NN&I - April 2010
Vascular Access 36 Nephrology News & Issues April 2010www.nephronline.com The year 2010 represents the 5th anni-versary of the establishment of the Fistula First Breakthrough Initiative (FFBI). In 2003, the Centers for Medicare & Medicaid Services, the End-Stage Renal Disease Networks, and key pro-vider representatives jointly adopted a National Vascular Access Improvement Initiative (NVAII) to increase the appro-priate use of arteriovenous fistulas (AVF) for hemodialysis (HD) access and to reach or exceed the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) recom-mendation of 50% incident and 40% prevalent AVF in HD patients. This goal was reached in 2005, at which time the NVAII was reorganized by CMS as the FFBI and the prevalent AVF goal was increased to 66%. The following year, the NKF-KDOQI revised its prevalent AVF goal to 65%. Since 2003, the prevalent AVF (two needle access) rate in the United States has increased from 32% to 54.2%, as of October 2009. Despite the remarkable achieve -ment of this collaborative effort, there has emerged increased skepticism as to whether the FFBI has the potential to continue its success. Not surpris-ingly, much of that skepticism comes from quarters that have made the least progress in increasing AVF rates and is based on misconceptions and myths regarding the translation of evidence and recommendations into best prac -tice. This editorial will address several of these more common myths and put them into perspective. Fistula First: myth vs. factBy Jay B. Wish, MD Dr. Wish is a consultant to the Fistula First Breakthrough Initiative. He is a professor of medi-cine at Case Western Reserve University and medi-cal director of hemodialysis services at University Hospitals of Cleveland. He is also co-chair of NN&I's Editorial Advisory Board. Table 1. FFBI strategic plan1. Nephrologist as leader: Encourage and support nephrologists to take a leader ship role and be accountable for vascular access management in all appropriate hemodialysis patients. 2. Leveraging partnerships: Partner to improve arteriovenous fistula (AVF) place-ment and utilization rates. 3. Hospital systems: Modify hospital systems to promote AVF placement. 4. Patient self-management: Promote patient self-management throughout the stages of chronic kidney disease. 5. Addressing access problems: Promote fast-track protocols for rapid identifi-cation and referral of vascular access problems, which include failure to mature, revision of the failing AVF, and placement of an AVF. 6. Practitioner training and credentialing: Promote training, experience, and cre-dentialing of health care professionals in the area of hemodialysis vascular access management. 7. FFBI Change Concepts: Expand and endorse the current Change Concepts for education and promotion throughout the renal, surgical, and interventional communities. Policy Recommendations 1. Pay-for-Performance 2. Assure Data FlowMyth No. 1: The FFBI has lost momentum Fact: During 2009 the FFBI, under the leadership of the Mid-Atlantic Renal Coalition (ESRD Network 5), had one of its most productive years. A root cause analysis for barriers to AVF placement was performed and a new strategic plan was developed to provide the basis for system change. The plan articulates seven strategies and two policy recom-mendations to move the FFBI agen -da forward (see Table 1), recognizing that many barriers to AVF placement and maintenance in 2009 have evolved since the original 11 Change Concepts (see Table 2) were developed by the NVAII in 2003. The Plan recommends the reinforcement and expansion of the Change Concepts and, in December 2009, two new Change Concepts were recommended by the FFBI: No. 12: Modify hospital systems to detect CKD and promote AV fistula planning and placement. No. 13: Support patient efforts to live the best possible quality of life through self-management. The FFBI's tactical plan involves the formation of several stakeholder com -mittees, which have already started meeting regularly to develop projects and recommendations (see Table 3). During 2009, the prevalent AVF (in use, two needle access) rate in the United States increased from 51% to 54% by October. This 3%-plus rise compares favorably to the average annual rise of 3.5% between the beginning of 2005 (37%) and the end of 2008 (51%). Myth No. 2: The 66% goal for prevalent fistulas is unrealistic Fact: Other than the United States VascAccess_NNI0410_5.indd 36 3/18/10 5:19:51 PM
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