F- 01: arteriovenous fistula

F- 01: catheters

Trends in US Vascular Access Use, Patient Preferences, and Related Practices: An Update From the US DOPPS Practice Monitor With International Comparisons

Ronald L. Pisoni, PhD, MS ; Lindsay Zepel, MS ; Friedrich K. Port, MD, MS ; Bruce M. Robinson, MD, MS

Journal : American Journal of Kidney Diseases

Year : 2015 / Month : June

Volume : 65

Pages905–915

ABSTRACT

Background

Since the bundled end-stage renal disease prospective payment system began in 2011 in the United States, some hemodialysis practices have changed substantially, raising the question of whether vascular access practice also has changed. We describe monthly US vascular access use from August 2010 to August 2013 with international comparisons, and other aspects of US vascular access practice.

Study Design

Prospective observational cohort study of vascular access.

Setting & Participants

Maintenance hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor (DPM) in the United States (N = 3,442; US patients) and 19 other nations (N = 8,478).

Predictors

Country, patient demographics, time period.

Outcomes

Vascular access use, pre–end-stage renal disease access timing of first nephrologist care and arteriovenous access placement, patient self-reported vascular access preferences (United States only), treatment practices as stated by medical directors.

Results

In the United States from August 2010 to August 2013, arteriovenous fistula (AVF) use increased from 63% to 68%, while catheter use declined from 19% to 15%. Although AVF use did not differ greatly across age groups, arteriovenous graft use was 2-fold higher among black (26%) versus nonblack US patients (13%) in 2013. Across 20 countries in 2013, AVF use ranged from 49% to 92%, whereas catheter use ranged from 1% to 45%. Patient-reported vascular access preferences differed by sex and race, with 16% to 20% of patients feeling uninformed regarding benefits/risks of different vascular access types. Among new (incident) US hemodialysis patients, AVF use remains low, with ∼70% initiating hemodialysis therapy with a catheter (60% starting with catheter when having≥4 months of predialysis nephrology care). In the United States, longer typical times to first AVF cannulation were reported.

Limitations

Noncompletion of surveys may affect the generalizability of findings to the wider hemodialysis population.

Conclusions

AVF use has increased, with catheter use decreasing among prevalent US hemodialysis patients since the introduction of the prospective payment system. However, AVF use at dialysis therapy initiation remains low, suggesting that reforms affecting predialysis care may be necessary to incentivize improvements in fistula rates at dialysis therapy initiation as achieved for prevalent hemodialysis patients.

Index Words: Hemodialysis, vascular access, arteriovenous fistula (AVF), arteriovenous graft (AVG), central venous catheter (CVC), treatment practices, practice patterns, nephrology referral, dialysis initiation, renal replacement therapy (RRT), Dialysis Outcomes and Practice Patterns Study (DOPPS), DOPPS Practice Monitor (DPM)

COMMENTS

This DOPPS’ study is informative on the care of end-stage renal disease in the USA and highlights the unclear medical behaviour for managing vascular access before starting hemodialysis in a changing economical background.

The native arteriovenous (AV) fistula (AVF) is widely recognized as the vascular access of first choice for most hemodialysis patients in that it provides the best outcomes overall compared with an AVgraft (AVG) or central venous catheter (CVC). Use of catheters has been associated with substantially higher rates of mortality, infection-related complications, central venous stenosis, hospitalization, and costs. Consequently, the US Fistula First Breakthrough Initiative, NKF-KDOQI (National Kidney Foundation−Kidney Disease Outcomes Quality Initiative), and many national guideline committees recommend the AVF as the access of first choice for hemodialysis.

Based on the US DOPPS sample, the DPM was launched in 2010 to report trends in dialysis care before, during, and after implementation of the new US Centers for Medicare & Medicaid Services (CMS) end-stage renal disease (ESRD) prospective payment system, which began in January 2011. Internationally, in 2012/2013 DOPPS data, the United States displayed intermediate AVF and CVC use among the 20 countries analyzed, but had the highest AVG use among all DOPPS countries.

Among approximately 1,400 patients who answered the question, 58% of females versus 69% of males preferred an AV access.

Vascular access use at study entry was collected for patients who entered the DOPPS within 60 days of their first-ever hemodialysis treatment for ESRD (Fig 5A). Among these patients, the United States showed one of the lowest uses of an AVF at study entry, with 28% using an AVF; 5%, an AVG; and 67%, a CVC.

Large improvements have been seen in vascular access use among prevalent hemodialysis patients in the United States, with AVF use increasing from 24% in 1997 to 68% in 2013, whereas CVC use has declined from 27% to 15%. Even in the most recent period from August 2010 to August 2013, improvements have been observed in both AVF and CVC use in the United States, indicating the continuing efforts by US dialysis units to optimize vascular access use for their patients.

In contrast to the large improvements in vascular access use in the United States since 1997 for prevalent hemodialysis patients, there has been no overall improvement in AVF and CVC use for new patients with ESRD when initiating hemodialysis therapy. In the current study, nearly 70% of patients were using a CVC at time of study entry, which on average was 33 ± 15.7 days after hemodialysis therapy initiation.

In summary, these results from the DPM show continuing large improvements in vascular access practice among prevalent hemodialysis patients in the United States. Notably, a culture devoted to closely monitoring and optimizing vascular access practice in the United States is highly evident from numerous perspectives. Differences in vascular access use are seen by race and sex, with new information on patient vascular access preferences and vascular access knowledge useful for further optimizing vascular access practices. Long times to first AVF cannulation continue to be seen in the United States and may hinder optimal vascular access use. Despite the large improvement in vascular access use for prevalent hemodialysis patients in the United States during the past 17 years, there has been no improvement in access use for new hemodialysis patients in the United States, with nearly 80% initiating hemodialysis therapy with a CVC.

Pr. Jacques CHANARD

Professor of Nephrology