April 05, 2016

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Strategies to improve access management in dialysis patients

Editor’s note: Since this article was published, the authors have clarified DaVita Kidney Care’s central venous catheter rate, based on Fistula First Breakthrough Initiative data. The article originally stated that the provider’s overall CVC rate is 6.5%. That percentage represents catheters in place among DaVita patients for < 90 days. For catheters in place greater than or equal to 90 days, the rate is 9.3%, and for those with other forms of access in addition to catheters the rate is 0.7%. Thus, the overall catheter rate for DaVita Kidney Care’s patient population is 16.5%.

Introduction

The kidney care community has long focused on the importance of vascular access because there is consensus on the direct link between a patient’s vascular access type and overall clinical outcomes and costs of care. Clinical outcomes and quality of care reached a new level of prominence in 2015 with the late-January launch of the Five-Star Rating System by the Centers for Medicare & Medicaid Services.

Vascular access (percentage of arteriovenous fistulas, AVFs, and percentage of catheters in use after 90 days) is a key clinical metric in the Five-Star program and also impacts other metrics (e.g., mortality rates and hospitalizations).

What the industry has witnessed for more than 10 years is a renewed focus on the importance of a permanent vascular access. This focus has resulted in the creation of federally sponsored programs and the development of new measurements that are inextricably linked to access types.

Several years ago, we asked our senior medical team what the greatest advantage we can offer our patients would be. The unanimous answer: minimize the use of catheters.

Consequently, DaVita’s Office of the Chief Medical Officer (OCMO), in partnership and coordination with its physician partners, has over the years developed a variety of programs to help ensure that permanent forms of vascular access are used and that the use of catheters is reduced.

A national initiative: Fistula First

More than 12 years ago, recognizing that an AVF is the optimal access for hemodialysis, CMS, along with the 18 End-Stage Renal Disease Networks and the Institute for Healthcare Improvement (IHI), launched a nationwide campaign to increase AVFs and decrease the rate of central venous catheters (CVCs). The Fistula First Breakthrough Initiative (FFBI), also known as the National Vascular Access Improvement Initiative (NVAII), was created as a task under the ESRD Network Coordinating Center funded by CMS and was designed to assist all 18 ESRD Networks in building upon their vascular access quality improvement initiatives.

When the initiative was launched on July 1, 2003, AVF prevalence was 32%, well below the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) practice guideline of 40% prevalent AVF use in the U.S. Dialysis experts generally agree that the AVF is the safest and longest lasting of the access types, although in certain populations, particularly the elderly, an arteriovenous graft may be the best choice. There is no debate over the fact that catheters should be the access type of last resort for nearly all patients. AVFs are associated with prolonged survival, fewer infections, lower hospitalization rates, and reduced costs to both taxpayers and the overall health care system. As a matter of fact, CMS estimates that complications related to synthetic accesses (grafts and catheters) account for an estimated $1.5 billion in costs to Medicare.

Given the enormous benefits of avoiding a catheter, the FBBI had necessarily ambitious goals: increasing the fistula rate among prevalent patients to 66% and decreasing the CVC rate in this group to 10%.

The kidney care industry as a whole has long understood that vascular access is a key clinical issue and as a group collectively applauded the FBBI for its focus on driving down the catheter rate for patients. According to June 2015 publicly reported Fistula First data, using the business rules created by FFBI, DaVita has 65.2% fistulas in use in its prevalent population. It also has the lowest overall CVC rate, at 6.5%, for catheters in place < 90 days. For catheters in place greater than or equal to 90 days, the rate is 9.3%, and for those with other forms of access in addition to catheters, the rate is 0.7%. Thus, the overall catheter rate for DaVita Kidney Care’s patient population is 16.5%.

DaVita’s patient-focused clinical pyramid

Vascular access is a key component of DaVita’s Clinical Quality Pyramid, which focuses on innovation in care delivery and examines the key outcomes that impact patients' quality of life, including mortality, hospitalizations and the patient experience with care.¹ The Clinical Pyramid is a conceptual framework that guides the strategic development of tools, processes and initiatives, with each step in the pyramid reflecting a higher order of complexity, interdisciplinary collaboration, and direct value to patients. Achieving these goals requires excelling in traditional clinical metrics, including maximizing the use of AVFs (and AV grafts where appropriate) and minimizing the use of catheters, coupled with success in tackling more complex clinical problems including, but not limited to, management of infections, medications, diabetes, and fluid status. To support the overarching goals of the clinical pyramid, DaVita focuses on a number of programs that embrace vascular access fundamentals and drive adoption of permanent access placement.

Kidney Smart: Helping prevent starts on catheters

An industry focus on the importance of vascular access issues—and a need to proactively address the quality of care prior to a patient starting treatment—was one of the drivers of the development of DaVita’s Kidney Smart program, a no-cost, provider-neutral chronic kidney disease education resource that was created by a multidisciplinary team of health care providers and health education professionals.

Classes are 90 minutes long, are open and available to the public, and can help people with CKD stages 3, 4 and 5, as well as their friends, family and caregivers, become better informed about their treatment options as CKD progresses. During class, attendees learn about the following:

the causes of kidney disease and how to delay its progression

the variety of available treatment options and the importance of proper preparation no matter what the choice, including the planned placement of a permanent vascular access or a peritoneal dialysis catheter

the important role that continued employment plays in helping people with CKD remain healthier and maintain an improved quality of life

available diet resources that can impact CKD progression

how insurance counselors can help navigate the myriad of coverage options.

There are nearly 2,000 certified Kidney Smart educators and 7,000 classes offered across the United States. Since the program’s inception in 2013, approximately 55,000 people have attended a Kidney Smart class. And the program has driven outstanding results, particularly in the area of vascular access: Kidney Smart-educated patients are 22% less likely than non-Kidney Smart-educated patients to start dialyzing with a CVC (64% vs. 82%, respectively). ²

CathAway: Emphasizing catheter removal

While avoiding the use of catheters in the first place is an important goal, driven by Kidney Smart, there are still a significant number of patients who start hemodialysis with a catheter. To address this group and to rapidly move from catheters to permanent access, DaVita established CathAway in 2008, the backbone of the company’s vascular access initiatives. Through the CathAway program, a multidisciplinary team including nephrologists, surgeons, and clinical teammates helps patients transition from catheters to vascular permanent access.

This program comprises seven steps to help patients transition from a catheter to a fistula: education, vessel mapping, surgical evaluation, fistula surgery, fistula maturation, fistula cannulation and, finally, catheter removal.

To support the goals of the program, CathAway also involves numerous best practices proven to drive catheter reduction. These practices include programs dedicated to educating patients about the importance of the access type through multi-platform communications vehicles.

Since the inception of the program, according to internal data, DaVita has achieved a 45% reduction in the number of "Day 90+" catheter patients (i.e., those patients who have been dialyzing at DaVita for 90 days or more with a CVC in place).

Vascular access management and dialysis patient education programs

Targeting patients who have a new permanent access in place, the New Fistula Assessment and Cannulation Team (NFACT) program is designed to identify skilled access cannulators who also have developed assessment skills specific to preserving the longevity of AVFs and AV grafts and avoiding access reversion.

NFACT members are focused on evaluating the health of a new AVF or graft and continually assessing the maturation of the AVF and the treatment of the graft site during dialysis, focusing on fistula development, maturation assessment (e.g., vein diameter, vein wall thickness and vein depth), graft site healing, and cannulation best practices.

DaVita’s Vascular Access Managers (VAM) program is an access-focused initiative in which at least one clinical teammate in each dialysis facility is charged with educating patients about their access options.

VAMs are the central source of vascular access information and care coordination within a facility. Their role includes the collection of vascular access data, coordination of care for access patients within the assigned facility, and communication and collaboration with the interdisciplinary care team to improve access-related outcomes.

Specifically, VAMs are tasked with collaborating with the medical director, facility administrator, and other center leadership to define the members of the DaVita Multidisciplinary Access Program teams. They ensure that teammates, provider partners, and hemodialysis patients are educated in the care and management of vascular accesses with particular attention to areas of improvement opportunity.

While patient education is a cornerstone of each and every program, DaVita has numerous initiatives designed specifically to help patients identify their access options and overcome the challenges they might perceive as standing in their way. These programs include:

step-by-step roadmaps for converting patients from CVC to AV access

Quick Access Check celebration cards that celebrate the patient’s choice of an AVF or graft. The cards serve as an educational tool by including an audio chip that allows patients to hear what an access should and should not sound like (a stethoscope allows them to monitor their own access)

a Patient Refusal Program designed to further educate patients who have chosen not to have a permanent access placed about the benefits of a fistula or graft as well as alternatives to a CVC

collaborative patient-centered forms of coaching to help elicit and strengthen patient motivation for change in the care they receive, which includes their access type

System-Targeted Interventions (STI), which identify specific opportunities to help patients improve health through modifying their behaviors

DaVita.com, which provides information about access choices as well as renal replacement therapies.

Lifeline: Avoidance of vascular access reversion

Another important contributor to use of dialysis catheters is failed permanent vascular access, with resultant reversion to a catheter. Lifeline Vascular Access was created and exists today to improve the delivery of vascular access care to patients by coordinating care among nephrologists, dialysis units and surgeons, including proactive evaluation of failing permanent access and proactive reparative procedures to avoid access failure. Physicians in the Lifeline network of centers have now performed more than 900,000 interventional procedures, with an overall procedure success rate of 98.6%.

Patients who have their access interventions performed in free-standing-office-based access centers, like Lifeline’s, have better outcomes than those who are seen in the hospital outpatient department. Much of this is driven by anticipatory care (angioplasties, etc., vs. waiting until an access is clotted). Overall, the findings were significant ³:

11% lower mortality rate

13% fewer hospitalizations

38% fewer infections

$7,000 lower annual cost per patient

Vascular access and the 5-Star Rating System

A focus on vascular access has numerous benefits on patient outcomes, but a relentless focus on avoiding catheters also plays a significant role in a provider’s performance in the Five-Star ratings. Last October 8, CMS released its second round of Five-Star ratings. DaVita led the industry with 46% of its centers being rated with four and five stars compared to 23% for the rest of the industry. Importantly, the data showed that 98% of DaVita centers that improved their star rating from last year also improved their AVF rate. Likewise, 75% of DaVita centers that improved their star ratings also improved their CVC rate.

Is the Five-Star system perfect? No, but it does inform patients and help them make decision regarding a choice of dialysis facility, and we applaud CMS for creating a model of transparency and understanding for our patients that previously didn’t exist in the kidney care industry.

We look forward to working with the industry and CMS to evaluate the future metrics that will be included in the Five-Star rating system to determine the best possible way to provide patients meaningful information to inform their choices. -by Allen R. Nissenson, MD; Davin Bradley, MBA

The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.

References

Nissenson AR. Improving outcomes for ESRD patients: Shifting the quality paradigm. Clin J Am Soc Nephrol 2014; 9:430-4

New to dialysis in-center patients who have a CVC in place or in use on the day of the first DVA treatment given from August 2014 to July 2015; DaVita Kidney Care data.

Dobson A, El-Gamil A, Shimer M, DaVanzo J, Urbanes A, Beathard G, Litchfield T. Clinical and economic value of performing dialysis vascular access procedures in a freestanding office-based center as compared with the hospital outpatient department among Medicare ESRD beneficiaries. Seminars in Dialysis, 26(5):624-32. Sep-Oct 2013