Fistula First Fistula First A CMS Sponsored Quality A CMS Sponsored Quality

InitiativeInitiativeWhat is it?What is it?

Where are we now?Where are we now?

Where do we need to go?Where do we need to go?

How are we going to achieve the How are we going to achieve the goals?goals?

Peggy Lynch, BSN, RN, CNNPeggy Lynch, BSN, RN, CNN

Quality Manager Network of New Quality Manager Network of New EnglandEngland

Fistula First :What is it?Fistula First :What is it?

CMS in collaboration with the 18 CMS in collaboration with the 18 ESRD Networks and the renal ESRD Networks and the renal community started the Fistula First community started the Fistula First Quality Improvement project in 2003Quality Improvement project in 2003

The goal is to improve the quality of The goal is to improve the quality of life for hemodialysis patients by life for hemodialysis patients by increasing the AV fistula rate in increasing the AV fistula rate in prevalent patients to greater than prevalent patients to greater than 40% and >50% in Incident patients 40% and >50% in Incident patients nationally by 6/06nationally by 6/06

Vascular Access Initiative: Vascular Access Initiative: RationaleRationale

Vascular access is one of the most critical Vascular access is one of the most critical issues in improving dialysis quality:issues in improving dialysis quality: 2003 trends: 2003 trends:

Access Patency, Morbidity/ Mortality, Access Patency, Morbidity/ Mortality, CostsCosts

Attributable to: Attributable to: AVF, AVG, Catheters AVF, AVG, Catheters

Access type is a major determinant of patient Access type is a major determinant of patient outcomes as well as financial outcomes outcomes as well as financial outcomes

Most VA-related morbidity & costs are due to Most VA-related morbidity & costs are due to grafts & cathetersgrafts & catheters

DHHS Healthy People 2010:DHHS Healthy People 2010: Chronic Kidney DiseaseChronic Kidney Disease

Overall Goal:Reduce new cases of chronic kidney disease and its complications, disability, death, and economic costs.

Vascular Access Goal:Increase the proportion of hemodialysis patients who use arteriovenous fistulas as the primary mode of vascular access.

National target for AVFs = 50% placement in incident patients40% use in prevalent patients

Why Fistula First ?Why Fistula First ? There are over 385,000 patients on There are over 385,000 patients on

dialysis in the USAdialysis in the USA There are over 11,000 patients on dialysis There are over 11,000 patients on dialysis

in New Englandin New England There are almost 5,000 patients on There are almost 5,000 patients on

Dialysis in MADialysis in MA Only 30% or < were dialyzing with a fistula Only 30% or < were dialyzing with a fistula

in 2003in 2003 Vascular access complications are the Vascular access complications are the

major cause of hospitalizations, morbidity major cause of hospitalizations, morbidity & mortality in the dialysis population& mortality in the dialysis population

Why Fistulas First?Why Fistulas First?

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

NontransposedFistulaTransposed Fistula

Graft

Catheter

Risk of Infection with Various Access Types

Why Fistulas First?Why Fistulas First?

1.91

1.64

11.16 1.12

1

00.20.40.60.8

11.21.41.61.8

2

Diabetics Non-Diabetics

CatheterGraftFistula

Relative Risk of Death by Access Type

Questions to be Questions to be AnsweredAnswered

What types of Vascular Accesses are What types of Vascular Accesses are commonly used for chronic dialysis commonly used for chronic dialysis patients?patients?

What are the advantages and What are the advantages and disadvantages of various types of disadvantages of various types of accesses?accesses?

What is the best Access and Why?What is the best Access and Why?

What are the commonly What are the commonly created chronic Vascular created chronic Vascular Accesses?Accesses?

AV FistulasAV FistulasAV GraftsAV GraftsRIJ CathetersRIJ Catheters

A direct surgical connection A direct surgical connection between a native artery and between a native artery and vein with cannulation of vein with cannulation of the patient’s own blood the patient’s own blood vessel for dialysis accessvessel for dialysis access

FistulaFistula

Where Fistulas are Where Fistulas are PlacedPlaced

WristWristElbowElbowElbow with vein transposedElbow with vein transposedLeg with vein transposedLeg with vein transposed

Drawing courtsey of James F. Whiting, MDDrawing courtsey of James F. Whiting, MD 1212

Sites for Native FistulasSites for Native Fistulas

Drawing courtesy of William Jennings, MDDrawing courtesy of William Jennings, MD 1313

Proximal radial artery Proximal radial artery AVFAVF

Drawing courtsey of James F. Whiting, MDDrawing courtsey of James F. Whiting, MD 1414

Brachiobasilic Brachiobasilic transpositiontransposition

A substance is interposed between A substance is interposed between an artery and a vein and used to an artery and a vein and used to connect them. This material is connect them. This material is cannulated for dialysis.cannulated for dialysis.Usually the material used is Usually the material used is polytetrafluoroethylene (PTFE), polytetrafluoroethylene (PTFE), but other materials, artificial or but other materials, artificial or organic, can be used.organic, can be used.

AV-AV-GraftGraft

Drawing courtsey of James F. Whiting, MDDrawing courtsey of James F. Whiting, MD 1616

Arm PTFE GraftsArm PTFE Grafts

Picture courtesy of William Jennings, MDPicture courtesy of William Jennings, MD 1717

Site of Loop GraftSite of Loop Graft

Complications of AV AccessComplications of AV Access Wound infectionWound infection

superficial or deepsuperficial or deep Prosthetic infectionProsthetic infection CellulitisCellulitis Seroma or hematomaSeroma or hematoma Chronic drainageChronic drainage Wound dehiscenceWound dehiscence Neuralgia or Neuralgia or

paresthesiaparesthesia Vascular steal Vascular steal

There are several types of There are several types of Catheters but all have in common Catheters but all have in common the fact that the Catheter resides the fact that the Catheter resides in a vein and there is a break in in a vein and there is a break in the skin to allow the catheter to the skin to allow the catheter to enter . There in lies the main enter . There in lies the main problem: prone to problem: prone to infection/thrombusinfection/thrombus

Temporary Temporary CatheterCatheter

Hemodialysis CathetersHemodialysis Catheters

Internal Jugular Double-Lumen Tunneled Dialysis Catheter

What are the characteristics What are the characteristics of an “Ideal Access”?of an “Ideal Access”?

Few complications during Few complications during creationcreation

Minimum time before being Minimum time before being usable for dialysisusable for dialysis

Comfortable to initiate dialysisComfortable to initiate dialysisQuick to terminate treatmentQuick to terminate treatmentMinimum of care required to Minimum of care required to

maintain accessmaintain accessAdapted from NKF-K/DOQI Guidelines: Vascular access: Introduction

2323

Which is Closest to the Which is Closest to the Ideal Access?Ideal Access?

Catheter Graft Fistula Failure Rate - - - + + Infection Rate - - - - + + + Infection Treatment

- - + +

Adequacy - - - + + + + + Complications - - - - +

+ = close to ideal, - = far from ideal

Why is the AVF rate low if it is Why is the AVF rate low if it is the “gold standard”?the “gold standard”?

50% of patients start dialysis 50% of patients start dialysis emergently, thus catheters are inserted emergently, thus catheters are inserted for a quick vascular access to initiate for a quick vascular access to initiate hemodialysishemodialysis

Patients may resist changing to an AVF Patients may resist changing to an AVF due to fear of needlesdue to fear of needles

Reimbursement for an AV graft is higherReimbursement for an AV graft is higher

AV Grafts can be used sooner than an AV Grafts can be used sooner than an AV fistulaAV fistula

How Did the USA Compare to How Did the USA Compare to the Rest of the World Prior to the Rest of the World Prior to

2003?2003?Prevalent Vascular Access Percent of Use by

Country: 1996 to 2001 (DOPPS)

0102030405060708090

100

Japan Italy Germany Spain France UK USA

AVF AVG Catheter

Where we were in 2003?Where we were in 2003?

0

5

10

15

20

25

30

35

40

45

50

U.S. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

42 % Prevalent AVF New England

Have we made any progress?Have we made any progress?

Source: March 2006 Network Provider Fistula First Reports

0

10

20

30

40

50

60

70

US 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Network of New England=47.5%

End Stage Renal Disease Network Regional MapEnd Stage Renal Disease Network Regional Map

Prevalent AVF Percentage Rates in USPrevalent AVF Percentage Rates in US

38.1%

48%44.2%

46.3%

58.5% 37.6%

40.7%38.8%

36.3%

34.6%

41.5%

37.5%

47.5%

48.9%

39.5%

35%

40.4%

Date Source: FF Dash Board100% of facilities may not of reported in each Network

Rates across USA & PossessionsRates across USA & Possessions

US US Rate =

How are the New England How are the New England States Doing?States Doing?

0

10

20

30

40

50

60

Fistula

Graft

Catheter

Where Do We Go From Here?Where Do We Go From Here?

CMS National Goal CMS National Goal for 2009=66% for 2009=66%

AV FistulasAV Fistulas

How are we going to get How are we going to get there?there?

Need to educate healthcare professionals to Need to educate healthcare professionals to be aware that CKD is becoming a major be aware that CKD is becoming a major Public Health problem (Apr. 2006-CDC)Public Health problem (Apr. 2006-CDC)

Primary Care Physicians must routinely Primary Care Physicians must routinely screen for kidney function and refer patients screen for kidney function and refer patients to the nephrologists when the GFR to the nephrologists when the GFR decreases. It is estimated that 19.2 million decreases. It is estimated that 19.2 million Americans are living with CKD (11% of the Americans are living with CKD (11% of the adult population)adult population)

Nephrologists must refer sooner to the Nephrologists must refer sooner to the vascular surgeon for access evaluation for vascular surgeon for access evaluation for dialysisdialysis

Stages of Chronic Kidney Stages of Chronic Kidney DiseaseDiseaseStageStage DescriptionDescription GFR(mL/min/GFR(mL/min/

1.731.73ActionAction

11 Kidney damage Kidney damage with normal GFRwith normal GFR

>90>90 Diagnosis,treatmeDiagnosis,treatment of co-morbid nt of co-morbid conditions, slow conditions, slow progressionprogression

22 Kidney damage Kidney damage with mild with mild decrease in GFRdecrease in GFR

60-9060-90 Estimate Estimate progressionprogression

33 Moderate Moderate decrease in GFRdecrease in GFR

30-5930-59 Evaluate & Evaluate & Treat Treat complications. complications. DM should start DM should start vascular access vascular access nownow

44 Severe drop in Severe drop in GFRGFR

15-2915-29 Preparation for Preparation for renal renal replacement replacement therapy,vasculatherapy,vascular accessr access

55 Kidney failureKidney failure <15<15 Renal Renal replacement replacement therapy: dialysis therapy: dialysis or kidney or kidney transplanttransplant

Would Earlier Referrals Help?Would Earlier Referrals Help?

46

19

35

2115

62

2

10

85

0

10

20

30

40

50

60

70

80

90

"Elective" Start "Emergency" Start PreviouslyUnknown

Fistulas

Grafts

Catheters

What else needs to change?What else needs to change?

Hospital staff need education to Hospital staff need education to consider vein preservation & reduce consider vein preservation & reduce the use of PICC lines & lab draws in the use of PICC lines & lab draws in high risk pts.high risk pts.

The lab could automatically do a The lab could automatically do a calculated GFR when a serum calculated GFR when a serum creatinine is 1.8(female) or 2.0(male) creatinine is 1.8(female) or 2.0(male) thus triggering nephrology consultthus triggering nephrology consult

Diabetics, HTN & Cardiac patients Diabetics, HTN & Cardiac patients should have routine screening for CKDshould have routine screening for CKD

Can We Make Better Plans for Can We Make Better Plans for Access During Hospitalizations?Access During Hospitalizations?

Acute care nurses can assist by asking if Acute care nurses can assist by asking if vein mapping has been ordered for AVF vein mapping has been ordered for AVF evaluation prior to discharge of a stage 3-4 evaluation prior to discharge of a stage 3-4 CKD patient considering hemodialysisCKD patient considering hemodialysis

Discharge planners need to be made aware Discharge planners need to be made aware that catheters are a bridge to a permanent that catheters are a bridge to a permanent access & appointments need to be made access & appointments need to be made with the vascular surgeon prior to dischargewith the vascular surgeon prior to discharge

Patient education on the benefits of AVF & Patient education on the benefits of AVF & potential dangers of catheters needs to potential dangers of catheters needs to improveimprove

And….And….

Vascular Access coordination needs to be Vascular Access coordination needs to be part of d/c planning of both CKD & ESRD part of d/c planning of both CKD & ESRD pts.pts.

Hospitals as part of their QI program could Hospitals as part of their QI program could track outcomes for fistula placement in track outcomes for fistula placement in patients with a GFR of 30ml or less who patients with a GFR of 30ml or less who are d/c from their institutionare d/c from their institution

To Reiterate: NO IVS, No PICC lines, no To Reiterate: NO IVS, No PICC lines, no venipunctures in potential AVF arm venipunctures in potential AVF arm (usually non dominant arm)(usually non dominant arm)

Fistula FirstFistula First Data on access cost Data on access cost

for grafts vs AV for grafts vs AV FistulasFistulas

CPT CodesCPT Codes AVF (36821) = $493.01AVF (36821) = $493.01 Graft (36830) = $643.49Graft (36830) = $643.49

AV Fistulas

?

$ Spent to encourage AVFs……

Payment for AVFs vs Grafts……

Strategies to Improve MoreStrategies to Improve More

The Networks and the QIOs are The Networks and the QIOs are collaborating to get the Fistula First collaborating to get the Fistula First message out to the acute care hospitals message out to the acute care hospitals nurses, discharge planners, quality nurses, discharge planners, quality managers and PCP office.managers and PCP office.

National Task force has been created with a National Task force has been created with a multi-faceted approach with all stakeholders multi-faceted approach with all stakeholders included to broaden the scope. included to broaden the scope.

Encourage CMS to remove reimbursement Encourage CMS to remove reimbursement barriers for the CKD patient & increase the barriers for the CKD patient & increase the reimbursement for AVF over AVG reimbursement for AVF over AVG

As Hospital Caregivers What As Hospital Caregivers What Can You Do?Can You Do?

Collaborate with vascular surgery dept. & Collaborate with vascular surgery dept. & nephrologists to create QIP for CKD & ESRD nephrologists to create QIP for CKD & ESRD pts. Vascular access placementpts. Vascular access placement

In-service hospital staff on vein preservation In-service hospital staff on vein preservation in high risk groupsin high risk groups

Collaborate with discharge planners to assure Collaborate with discharge planners to assure vascular access planning is part of the d/c vascular access planning is part of the d/c planplan

Become Familiar with the KDOQI guidelines Become Familiar with the KDOQI guidelines for CKD & ESRD (for CKD & ESRD (For the KDOQI guidelines go to: NKF For the KDOQI guidelines go to: NKF site http://www.kidney.org/professionals/)site http://www.kidney.org/professionals/)

Fistula First at the Fistula First at the National & Local LevelNational & Local Level

Visit the National Fistula First Project Website at:Visit the National Fistula First Project Website at:http://www.fistulafirst.orghttp://www.fistulafirst.org

Visit the Network Website at:Visit the Network Website at:http://www.networkofnewengland.orghttp://www.networkofnewengland.org

Visit the MassPro website at: Visit the MassPro website at: http://www.masspro.org/http://www.masspro.org/

AVF versus AVGAVF versus AVG