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Specific surgeon factors influence discouraged AV graft use for hemodialysis access
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Researchers found one-fifth of surgeons diverged from recommended best practice guidelines by using an arteriovenous graft — rather than an AV fistula — for initial permanent hemodialysis access, with specific surgeon factors influencing these practice patterns.
“The type of hemodialysis access chosen for a patient has a direct effect on complication rates and health care costs,” Caitlin W. Hicks, MD, MS, of the division of vascular surgery and endovascular therapy at Johns Hopkins University School of Medicine, and colleagues wrote. “Typically, complications and mortality are significantly lower with AV fistula compared with AV graft or central venous catheter use. In addition, the cost associated with an AV fistula ($60,000 per person per year) is markedly lower than the cost of an AV graft ($72,729 per person per year). As a result, the NKF’s Kidney Disease Outcomes Quality Initiative clinical practice guidelines for hemodialysis access recommend the use of AV fistula whenever feasible, [while] CMS and end-stage renal disease networks [have] joined together to create the National Vascular Access Improvement Initiative called the Fistula First Breakthrough Initiative.”
Researchers sought to examine contemporary practice patterns of high AV graft use, as well as to determine associated surgeon characteristics. Researchers reviewed Medicare claims made between January 2016 and December 2017, including 85,320 patients who underwent initial permanent hemodialysis placement with AV fistula (77.9%) or AV graft (22.1%) and 2,397 surgeons who performed more than 10 access procedures (59.6% specialized in vascular surgery).
Researchers found that, while the median use rate of AV grafts was 18.2%, 20.8% of total surgeons had use rates greater than the recommended 34%.
After accounting for patient characteristics, it was determined that surgeons who had more than 30 years of clinical practice were more likely to use AV grafts than those who had 21 to 30 years (odds ratio = 0.85). In addition, those who practiced in a metropolitan setting (OR = 1.25) or who specialized in vascular surgery (OR = 0.77) vs. general surgery had higher AV graft use rates. Compared with surgeons in the South, those in the Northeast region had the lowest use rate (OR = 0.83).
“Overall, most physicians are achieving the AV fistula target established by CMS as part of the Fistula First Breakthrough Initiative,” the researchers wrote. “However, when considering performance at an individual surgeon level, there appears to be wide variation in quality and clear opportunities for focused improvement. These data suggest that high AV graft use is an area of low-value care that can be addressed at the surgeon level.” – by Melissa J. Webb
Disclosures: The authors report no relevant financial disclosures.
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