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Why Fistula First?

The National Vascular Access Improvement Initiative

It has long been documented that the native AV fistula is the best choice for hemodialysis access. Compared to catheters and AV grafts, the AV fistula has greater patency rates and fewer complications, thus fewer hospitalizations, decreased patient morbidity, and lower costs. Despite the evidence, AV fistula rates in the US remain at unacceptably low levels. According to the 2002 CDC data, only 32% of the prevalent (existing) hemodialysis patients in the US were using an AVF as their primary HD access. In the Network 8 region, only about 27% of prevalent patients were using an AVF, compared to 52% AV grafts and 21% catheters. The Dialysis Outcome and Practice Patterns Study (DOPPS) reports that Japan and European countries have AVF prevalence rates of 67%-93%.

The Fistula First project was initiated in 2003, by CMS, to address the barriers that existed in preventing higher AVF rates and improved vascular access outcomes. The original project goals were to reach or exceed the K/DOQI guidelines for AVF rates of 50% in incident patients and 40% in prevalent patients. Following the designation of the project as a CMS “breakthrough initiative” and the establishment of a national coalition, the national goal for prevalent patients was reached in August 2005.

CMS's goal for AVF prevalence is 66%, and the 2006 update of the K/DOQI guidelines for vascular access echoes a similar goal of prevalent functional AVF placement rate of > 65% of patients.

Achievement of these goals will rely on the cooperation of a multi-disciplinary team, extending beyond the dialysis facility to other clinicians such as surgeons, radiologists and primary care physicians. However, the dialysis facility does play a key role in many of the change elements outlined by the project, such as CQI, cannulation, access monitoring and education. Throughout the project, the ESRD Networks will develop strategies to assist key partners in achieving project goals.

Fistula First: Exceeding Expectations

The 2009-2010 Statement of Work requires Network 8 to achieve a Network-wide AVF prevalence rate of 52.5% by March 2010. In order to reach this goal, the current Quality Improvement Project focuses on facilities with AVF rates < 50% along with population characteristics determined by data modeling (patient gender and nursing home residence). This project includes 15 new facilities and 8 “carryover” facilities from the previous contract cycle. In addition to this project, additional efforts will be focused on ALL facilities in the Network with more than 50 patients and less than 50% prevalent AVF rate.

Your are encouraged to participate in project activities and utilize information received from the Networks in assessing and developing your own plan for improving vascular access outcomes.

Please contact Sheila McMaster, Network 8 Quality Improvement Coordinator, for more information (601-936-9260 or Email).

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