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Achieving the goal: results from the Fistula First Breakthrough Initiative

Lynch, Janet R.a; Mohan, Sumitb; McClellan, William M.c

Current Opinion in Nephrology and Hypertension: November 2011 - Volume 20 - Issue 6 - p 583–592
doi: 10.1097/MNH.0b013e32834b33c4
Dialysis and transplantation: Edited by Jonathan Himmelfarb and Roy Bloom

Purpose of review This review summarizes the background and implementation of the Fistula First Breakthrough Initiative (FFBI), published information about changes in vascular access practice since its inception, and several issues raised by the program.

Recent findings The FFBI is a surveillance system using the End-Stage Renal Disease (ESRD) Networks to spread improvement ideas. Concomitant with implementation of the program, prevalent arteriovenous fistula use has increased an average of 3.3% annually since 2003, an incremental improvement of 1.3% over the preexisting trend. At the same time, long-term central venous catheter (CVC) use declined among the prevalent population. Increasingly, individual facilities are achieving the FFBI goal of 66% prevalent arteriovenous fistula use; however, results vary across geographic regions and are not explained by patient demographic and clinical characteristics alone.

Summary ESRD Network interventions as a function of the FFBI are associated with increasing arteriovenous fistula use and likely contributed to improvement, but improvement cannot be unequivocally attributed to the Networks due to lack of rigorous research design. Questions and opportunities remain. It is not yet clear how to identify patients who may not be appropriate candidates for an arteriovenous fistula. The ultimate impact of the FFBI on patient mortality is yet to be determined. The FFBI must continue to identify variations in use and the contributing causes, and implement strategies to address these causes if the FFBI goal is to be fully achieved.

aMid-Atlantic Renal Coalition, Richmond, Virginia

bColumbia University College of Physicians and Surgeons, New York

cEmory University School of Medicine, Atlanta, Georgia, USA

Correspondence to Dr William M. McClellan, MD, MPH, Emory University, Rollins School of Public Health, 1518 Clifton Road, Atlanta, GA 30322, USA Tel: +1 678 358 4449; fax: +1 404 727 8737; e-mail:

© 2011 Lippincott Williams & Wilkins, Inc.