Fistula First Breakthrough Initiative: Targeting Catheter Last in Fistula First

Abstract

An arteriovenous fistula (AVF) is the optimal vascular access for hemodialysis (HD), because it is associated with prolonged survival, fewer infections, lower hospitalization rates, and reduced costs. The AVF First breakthrough initiative (FFBI) has made dramatic progress, effectively promoting the increase in the national AVF prevalence since the program's inception from 32% in May 2003 to nearly 60% in 2011. Central venous catheter (CVC) use has stabilized and recently decreased slightly for prevalent patients (treated more than 90 days), while CVC usage in the first 90 days remains unacceptably high at nearly 80%. This high prevalence of CVC utilization suggests important specific improvement goals for FFBI. In addition to the current 66% AVF goal, the initiative should include specific CVC usage target(s), based on the KDOQI goal of less than 10% in patients undergoing HD for more than 90 days, and a substantially improved initial target from the current CVC proportion. These specific CVC targets would be disseminated through the ESRD networks to individual dialysis facilities, further emphasizing CVC avoidance in the transition from advanced CKD to chronic kidney failure, while continuing to decrease CVC by prompt conversion of CVC-based hemodialysis patients to permanent vascular access, utilizing an AVF whenever feasible.

Initial Hemodialysis with a Temporary Catheter Is Associated with Complications of a Later Permanent Vascular Access

“…Some authors reported CVC usage in incident patients was high at the range of 60-82.5% [32,33,34,35,36,37]. Although prolongation of access lifespan is an important endpoint, reduction of CVC use and acute dialysis in the incident dialysis population reduces the risk resulting from access event occurrence.…”

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

“…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. 6 In comparison, across DOPPS countries, fistula use ranged from 49% to 92% in 2013, while catheter use ranged from 2% to 45%.…”

Tracking Arteriovenous Fistula Maturation: A Novel Approach

“…An AVF is favored due to its advantage over CVC usage with respect to sur- vival outcomes, hospitalization rates, and cost to the healthcare system [1][2][3][4]. Notwithstanding this evidence, most US incident patients start HD using a CVC [5][6][7][8].…”