Medical Director/Surgeon as Partners WebEx February 11, 2010
Over 400,000 patients are treated yearly for ESRD in the USA; 60% of these patients receive some form of hemodialysis Despite major advances in dialysis knowledge and technology, ESRD patients continue to suffer from the debilitating effects of renal disease, and die prematurely Vascular access failure represents a major source of morbidity in ESRD patients 25% of all hospital stays for ESRD pts are related to problems with vascular access ~500,000 vascular access procedures/year in US; COST: >$200 million/year Proper selection, creation, and maintenance of vascular access in ESRD pts cannot be overemphasized 2
Vascular access is one of the most critical components in improving dialysis quality: Recent trends: Access Patency, Morbidity/ Mortality, Costs Attributable to: AVF, AVG, Catheters Access type is a major determinant of patient outcomes as well as financial outcomes Most VA-related morbidity & costs due to grafts & catheters 3
Raymond M. Hakim and Jonathan Himmelfarb Kidney International advance online publication, 26 August 2009; doi:10.1038/ki.2009.318 4
Increased event free patency Decreased morbidity & mortality Decreased costs Per annum cost savings $4500 vs. AVG $9000 vs. Catheter 5
Fistulas Grafts Cuffed Cath Events per 100 ptmos Non- Cuffed Cath Admits 9.40 12.90 20.50 32.00 Out Pt abx Out Pt Vnco Pos Bld Cltrs 2.02 2.39 7.87 7.80 1.21 1.72 6.48 7.80.52.94 5.80 9.95 6
AVF AVG CC NCC 0.2 0.5 5.0 8.5 7
RR of death 1.4 1.2 1.23 1.03 1.28 1.18 1.25 1.33 1.30 1.21 Higher AVG (AVG:AVF = 3:2 or more) Intermediate AVG Lower AVG (AVG:AVF = 1:8 or less) 1 1.00 0.8 Cath <10% Cath 10-20% Cath > 20% Facility catheter use Model adjusted for age, gender, race, time on dialysis, 13 summary comorbid conditions, laboratory values, unit type, stratified by region, and accounted for facility clustering effects. DOPPS I + II
RR of Death among Facility Patients per 20% more facility use of indicated access type p<0.0001 Ref. p<0.0001 Ref. p<0.0001 *DOPPS I+II, 1996-2004; n=25,709; adjusted for age, gender, black race, yrs with ESRD, 14 comorbidity classes, baseline Hgb, Kt/V, serum albumin, calcium, PO 4, accounted for facility clustering effects; stratified by continent [Japan, US, EUR (Fr,Ge,It,Sp,UK]; RR based upon access in use at study entry. Pisoni et al, ASN 2005
The 2006 update for the KDOQI guidelines say that >65% of prevalent patients should have a functional AV fistula The Clinical Performance Measures (CPM) defines a working fistula as one that can be used for a dialysis treatment with 2 needles regardless of any other access that may be present 10
Simple (radiocephalic & brachiocephalic) Vein transposition (BVT & CVT) 2 step - simple then transposition Superficialization of veins by surgical removal of tissue between skin and vein 11
Post operative evaluation Usually done by surgeon at 2-4 weeks Maturity evaluation Surgeon or nephrologist at 4-8 weeks Post-maturity evaluation Nephrologist Healing, complications Is it beginning to mature? Is it ready for use? Surgeon may not be best at this assessment, work until mature Does it remain ready for use? Act on problems 12
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? 13
Median Days to First Cannulation 100 80 60 40 20 86 41 27 25 n = 694 80 96 98 0 France Germany Italy Japan Spain UK US Note: Prospective, observational data from a random sample of incident patients initiating hemodialysis, hemofiltration, or hemodiafiltration in 309 facilities in France, Germany, Italy, Japan, Spain, the United Kingdom, and the US. Rayner H, et al. Kidney Int. 2003;63:323-330. 14
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? 15
Greater than 600mL per min flow Greater than 6mms in diameter Less than 6mms below skin surface AND All fistulae should be thoroughly examined no later than 6 weeks post op 16
Abnormal physical exam Mechanical surveillance Identified stenosis 17
Flow monitoring Static venous pressure (VP0) trends Venous dialysis pressure (VDP) trends Pre-pump arterial pressures Blood volume processed (BVP) Online clearance monitoring Other signs and symptoms of access pathology recirculation and/or decreased URR difficulty cannulating and pain in the access changes in thrill and bruit prolonged bleeding post-dialysis arm swelling & prominent collaterals sudden appearance of aneurysms patient concerns 18
Beathard, Seminars in Dialysis, 1998, 4:231-236
Beathard, Seminars in Dialysis, 1998, 4:231-236
Inadequate maturation Repeated infiltration Steal syndrome or nerve damage Stenosis Thrombosis Infection Aneurysms/one site-it is High flow vein hypertrophy 21
Early - Problems have generally fallen into three categories: Lesions that should have been detected with good vessel mapping, artery that is too small or the presence of arterial disease vein that is too small or veins that are fibrotic or stenotic due to past trauma such as venipuncture Inflow Problems arterial anastomosis or juxta-anastomotic stenosis Outflow Problems presence of accessory veins Late - Failure that occurs after 3 months: Venous stenosis Thrombosis Acquired arterial lesions
Ligation Angioplasty Stent Surgical Revision 23
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 24
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 25
1. More fistulae and less catheters 2. Regular, efficient, uninterrupted dialysis 3. Infrequent, planned procedures 4. Good patient outcomes 5. Rapid response to access complications 26
Patient starts dialysis and only has a catheter Automatic referral to surgeon Expected timelines (urgency) Patient has catheter and fistula When to cannulate (who decides?) What to do if immature How to follow up until it is ready or a new access is placed When to remove the catheter (after 3 successful uses) 27
How involved is the Nephrologist? Is my Surgeon engaged? Do we have surgical options? Physicians Facilities Is there endovascular support? Are the doctors talking to each other? 28
Needs a baseline working knowledge Anatomy and physical exam Surgical techniques and options Endovascular techniques Work with hemodialysis staff and surgeons Develop protocols so there are no delays Negotiate for best access option Provide the medical perspective Oversee initial fistula use Focus on early intervention Evaluate patient s access with every visit Guide cannulation technique Decide when to intervene in borderline cases The more involved in the process the better! 29
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! 30
Committed to Fistula First Initiative Vessel mapping Early AVF placement Technique/option tailored to each patient Willing to utilize protocols Able to be a team player Has basic understanding of CKD and dialysis 31
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 Embrace the AVF Only philosophy! 32
[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
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AVF Rates for November 2009 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% NW9 NW6 NW5 NW8 NW11 NW10 NW4 NW12 NW14 NW13 NW7 US NW3 NW2 NW1 NW18 NW17 NW15 NW16 Nov-10 49.8% 49.9% 50.9% 51.7% 52.7% 52.8% 53.1% 53.5% 53.6% 53.8% 54.3% 54.4% 54.6% 57.4% 58.1% 58.6% 59.7% 60.3% 64.5% 35
70.0% AVF Rates for November 2009 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% IN KY OH Net 9 IL/ Net 10 US 36
ESRD SURGICAL QUALITY REPORT Facility Name This report indicates the AVF and Catheter rates for your facility for all of 2009. Page 2 of the report compares facility rates to region, state, ESRD Network, and US vascular access rates. The Renal Network gathered this data so the facility Medical Director can share the rates with the surgeons who provide Vascular Surgical Services to this facility. Arteriovenous fistulae (AV fistulas) are considered the gold standard for hemodialysis vascular access based on their superior patency, low complication rates, improved adequacy, lower cost to the healthcare system, and decreased risk of patient mortality. Facility Region State Network Nation Overall Yearly Fistula Rate 62.0% 55.4% 50.7% 50.7% 52.4% Your facility's yearly fistula rate ranks 104 out of 705 facilities in the Network. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % Above % Below 1 Your Facility 2009 Prevalent Fistula Rate by Month Prevalent Catheter Rate by Month 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Facility Nation CMS Goal Facility Network
Because, usually, that is what s best for your Patients! 38