FISTULA FIRST: PAST, PRESENT AND FUTURE Jay Wish, MD Nephrology Clinical Consultant Fistula First Breakthrough Initiative
Jay Wish, MD: Disclosures No disclosures with regard to this presentation Wear 4 hats with regards to Fistula First 1. Practicing nephrologist: Want to do what s best for my individual patients weighing risk vs. benefit 2. Dialysis medical director: Want to improve my facility s numbers with appropriate QAPI activities 3. ESRD Network MRB and BOT member: Want to improve my Network s numbers with best practices and education 4. FFBI clinical consultant: Want to accumulate evidence to support clinical decision making
What is FFBI? Fistula First Breakthrough Initiative is a COALITION of stakeholders including CMS (which funds the project and sets the deliverables for the FFBI contractor, ESRD Networks, and dialysis facilities) ESRD Networks Dialysis providers The Renal Community including professionals, patients, organizations and scientists
The Mission of FFBI Maximize AVF placement in all suitable patients Minimize dialysis catheter use Avoid all types of vascular access complications
Change Concept - Defined A change concept is a general approach to change that has shown usefulness in developing specific ideas for changes that lead to improvement. Change concepts are intended to encourage development of specific changes that make sense within a particular setting.
1. Routine CQI Review of Vascular Access Possible specific changes: Facilities and/or hospitals designate staff member responsible for vascular access CQI Assemble multi-disciplinary vascular access team in facility or hospital Investigate and track all non-avf access placements and AVF failures
2. Early Referral to Nephrologist Possible specific changes: Primary care physicians use ESRD/CKD referral criteria to ensure timely referral to nephrologists Nephrologists document AVF plan for all patients expected to require renal replacement therapy Designated nephrology staff person educates family and patient to protect vessels
3. Early Referral to Surgeon for AVF Only Possible specific changes: Nephrologist/skilled nurse performs evaluation and physical exam Nephrologist performs or refers patient for vessel mapping Nephrologist refers patient to surgeon for AVF only, with the understanding that the surgeon will discuss alternate options with the nephrologist if AVF success is not realistic
4. Surgeon Selection Possible specific changes: Nephrologists refer to vascular access surgeons willing to meet specific standards and expectations Surgeons are evaluated on frequency, quality, and patency of access placements
5. Full Range of Appropriate Surgical Approaches Possible specific changes: Surgeons utilize current techniques for AVF placement including vein transposition Surgeons ensure mapping is performed (if suitable vein not identified on physical exam) Surgeons work with nephrologists to plan and place secondary AVF in AV graft.
6. Secondary AVFs in AVG Patients Possible specific changes: Nephrologists evaluate every AV graft patient for possible secondary AV fistula conversion Dialysis facility staff and/or rounding nephrologists examining outflow vein of all graft patients ( sleeves up ) at least monthly Nephrologists refer to surgeon for placement of secondary AVF before failure of AV graft
7. AVF Placement in Catheter Patients Possible specific changes: Regardless of prior access (e.g. AV graft), nephrologists and surgeons evaluate all catheter patients as soon as possible for AVF Facility implements protocol to track patients for early removal of catheter
8. Cannulation Training Possible specific changes: Facility uses best cannulators and best teaching tools to teach AVF cannulation to all facility staff Dialysis staff use specific protocols for initial dialysis treatments with new AVFs and assign the most skilled staff to such patients Facility offers option of self-cannulation to patients who are interested and able
9. Monitoring and Surveillance Possible specific changes: Nephrologists and surgeons conduct postoperative physical evaluation of AVFs in 4 weeks to detect early signs of failure/refer for intervention Facilities adopt standard procedures for monitoring, surveillance, and timely referral for the failing AVF Medical team adopts standard criteria for appropriate extent of intervention in existing access before placing new access
10. Continuing Education: Staff and Patient Possible specific changes: Routine facility staff in-servicing and education program in vascular access Continuing education for all care-givers including inservices by nephrologists, surgeons, and interventionalists Facilities educate patients to improve quality of care and outcomes (e.g. prepping puncture sites, applying pressure at needle sites, etc.)
11. Outcomes Feedback Possible specific changes: Networks work with dialysis providers to give specific feedback to all decision-makers on incident and prevalent rates of AVF, AVG, and catheter use Review data monthly or quarterly in facility staff meetings
How is FFBI Doing? Completed root cause analysis of barriers to AVF placement and developed new strategic plan in 2009 Redesigned webpage to make it more user-friendly and a complete resource to stakeholders Reorganized committees to increase stakeholder input and ownership
FFBI Strategic Plan 1. Nephrologist as leader 2. Leveraging partnerships 3. Modify hospital systems 4. Patient self-management 5. Promote fast-track protocols 6. Practitioner training and credentialing 7. Expand FFBI change concepts
FFBI Change Concepts Original 11 change concepts reviewed and reendorsed Change concept 12: Modify hospital systems to detect CKD and promote AV fistula planning and placement Change concept 13: Support patient efforts to live the best possible quality of life through selfmanagement
Policy Recommendations Pay-for-performance Pay for AVF placement during a hospitalization Access to patient-level data For targeting Network QI activities For research into barriers to AVF placement For evidence to develop more patient-specific practice recommendations and algorithms
Fistula Myth #1: The 66% AVF goal is unrealistic Other than the US and Canada, every country in DOPPS (Europe, Japan, Aus, NZ) has a prevalent AVF rate >66% The NKF/KDOQI vascular access workgroup examined the evidence and supports this goal Facilities with more than 66% AVFs increased from 6.2% in 2007 to 12.7% in 2009 40.8% of facilities in one Network have done it
Fistula Myth #2 FF has caused catheters to increase FFBI AVF Total CVC
Fistula Myth #3 Poor AVF prevalence is due to patients not seeing a nephrologist prior to dialysis
FFBI Ongoing Activities Development of algorithms/care paths for vascular access evaluation and placement Access to and use of patient-level data to better stratify risk vs. benefit of AVF vs. AVG placement Reframing of message Acknowledgment that some patients should get AVGs (66% AVFs means 34% other) Catheter reduction is paramount Greater emphasis on pre-dialysis AVF placement
Overcoming barriers to AVFs Solutions not excuses! We all have sick, old, poorly compliant patients with poor vessels The fact that some Networks and facilities have achieved high AVF rates means that solutions exist Every facility has unique barriers requiring a customized QAPI. No one size fits all.
Common Barriers to AVF Placement/Maturation 1. Ineffective leadership by medical director 2. Ineffective quality assessment & performance improvement programs 3. Lack of community partnerships 4. Lack of fistula maturation protocol 5. Ineffective fistula surveillance & cannulation protocols 6. Lack of CKD program for early AVF placement 7. Ineffective patient culture
Barrier 1: Ineffective Leadership by Medical Director
The Conditions For Coverage: Medical Director Responsibilities 494.150 [is] responsible for the delivery of patient care and outcomes in the facility. Is accountable to the governing body for the quality of medical care provided to patients. (a) Quality assessment and performance improvement program (b) Staff education, training, and performance (c) Polices and procedures
Barrier 2: Ineffective Quality Assessment & Performance Improvement (QAPI) Program
Identifying the Problems Poor communication Delayed access procedures Poor follow up Minimal radiology intervention Poor cooperation between surgeons and radiologist. Too many catheters Need for more fistulas Staff frustration Need for change
Getting Started: The Initial Team Medical director: Instrumental in starting the program Appointed as the leader Shared concerns with surgeons and radiologist Access Coordinator: Scheduled monthly access meetings Established communication between disciplines Identified access concerns and collect data Acute Manager: Coordinated in hospital and post procedure care Maintained open communication with the out patient center Staff Educator: Provided on going education to all care givers Initiated pre-dialysis program.
Success - Increased Prevalent Fistula Rates Medical Director was very involved Rapid referral to the surgeon for access evaluation Vein mapping mandatory Only fistulas to be placed Follow up at 2-4 and 6 weeks to evaluate maturity Access monitoring and quick intervention to salvage fistulas Surgeons became more creative placing fistulas Developed specific protocols to be followed Education of staff and patients
Barrier 3: Lack of Community Partnerships
Everyone Working Together 34 CQI Review Training Surveillance Education Outcomes Facilities Surgeons Surgical Approach Secondary AVF AVF in Catheter Pt Patient Nephrologists Early Referral AVF Only Surgical Selection Interventional Radiology Pre Access imaging Early intervention for Failing Access CQI of interventions
35 Good nephrologist surgeon communication requires: An informed, involved nephrologist An engaged, committed surgeon Has basic understanding of CKD and dialysis Commitment to Fistula First Initiative Vessel mapping Early AVF placement Technique/option tailored to each patient Defined roles Willingness to utilize protocols Streamlined processes that do not have to wait for a busy physician/surgeon to be available for every decision
What Nephrologists Should Do 36 Work with local primary care practitioners and hospitals on early patient referral Foster relationships with local surgeon(s) for early vascular access referral Refer patients for vessel mapping Refer patients to surgeon(s) who have the BEST AVF outcomes Provide AVF results profiles (feedback) to local surgeon(s) Support tracking systems at facility level to review catheter and AV graft patients Embrace the role of renal team leader!
What Surgeons Should Do 37 Support specific standards and expectations as described by the nephrologist(s) and vascular access team Ensure mapping is performed if suitable vein not identified on physical exam Utilize current techniques for AVF placement including vein transposition Work with nephrologist(s) to evaluate all catheter patients as soon as possible for AVF Work with nephrologist(s) to conduct post-operative physical evaluation of AVFs in 4 weeks to detect early signs of failure/refer for intervention Work with nephrologist(s) to plan and place secondary AVF if AV graft is failing
Barrier 4: Lack of Fistula Maturation Protocol
Maturation Time 39 How long should you wait till cannulation attempt? in Europe they say at 4 weeks there are no more complications than waiting 8-12 weeks in the US the general wisdom is 8-12 weeks Shouldn t it depend on the individual patient s vein development, alternative access situation, and the cannulation expertise of the staff?
40 Fistula Maturation You should have a sense at 2 weeks if it will be large enough at 8 weeks Veins not large enough to cannulate at 6 weeks should be referred to surgeon or interventionalist There may be collaterals that can be tied off or a fistulogram may detect stenosis that could be plastied for better flow The fistula itself may need to be revised surgically or recreated more proximally on the artery Is the artery integrity and cardiac output adequate to expand vein?
Barrier 5: Effective Fistula Surveillance & Cannulation Techniques
Barrier 6: Lack of CKD program for early fistula placement
CKD Care 43 Provide early patient education on modality choice and vascular access selection with an emphasis on AV fistula selection for those patients choosing hemodialysis Provide resource linkage and referrals for transportation, vascular center options, etc. Become familiar with vessel preservation concepts which include: Avoiding the use of the subclavian vein in patients with impaired renal function Avoiding PICC lines or veinipunctures in the antecubital vein or cephalic vein of the arms in patients with impaired renal function
Hospitals can identify CKD patients Florida QIO conducted QI program with hospital systems to identify patients with late stage 3 and stage 4 CKD patients based on labs done for other indications (e.g. CT and MRI with contrast) Such patients automatically referred to nephrologist Such patients automatically undergo venous mapping and referred to surgeon for AVF placement on THAT ADMISSION if egfr <20 Incident fistula rate dramatically increased
Increased opportunity for CKD care As of Jan. 2010, Medicare will pay for pre-esrd education in stage 4 CKD patients Presents an opportunity to provide repeated reinforcement regarding pre-esrd AVF placement to avoid dangers of dialysis catheter The APN/PA providing the education can also serve as the vascular access concierge who shepherds the patient through the AVF process (venous mapping, surgical evaluation, AVF placement and follow-up)
Barrier 7: Ineffective Patient Culture
Patient Culture First ask is this truly a patient culture barrier or could it possibly be a staff culture barrier! Culture change begins at the top the Medical Director is key to success Resources Peer to Peer Counciling Motivational Interviewing
Fistula Coach Coordinator Designs program for facility Facilitates recruitment of coaches Trains coaches Coordinates referrals Provides supervision
Implement Coaching Program New patient team Waiting room activities Individual meetings Phone meetings
Patient Coach Activities Visits patients Provides resources Helps with problem-solving Gives encouragement Provides emotional support
Vascular Access Coordinator Pre-ESRD patients are often in denial and need to be nagged to follow through on vascular access appointments. Nephrologists will not do this. Someone else has to. Dialysis patients who are satisfied with their lethal catheter need to be nagged to follow through on vascular access appointments. Nephrologists will not do this. Someone else has to. The nagger doesn t have to be a nurse, but should be working with a nurse coordinator who is responsible for implementing protocols
Predictions are dangerous, particularly those about the future Yogi Berra
What does CMS have in mind? The FFBI contract is being moved from ESRD Network 5 to ESRD Network 2 This may signal a phasing out of funding for FFBI There are signals that CMS is planning a shift in emphasis from Fistula First to Catheters Last It is not clear how vascular access-related payment for performance will play out Claims data collected in 2010 Fistula First dashboard to be continued for now Eventually to be incorporated into CROWNWeb
Collection of baseline data for P4P Starting July 1, 2010, all Medicare claims for HD patients require codes for vascular access type and presence of infection Modifier V5: Catheter Modifier V6: Graft Modifier V7: Fistula Modifier V8: Infection Present Modifier V9: No Infection Present
Making sense of all the TEP recommendations re vascular access infections as a basis for P4P These are rates of infection per 1000 patient days There will need to be a baseline data collection to establish national performance standards The data collection starting July 2010 is not detailed enough to establish any standards that apply to the CPMs proposed by the TEP Unlikely that CROWNWeb will be able to collect these data for at least 1-2 years, meaning the P4P effect will not be seen at least until 2014 The P4P is only 2%, so the contribution of any single indicator is trivial
Effects of bundling on vascular access Since antibiotics are no longer separately billable, catheter-related infections will be costly to the facility Since TPA is no longer separately billable, nonfunctional catheters will be costly to the facility Infection increases ESA requirements which is costly to the facility Absenteeism due to poorly functioning or infected access will be lost revenue to the facility
Summary and Conclusions FFBI remains a strong resource for professionals in the pursuit of higher AVF prevalence The nephrologist is the key driver of the practices at the patient care level that will improve AVF prevalence Collaboration/partnerships will facilitate seamless patient movement through the CKD-dialysis continuum There will be a more compelling business case for AVF placement due to P4P features regarding access and the direct costs of vascular access dysfunction and infection