NN&I - April 2010
Vascular Access 40 Nephrology News & Issues April 2010www.nephronline.com AVF. For the sub-group of patients seen by a nephrologist for >12 months prior to dialysis, there was more of a correla-tion with risk score, with 31.6% of low risk, 29.2% of moderate risk, 26.4% of high risk, and 22.0% of very high risk patients starting dialysis with an AVF. Nonetheless, the assignment of highest risk was still associated with an AVF success rate only 10% lower than that in patients with low risk and certainly cannot be interpreted as a contraindi -cation for AVF placement. Myth No. 5: Poor fistula preva -lence is caused by patients not see -ing a nephrologist prior to dialysis Fact: Data from the 2728 Medical Evidence Report suggest that less than 40% of incident HD patients have seen a nephrologist prior to the onset of renal replacement therapy. These forms which are completed by the nephrologist who assumes care for the patient on dialysis do not necessarily reflect care provided by other neph-rologists during the year or two prior to the onset of ESRD. When the USRDS examined Medicare claims data for the prior two years among incident HD patients ages 67 and older, it found that close to 80% of these patients had received nephrology care. This rate has remained constant over several years (see Figure 2). Instead, the FFBI nephrology com-munity has found that we, in fact, are the problem. The No. 1 point in the FFBI Strategic Plan is "Nephrologist as Leader: Encourage and support neph-rologists to take a leadership role and be accountable for vascular access management in all appropriate hemo -dialysis patients." The role of the neph- rologist in promoting AVF placement starts long before the patient needs dialysis and should be system-based. The large disparity between nephrol -ogy encounters based on claims data compared to 2728 data suggests that nephrologists should take what may be limited in-patient encounters with CKD patients more seriously as an opportunity to initiate AVF placement. Hospitals are increasingly identify -ing patients with Stages 3 and 4 CKD because radiology departments require GFR measurement prior to administer -ing iodinated radiocontrast or gado -linium. Systems can be developed at the institutional level to refer an appro -priate patient for venous mapping and surgical evaluation for vascular access while the patient is undergoing what may be unrelated tests and procedures. The Florida QIO has achieved success with such an approach among several hospital systems to improve AVF place -ment prior to HD initiation. Summary It is estimated that there are fewer than one million patients with Stages 4 and 5 CKD not on dialysis. Most of these patients have regular encounters with the health care system because of diabetes, hypertension, and other dis -eases of aging. Many of these patients are not under the ongoing care of a nephrologist, but could be if the appro-priate triggers for nephrology refer -ral are established at the system level. Even among patients who have been cared for by a nephrologist for >12 months prior to the onset of dialysis, the incident AVF rate is only around 25%. This is an embarrassingly low rate and reflects an opportunity for the nephrologist to emerge as a leader to drive the system changes that will Table 3. FFBI leadershipCommunity Education Taskforce Co-Chairs: Andrew S. Narva, MD Joseph Vassalotti, MD Clinical Practice Taskforce Co-Chairs: Clifford Sales, MD Rebecca Schmidt, DO Health Policy Taskforce Co-Chairs: W. Kline Bolton, MD Sean P. Roddy, MD Website Taskforce Chair: Lynda K. Ball, MSN, RN, CNNData Committee Chair: William McClellan, MD, MPH CMS Contract Leaders: Teresa Casey, RD, LD Government Task Leader Edwin D. Huff, PhD Project Officer Clinical Consultants: Jay Wish, MD, nephrology Michael Lilly, MD, surgery % Prevalence10.0% 0.0% 20.0% 40.0% 50.0% 60.0% 70.0% 30.0% 072003 012004 072004 012005 072005 012006 072006 012007 072007 012008 072008 022009 072009 Total CVC AVG Figure 1. Prevalent vascular access July 2003 to November 2009 VascAccess_NNI0410_5.indd 40 3/18/10 5:20:31 PM
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