When the CMS-led Fistula First Breakthrough Initiative began in 2003 to encourage creation of fistulas, there was limited access to patient-focused, non-hospital vascular access services. ESRD patients were given no choice other than to seek care in HOPD emergency rooms and await vascular access services as capacity would allow. Significant delays in vascular access services were common, resulting in failed fistulas, the use of the inferior alternatives, decreased quality of care and worse outcomes, with increased mortality, higher rates of infection, and greater cost associated with catheters and grafts.
As the importance of fistulas became more widely recognized, non-hospital vascular access centers developed in the physician office and ASC settings to meet this clinical demand. Since the early 2000s, fistula use has increased significantly from approximately 32% in 2003 to 63% by 2014. Total Medicare spending for these services concurrently decreased markedly since that time.
In 2019/2020, the National Kidney Foundation launched a new initiative to update the clinical evidence relating to vascular access with its “Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Vascular Access.” While the updated KDOQI guidelines continue to recognize the paramount importance of fistulas, the guidelines also recognize that newer technologies (e.g. peritoneal) and earlier interventions (e.g. a permanent functioning fistula created at the CKD, or “pre-ESRD” stage) mean that a patient’s vascular access needs are likely to involve multiple modalities over the course of a patient’s life.
This care continuum is illustrated below.
DVAC strongly supports Medicare’s adoption of a “Vascular Access Life Plan” for ESRD patients to review options relating to transplant, in-center/home dialysis, end-of-life care, and other important considerations.
This Life Plan should be reviewed annually and evaluated quarterly.
We encourage CMS to launch a new CMS Breakthrough Initiative similar to Fistula First to raise awareness around the new Vascular Access Life Plan. In addition, DVAC encourages Medicare’s use of the KDOQI sample documentation of a vascular access “Life Plan” to plan – and regulatory check relative to that plan over the course of an ESRD patient’s life – for the right access at the right time for a given ESRD patient.