Achieving the Goal of the Fistula First Breakthrough Initiative for Prevalent Maintenance Hemodialysis Patients

Abstract

Background The Centers for Medicare & Medicaid Services (CMS) established a national goal of 66% arterio-venous fistula (AVF) use among prevalent hemodialysis (HD) patients for the current Fistula First Breakthrough Initiative (FFBI). The feasibility of achieving the goal has been debated. We examined contemporary patterns of AVF use among prevalent patients to assess the potential for attaining the goal by dialysis facilities and their associated end-stage renal disease (ESRD) Networks in the United States (US). Study Design Observational study. Setting and Participants US dialysis facilities with a mean HD patient census of 10 or more over the 40 month study period, January 2007 to April 2010. Outcomes and Measurements Mean changes in facility-level AVF use and the percent of facilities achieving the 66% prevalent AVF goal within the US and each Network. Results US mean prevalent AVF use within dialysis facilities increased from 45.3% to 55.5% (P < 0.001) in the US but varied substantially across regions. The percent of facilities achieving the 66% AVF use goal increased from 6.4% to 19.0% (P < 0. 001). Over the 40 months, 35.9% of facilities achieved the CMS goal at least one month. On average, these facilities sustained mean (SD) use of 66% or greater for 12.9 (11.7) months. Casemix and other facility characteristics explained 20% of the variation in the proportion of facility patients using an AVF in the last measured month, leaving substantial unexplained variability. Limitations This analysis is limited by the absence of facilities’ case-mix data over time and the national scope of the initiative precludes use of a comparison group. Conclusions Achieving the CMS goal of 66% prevalent AVF use is feasible for individual dialysis facilities. There is a need to reduce regional variation before the CMS goal can be fully realized for US hemodialysis facilities.

Decreasing Exposure to Hemodialysis Catheters in ESRD—More Work to Be Done

“…The early collaborative efforts of the nephrology community led to substantially higher prevalence rates of fistulas; however, this was accomplished with only modest success in decreasing catheter rates, suggesting that many AV grafts have been replaced with fistulas. 3 Recognizing not only the benefits of fistulas but also the risks associated with catheters, the Centers for Medicare & Medicaid Services (CMS) adjusted its breakthrough initiative, Fistula First, to elevate this "catheter last" concept as a coprimary goal. 4 In this issue of the AJKD, Pisoni et al 5 extend the findings of Lynch et al 3 (who reported on the early successes of Fistula First at increasing fistula rates) to evaluate trends for fistula and catheter prevalence, focusing on 2010 to 2013, a period during which CMS payment policy evolved to penalize facilities with lower fistula and higher catheter rates.…”

Fistula First: Recent Progress and Ongoing Challenges

“…In this issue of the American Journal of Kidney Diseases , Lynch et al 2 provide a wealth of information regarding progress in achieving the AVF goals in the United States between 2007 and 2010. Overall, AVF use increased from 45.3% to 55.5% among the prevalent hemodialysis population.…”

“…Lynch et al 2 highlight 2 important observations regarding vascular access management. First, the enormous variability in AVF use among dialysis networks, and within single networks, suggests major differences in practice patterns and is consistent with results from several prior publications.…”

“…Possibly, AVF use in incident patients would be higher if lack of insurance were removed as a barrier. While the study by Lynch et al 2 excluded patients receiving dialysis in Veterans Administration (VA) facilities, a model of universal health care coverage in the United States, another recent study reported that AVF use among incident hemodialysis patients receiving their care in the VA system was significantly higher than that obtained in patients with standard Medicare coverage (21.4% vs 13.5%). 7 Nevertheless, the incident AVF rate in hemodialysis patients in the VA system is still much lower than in Europe (~65%), 1 suggesting that additional factors are at play.…”

“…24 These phenomena may be related to low educational levels, low income, or distrust of the health care system, and are not easily modified. It is unknown whether socioeconomic variables contribute to the large variability in AVF use among and within US dialysis networks, as these factors were not specifically analyzed by Lynch et al 2 …”