from the University of Colorado at Denver. Twitter: @Dr_Giullian_MD