Clinicians re-evaluate options for vascular access placement
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The arteriovenous fistula remains the “gold standard” in vascular access placement for patients on hemodialysis, clinicians said in interviews with Nephrology News & Issues.
“When they work well, (arteriovenous fistulae) AVF provide the patient with the most efficient and durable access for dialysis and offer the lowest risk of infections compared to the arteriovenous graft or the central venous catheter,” Timmy Lee, MD, MSPH, professor of medicine and vice chair of research in the Department of Medicine and Division of Nephrology at the University of Alabama at Birmingham, told Nephrology News & Issues. “However, the views are changing in the United States on access placement; the thinking now is it should be tailored to the patient’s “life-plan” vs. placing AVF in all cases.”
The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (K/DOQI) clinical practice guideline for vascular access was recently revised and published in 2020. The workgroup, chaired by Charmaine E. Lok, MD, MSc, FRCP(C), a professor of medicine at the University of Toronto and senior scientist at the Toronto General Research Institute, Toronto, took a new approach in accessing vascular access needs, Lok told Nephrology News & Issues.
“The vascular access needs of a patient must consider many variables, including the patients anatomy, clinical circumstances, preferences and goals. If we can get to know our patients, we can get the right access at the right time for the right reasons and hopefully make their (end-stage kidney disease) ESKD journey smoother.
“We hope that in many patients the right access includes the use of AVF when it makes sense,” Lok said.
Early expansion of AVF
That is a sea change in vascular access management compared with the first set of guidelines released by the NKF in 1997. The vascular access workgroup endorsed greater use of AVF to improve access outcomes and reduce access-related infections.
The following year, CMS used the guideline as a base to develop clinical performance measures for the kidney community. The vascular access-related clinical performance measure included three components: tracking the proportion of patients on HD with a fistula; the proportion of patients on HD with a central venous catheter (CVC); and monitoring arteriovenous grafts for stenosis.
Fistula First Breakthrough Initiative
In April 2003, CMS launched the Fistula First Breakthrough Initiative (FFBI), a program initiated in response to the low use of AVF in the United States – CMS estimated close to 30% – among patients on HD.
However, Lok suggested in a review article published in Clinical Journal of the American Society of Nephrology in 2007 that a re-evaluation of the way the K/DOQI guideline and the FFBI were being implemented should occur in light of surfacing problems associated with a “one size fits all” approach to vascular access.
“AVF have been promoted as the ‘best form of HD VA’ on the basis of reports indicating their superior patency, low complication and procedure rates and subsequent low overall cost,” she wrote, but Lok was concerned about the exclusive focus on the fistula as the best access for all patients. The concern arose from the biased data reporting superiority which was derived from only patients with a working fistula and excluded analysis of the many AVF that failed. The data did not represent “all patients.”
Lok acknowledged in the CJASN paper that all accesses have flaws. “It is evident that there is no ‘perfect’ VA, although the fistula is the closest to ideal,” she wrote. “Given some of the uncertainties raised, room should be made to consider possible roles of grafts in helping to reduce inappropriate CVC use,” she wrote.
Latest guidelines
In the revised guideline published in 2020, Lok and the VA workgroup focused on an “individualized and comprehensive map for dialysis modalities for the lifetime of the patient,” according to a NKF press release. The End-Stage Kidney Disease Life-Plan is achieved by creating a plan for each patient that considers corresponding Access Needs, the NKF said in the release. “For each access, the ‘Access Needs’ part of the P-L-A-N includes designing and documenting the patient’s access creation plan, contingency plan, succession plan and underlying vessel preservation plan. The end-result is a comprehensive vascular access management plan that will best suit the patient throughout his or her time with end-stage kidney disease,” according to the release.
In comments about the revised guidelines, Lok said, “These guidelines emphasize an integrated, individualized approach to patient care that promotes optimal dialysis access management based on the best available evidence.
“It recognizes the need for further research, data and timely revision that incorporates evolving practices, innovation and new advances in vascular access. We are excited for clinicians to start using these guidelines. Hopefully, in doing so, it will reduce complications and unnecessary procedures.”
Concerns about access payments
Clinicians agree that decisions and discussions about the correct access choice for patients are keys to improving the effectiveness of access placement. But upcoming Medicare cuts to payments to interventionalists and surgeons who repair and place accesses are a major concern, according to the Dialysis Vascular Access Coalition (DVAC).
The Washington, D.C.-based organization said it has joined coalitions in other specialties, such as cardiology, in support of H.R. 6048, the Medicare Stability for Patients and Providers Act. The bill, sponsored by U.S. Reps. Bobby Rush, D-Ill., and Gus Bilirakis, R-Fla., would prohibit the implementation of certain clinical labor price updates included in the Medicare Physician Fee Schedule final rule for calendar year 2022.
“Specialty providers are facing cut after cut after cut, year after year after year, while CMS is busy counting pennies,” Rush said in a press release. “Moving forward with these misguided cuts will be detrimental to the Biden administration’s stated goals of achieving health equity and will undoubtedly inflict disproportionate harm on minorities and other vulnerable patient groups.”
On its website, www.vascularaccess.org, DVAC wrote, “In the 2017 Physician Fee Schedule, the Centers for Medicare & Medicaid Services (CMS) cut payments to a key vascular access code by 39%. A survey by the American Society of Diagnostic and Interventional Nephrology (ASDIN) in 2017 found that reimbursement levels were so inadequate that more than 20% of respondents stated their centers had closed due to the cuts.
“Unfortunately, the 2022 Physician Fee Schedule finalizes yet another round of drastic cuts to office-based vascular access. CMS cuts threaten the viability of vital outpatient, office based interventional services. If enacted, the proposed cuts from CMS will further health care inequity across the country and leave patients with fewer options for life-saving care,” according to the coalition.
In an interview with Nephrology News & Issues, Gregg Miller, MD, chair of health policy for DVAC, said vascular access centers of excellence treat more than half of a million cases in the United States “in a safe, patient-preferred setting and this deep cut of 20% will force many of these centers to close.”
Miller told Nephrology News & Issues that the bipartisan Rush-Bilirakis bill would make sure that “hundreds of thousands of Americans in need of dialysis treatment can get the best possible care without interruption. There is significant momentum to fix this by the end of the year due to the widespread negative impacts this would have on patients and our entire health care delivery system.”
- References:
- https://rush.house.gov/media-center/press-releases/medicare-pay-cuts-looming-rush-bilirakis-introduce-bipartisan
- Lok C.CJASN.2007;doi:10.2215/CJN.01080307.
- For more information:
- Timmy Lee, MD, MSPH, is a professor of medicine and vice chair of research in the Department of Medicine and Division of Nephrology at the University of Alabama at Birmingham. He can be reached at tclee@uabmc.edu.
- Charmaine E. Lok, MD, MSc, FRCP(C), is a professor of medicine at the University of Toronto and senior scientist at the Toronto General Research Institute. She can be reached at charmaine.lok@uhn.ca.
- Gregg Miller, MD, is senior vice president of operations for Azura Vascular Care and leads clinic operations, business integration and physician services. He is chair of health policy for the Dialysis Vascular Access Coalition, based in Washington, D.C. Miller and the organization can be reached at dialysisvascularaccess.org.
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