Vascular Access News

Placing the “gold standard” of access types – the arteriovenous fistula – in patients can be costlier in terms of access-related procedures and complications compared to placing an arteriovenous graft if a central venous catheter is also used at some point during dialysis, according to results of a recently published study.

An analysis completed on the first year of the Comprehensive ESRD Care demonstration indicated the 13 physician-provider groups that participated in the project showed improvement in vascular access management and reducing hospitalizations, but no measurable change was seen in patient quality of life or mortality. No significant increase was seen in the use of home dialysis as well.

Editor’s note: In the June issue of NN&I, our Legal Angle editors looked at the regulatory and legal risks and rewards of turning an interventional access suite into an ambulatory surgical center where fistulas and grafts could be placed. This month we asked two developers to explain the reimbursement opportunities in building these centers. 

Taking a holistic approach to patient care makes sense, but at what point in the timeline of the ESRD patient’s health status can care coordination be most successful? We asked Dugan Maddux, MD, lead author of the paper, “Effects of renal care coordinator case management on outcomes in incident dialysis patients” (Clin Nephrol. 2016 Mar;85(3):152-8). how to identify a “good start” on dialysis and how care coordination can have an influence. Dr. Maddux is vice president of Kidney Disease Initiatives at Fresenius Medical Care North America.

Vascular access is critical for a patient´s well-being and overall health. The Fistula First Breakthrough Initiative was instrumental in reducing the number of arteriovenous grafts (AVG) and boosting the construction of arteriovenous fistulas (AVF) as the preferred permanent vascular access for hemodialysis.1 The construction of a distal radiocephalic AVF in the non-dominant arm is the “ideal” vascular access, as initially described by Cimino and Brescia.2

On November 2, 2016, the Centers for Medicare & Medicaid Services (CMS) released the 2017 Medicare Physician Fee Schedule (MPFS) Final Rule. Although the impact of the Final Rule on nephrology reimbursement has been minimal this year, dialysis vascular access services typically provided by interventional nephrologists experienced an overall reduction in reimbursement due to CMS policy requiring services that are billed together more than 75% of the time to be bundled. As a result of this policy, the following new interventional CPT code bundles were developed resulting in reimbursement reductions for a variety of interventional services:

Death rates in patients who had an arteriovenous fistula created prior to starting dialysis were lower than rates in patients who started dialysis using a catheter, according to an analysis of adults who initiated hemodialysis between 2004 and 2012. But only 2.3% of deaths were related to complications of vascular access, suggesting that a fistula attempt could be a surrogate marker for a healthy patient who has had good care prior to starting dialysis while catheters were used preferentially in patients with acute kidney injury, short life expectancy, and in those with poor blood vessels, the study authors said.

A reliable vascular access is a key component of successfully treating end-stage renal disease. Surveillance of the access can identify luminal narrowing and provide sufficient lead time for intervention prior to thrombosis.1

Editor’s Note: Getting catheters out of new patients has been a challenge for all dialysis staff for years, because close to 80% of new patients start with a temporary catheter. Developing a process to expedite permanent access placement has been underway at Fresenius Vascular Care, and the company’s clinical team presented results from a pilot project at the National Kidney Foundation’s Spring Clinical Meetings in April via the poster, “Vascular access process metrics as a novel identifier in the dialysis access care continuum.” FVC’s aim is to reduce the period of time to transition patients from their use of a catheter to that of a permanent vascular access. We asked Walead Latif, DO, MBA, medical director of Fresenius Vascular Care, about the details of the pilot.

It shouldn’t be Fistula First, or Catheter Last. The best approach, if evidence shows it, should be individualized for placing a patient’s vascular access.