NN&I - June 2010

Vascular Access 30 Nephrology News & Issues June 2010Subscribe to our free eNewsletter at www.nephronline.com Is there a need to mandate access surveillance in the dialysis clinic? In 2008, the Centers for Medicare & Medicaid Services established a set of revised requirements that dialysis facilities must meet in order to be cer -tified under the Medicare program.1,2 These new Conditions for Coverage are designed to promote continuous quality improvement, and to reflect advances in technology and standard care practices since the requirements were last revised in 1976. CMS subsequently issued an ESRD Interpretive Guidance Update that has generated much controversy.3 The updated Interpretative Guid-ance V551 states, "The [dialysis] facility must have an ongoing program for vas-cular access monitoring and surveil -lance for early detection of failure and to allow timely referral of patients for intervention when indications of signif -icant stenosis are present. Monitoring strategies may include physical exami -nation of the vascular access; obser -vance of changes in [dialysis] adequa-cy or in [dynamic venous] pressures measured during dialysis; difficulties in cannulation; or in achieving hemo -stasis. ... Surveillance strategies include device-based methods such as access flow measurement, direct or derived static venous pressure ratios, duplex ultrasound, etc." The Guidance Update indicates a clear CMS requirement for surveill-ance of the vascular access. In res- ponse to this new requirement, the 17 authors of this article (see the "Authors" box below) sent an "Access Surveill-ance Statement" to CMS Chief Kenneth Abreo, MD Professor of Medicine and Chief of Nephrology, Louisiana State University School of Medicine Medical Director, FMC Dialysis Center of Shreveport and Michael Allon, MD Professor of Medicine, University of Alabama at Birmingham Medical Director, UAB Dialysis Operations Chair, 2008 National Kidney Foundation Program Arif Asif, MD Past President, American Society of Diagnostic and Interventional Nephrology Director, Interventional Nephrology Professor of Medicine, University of Miami Naveen Atray, MD Chair, Communications Committee, ASDIN Medical Director, Capital Nephrology Access Center Sacramento, Calif. Anatole Besarab, MD Co-Chair, Vascular Access Working Group, KDOQI Clinical Practice Guidelines, 2006 Director, Clinical Research, Henry Ford Hospital Adjunct Professor of Medicine, Wayne State University The authors Laura M. Dember, MD Associate Professor of Medicine, Boston University Bradley S. Dixon, MD Associate Professor of Medicine, Roy and Lucille Carver College of Medicine Iowa City, Iowa Maria DeVita, MD Associate Director Nephrology Training Program Director James Kaufman, MD Staff Physician, Renal Section, VA Boston Healthcare System Professor of Medicine, Boston University Brian M. Murray MD, FACP, FRCPI Chief Medical Officer, Erie County Medical Center Vo D. Nguyen, MD Fistula First Leadership Group member William D. Paulson, MD Chief of Nephrology, Charlie Norwood VA Medical Center Professor of Medicine, Medical College of Georgia Director of the End-Stage Renal Disease Program, MCG Medical Director, Sunanda J. Ram, PhD Associate Professor of Medicine (Research), Louisiana State University Health Sciences Center Tushar Vachharajani, MD, FACP, FASN Associate Professor Internal Medicine/Nephrology, Wake Forest University School of Medicine Director, Dialysis Access Group of WFU Winston-Salem, N.C. Thomas M. Vesely, MD Vascular Access Working Group, KDOQI Clinical Practice Guidelines, 2006 Interventional Radiologist Vascular Access Center of Frontenac Grove St. Louis John J. White, MD Associate Professor of Medicine, Medical College of Georgia Medical Director, South Augusta Dialysis Unit and Riverview Kidney Center, Renal Advantage, Inc. Augusta, Ga. Jack Work, MD Co-Chair, Vascular Access Working Group, KDOQI Clinical Practice Guidelines, 2006 Professor of Medicine, Emory University Director of Interventional Nephrology, VascAccess_NNI0610_8.indd 30 5/17/10 3:46:50 PM