Can we turn the table on vascular access in 2016?

In a paper published in NN&I last month by Provenzano et al., the authors said they struggled to reach a target sample size for their study, particularly in finding a control group of patients with catheters. "Several clinic policy changes...targeted reduction of catheter access which in turn reduced the number of eligible patients. The Fistula First initiative was implemented prior to study initiation...Directly following this, a dialysis provider initiative targeting central catheter rates was also introduced; this policy required central catheter target rates of less than or equal to 13% in each dialysis facility.."

That's a nice problem to read about. The irony of failed access management in the U.S. for kidney disease patients, particularly the incident population, is that, simply, the renal community knows what needs to be fixed and understands the present-day risks of not taking action. But how to fix it?

A movement grows

Like the presidential debates, vascular access is always in the news. And lately, some of that has been good.

Data released during the American Society of Nephrology's Kidney Week suggested that increased use of fistulas has helped to drive down mortality rates among prevalent dialysis patients (see Fig. 1). PEER Kidney Care Initiative researchers, in a review of Medicare data, sug gest the plateauing and a slight decline of new placements-logical in light of a gradual decrease in the inci dent rate-means more fistulas are surviving longer.

The National Institutes of Health held a two-day work shop in September on access issues, with the aim of directing research dollars toward making better choices.

Vascular access was the focus of a technical expert panel organized earlier this year by the University of Michigan's Kidney Epidemiology and Cost Center, under contract with the Centers for Medicare & Medicaid Services, to look at ways to improve and expand the vascular access quality measures used in the Quality Incentive Program. One message: fistulas don't always have to be the only choice.

"Discussions covered concerns about the current paradigm that always treats AV fistula as the preferred access type and less recognition of AV graft (or catheter) as potentially a more appropriate access type for certain patients;' the report said. Other recommendations in the TEP report:

To prevent gaming of the system in reporting fistula use in the QIP, the TEP recommended that patients are only counted if the AVF is being used with two needles and no dialysis catheter is present.

The TEP discussed the merits of incorporating grafts specifically in a quality measure, rather than continuing to treat grafts as neutral outcomes.

Pay now, make gains later

All this activity is heading in the right direction. But the key is synchronizing good intentions with support ing payment policy. Larry Spergel, MD, a vascular access surgeon who took charge of Fistula First at its inception and was on an earlier TEP for access issues, says Medicare coverage is needed prior to kidney failure so that AVF placement is covered before dialysis is needed. "We know about the long-term benefits and cost-savings, but no one will authorize putting up the money unless they can show the immediate benefit to the bottom line," he told NN&I.

Let's end the disconnect between what we know about timely placement and bad payment policy: find a way to invest in pre-dialysis access care. And ask payers to be open-minded on allowing the best access for patients even if it isn't a fistula. Don't penalize nephrologists and dialysis providers if that choice makes good medical sense for the patient sitting in front of them. -by Mark Neumann