Quality Improvement Project

Vascular Access: Increasing & Maintaining AV Fistulas

(1998-2000)
ESRD Network 18

ABSTRACT

Numerous formal medical research studies and the NKF-DOQI guidelines concluded that an arteriovenous fistula (AVF) should be the preferred type of dialysis access.  In 1996, ESRD Network 18 had an AVF rate of only 18%, and an artificial graft rate of 73%, the opposite of the clinical practice recommendations.  A formal QIP was launched to address the issue.  Using baseline data on AVF rates, hemodialysis facilities were ranked, and two groups (high AVF and low AVF) were chosen.  “Best practices” were analyzed in the high AVF group, and interventions for the low AVF group included educational sessions, a Medical Review Board standard recommending AVF placement, formal feedback letters to individual facilities, and a vascular access “tool kit”.  Many variables were found to confound the initiation of AVF placement, including poor communication between nephrologists, vascular surgeons and HMO’s, and reimbursement issues.  Formal recommendations to HCFA (CMS) resulting from the study included formal support of the NKF-DOQI guidelines, promotion of free-standing “centers of excellence” for treatment of access problems, re-evaluation of CPT codes for access procedures, and promotion of vascular access training programs for new physicians/surgical residents.