History of the Fistula First Project

Introduction

As part of the ESRD Network Scope of Work beginning July 2003, CMS, the ESRD Networks and key provider representatives jointly recommended adoption of a National Vascular Access Improvement Initiative (NVAII). The principal goal of the initiative was to increase the appropriate use of AV fistulas for hemodialysis access, reaching or exceeding the CPM and K/DOQI guidelines for AVF incidence and prevalence.

The "change concepts" describe a set of improvement activities for increasing AV fistula use that have been found to be successful in a variety of clinical settings. Identification and development of these change concepts was provided by a multi-disciplinary Working Group with representation from the following groups: ESRD Network Executive Directors and Quality Improvement Directors, corporate and independent dialysis providers, nephrologists (including interventional nephrologists), nephrology nurses, vascular surgeons, interventional radiologists, patients, CMS project leaders and quality improvement staff, and the Institute for Healthcare Improvement. Lawrence Spergel, MD, a vascular access surgeon with substantial experience in clinical and quality improvement issues, chaired the initial working group.

The working group identified two main approaches to increasing AV fistula use -
• Clinical and organizational changes that can be adapted and applied locally to improve AVF prevalence and success. These changes can be undertaken immediately.
• System changes that must be implemented at a national level. These will require national leadership from CMS and should be expected to take longer to accomplish.

Many within the ESRD community pointed out the need for system-level policy changes to encourage more AV fistula placement. These include reimbursing AVFs at a higher rate than AV grafts or catheters, and reimbursing vessel mapping for new AVFs. These and other policy changes are intended to encourage AVF placement and to improve the likelihood of success. CMS stated its commitment to examining these issues carefully and considering appropriate changes. As a result, in January 2005, a reimbursement policy for pre-AVF vessel mapping was instituted through a new government code (G0365).

National Vascular Access Improvement Initiative

The focus of the original NVAII was on the first issue stated above - to address clinical and organizational improvements that will lead to more successful use of AV fistulas. ESRD Networks, dialysis providers, medical specialists, hospitals and clinics, all share the responsibility for improving dialysis care by increasing appropriate and successful AVF placement. The ESRD Networks played a major role in catalyzing change, creating efficient ways to share knowledge and resources, and building strong alliances with the facilities and medical professionals in their regions. The change concept document focuses on changes that can be made immediately, to give all suitable hemodialysis patients the opportunity to receive an AV fistula.

Vascular Access Working Group Members

Chair
Lawrence M. Spergel, MD, FACS, Dialysis Management Medical Group (Vascular Access Surgeon)

Network/Forum Members
Jeanette Cain, QI Director, Network 9/10
Janet Crow, MBA, Administrator, Forum of ESRD Networks
Jennie Kitsen, Executive Director, ESRD Network 1
Doug Marsh, Executive Director, ESRD Network 18 (Network Coordinating Center)

Provider Representatives
Maureen Herget, RN, VP CQM, Fresenius Medical Care (designated by Michael Lazarus, MD)
John Sadler, MD, Pres. & CEO, Independent Dialysis Foundation

Patient Representative
Mike Zecca, ESRD Patient

Clinicians
Deborah Brouwer, RN, Allegheny General Hospital (Nephrology Nurse)
Richard Gray, MD, Medstar Health (Interventional Radiologist)
Vo D. Nguyen, MD, Renal Care Group of the Northwest (Nephrologist)
Jack Work, MD, Emory University (Interventional Nephrologist)
Bessie Young, MD, MPH, VA Puget Sound Health Care (Nephrologist)

CMS
Jefferson Rowland, Government Task Leader
David Hunt, MD, Medical Officer, Quality Improvement Group

Institute for Healthcare Improvement
Carol Beasley, Project Director
Kevin Nolan, Improvement Advisor
Rebecca Steinfield, Project Manager

The original intent was for the FFBI Coalition to reach or surpass the goals set forth in the KDOQI Clinical Practice Guidelines (2000) and CMS Clinical Performance Measures project; that is, regional and national AVF rates of 50% or greater for incident patients, and at least 40% for prevalent patients undergoing hemodialysis. CMS committed to a system-wide improvement project on vascular access over the course of the three-year ESRD Network contract, starting July 2003 and ending in June 2006. As a result of these efforts, by August of 2005, the national prevalence AVF rate was 40%, reaching the prevalence goal 10 months early.