Achieving the Centers for Medicare & Medicaid Services (CMS) goal of 66% prevalent arteriovenous fistula (AVF) use is feasible for individual dialysis facilities, though there is a need to decrease regional variation before the CMS goal can be fully achieved for all US hemodialysis facilities, according to a study published in the American Journal of Kidney Diseases (2011;57:78-89).
CMS established this national goal for the current Fistula First Breakthrough Initiative, which was developed to collect, awnalyze, and disseminate information to improve AVF use in the United States, similar to registry-based programs in Asia, Europe, and South America. CMS established the 66% goal after reaching its initial 40% goal.
The goal of 66% prevalent AVF use was chosen because 60% to 90% of hemodialysis patients in Europe and Asia dialyze with a fistula. However, AVF performance in the United States is measured for the entire ESRD population, while international estimates are commonly based on treatment facility samples that may not fully capture care of the end-stage renal disease (ESRD) population, which led to questions about the appropriateness of the goal for the United States.
To address this issue, Janet R. Lynch, PhD, CPHQ (Certified Professional in Health Care Quality), of the Mid--Atlantic Renal Coalition, and colleagues conducted an observational study of 4,058 US dialysis facilities with an average patient census of 10 or more during the study period of January 2007 to April 2010.
Dr. Lynch and colleagues examined contemporary patterns of AVF use in prevalent patients to assess the potential for attaining the Fistula First goal in dialysis facilities and their associated End-Stage Renal Disease Networks.
During the study period, 1,458 facilities (35.9%) were able to achieve the AVF use target at least once, and these facilities sustained this target for a mean of 12.9 months. Additionally, improvements in AVF use and goal attainment were observed in facilities in all networks regardless of initial measurement, suggesting that additional AVF use increases are attainable.
The study authors noted that the regional variability represented by differences across US ESRD Networks is similar to national variations in AVF use reported by the Dialysis Outcomes Practice Patterns Study (Nephrol Dial Transplantation 2008;23:3219-3226). Factors that contribute to within- and between-country variations in quality of care are poorly understood and warrant attention.
“Understanding the nature of differences and what can be done to reduce variation while simultaneously improving performance is imperative,” Dr. Lynch and colleagues wrote. •