Vascular Access Initiative: Rationale

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Vascular Access Initiative Rationale

• Vascular access is one of the most critical
  issues in improving dialysis quality
• Recent trends Access Patency,
  Morbidity/ Mortality, Costs
• Attributable to AVF, AVG,
  Catheters
• Access type is a major determinant of patient
  outcomes as well as financial outcomes
• Most VA-related morbidity costs due to grafts
  catheters

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DHHS Healthy People 2010 Chronic Kidney Disease
Overall GoalReduce new cases of chronic kidney
disease and its complications, disability, death,
and economic costs. Vascular Access
GoalIncrease the proportion of new hemodialysis
patients who use arteriovenous fistulas as the
primary mode of vascular access. National target
66 AVFs in prevalent patients
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CMS Goals2006 2009Increase the percentage
of prevalent fistula by 4 percentage points each
year in each Network

• Network 9
• Sept 05 rate 37.6
• May 06 rate 39.5
• 2007 Goal 41.6
• 2008 Goal ????
• 2009 Goal ????

• Network 10
• Sept 05 rate 38.5
• May 06 rate 40.5
• 2007 Goal 42.5
• 2008 Goal ????
• 2009 Goal ????

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Network Goals2006 2009Prevalent AV
fistula goals for each year in each Network

• Network 9
• May 06 rate 39.5
• 2007 Goal 50.0
• 2008 Goal 58.0
• 2009 Goal 66.0

• Network 10
• May 06 rate 40.5
• 2007 Goal 50.0
• 2008 Goal 58.0
• 2009 Goal 66.0

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Change Concept - Defined

• A change concept is a general approach to change
  that has shown usefulness in developing specific
  ideas for changes that lead to improvement.
• Change concepts are intended to encourage
  development of specific changes that make sense
  within a particular setting.

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NVAII Change Concepts

• Routine CQI review of vascular access
• Early referral to nephrologist
• Early referral to surgeon for AVF only
• Surgeon selection
• Full range of appropriate surgical approaches

• Secondary AVFs in AVG patients
• AVF placement in catheter patients
• Cannulation training
• Monitoring and surveillance
• Continuing education staff and patient
• Outcomes feedback

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Change Concepts
CQI Review Training Surveillance Education Outcome
s
Surgical Approach Secondary AVF AVF in Catheter Pt
Surgeons
Facilities
Nephrologists
Patient
Early Referral AVF Only Surgical Selection
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AV Fistulae are Superior to Grafts and Catheters

• Increased event free patency
• Decreased morbidity mortality
• Decreased costs
• Per annum cost savings
• 4500 vs. AVG
• 9000 vs. Catheter

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Bacteremias/100 patient months
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There Are Significant Differences in the Types of
Vascular Accesses Used for Prevalent Patients in
Europe and the US
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Changes in AV Fistula and Catheter Use in US HD
Patients DOPPS I vs II
AV Fistula Use
Catheter Use
Catheter use
Fistula use
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Vascular Access RatesMay 2006
Prevalent Fistula
Prevalent Catheter
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Why the New Focus on CKD?

• Its common
• Its devastating
• Its expensive
• Its treatable
• Its about time!

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Mean Estimated Number of AVFs and Grafts Placed
by Operator During Training, by Country
Accesses
n
18
17
16
9
14
13
40
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16
10
35
Country
DOPPS II, restricted to operators placing gt1 AVF
or graft in prior year
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Median of Surgeons per Facility and of
Surgeons per 100 Patients
of Days
n 20 20 20
18 18 17 7 20
20 66
From the Medical Directors Questionnaire
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