A journey in reversing practice patterns: a multidisciplinary experience in implementing DOQI guidelines for vascular...

Area of Science:

• Nephrology
• Vascular Surgery
• Quality Improvement in Healthcare

Background:

• Increasing morbidity and costs associated with haemodialysis vascular access in end-stage renal disease (ESRD) patients necessitate improved strategies.
• The National Kidney Foundation (NKF) developed guidelines to address these challenges.

Purpose of the Study:

• To evaluate the impact of implementing the Dialysis Outcome Quality Initiative (DOQI) guidelines on vascular access practices and patient outcomes.
• To assess the shift from non-autogenous grafts to autogenous fistulae for haemodialysis.

Main Methods:

• Formation of a multidisciplinary quality assurance committee to implement DOQI guidelines starting September 1999.
• Implementation of a 'Save the Vein Programme' prioritizing native fistulae for new patients from January 2000.
• Increased use of Doppler ultrasound for pre-operative vascular anatomy evaluation and replacement of failed grafts with autogenous fistulae.

Main Results:

• Fistula creation increased significantly, from 48 in 1999 to 77 and 96 in the subsequent two years, while graft creation decreased from 50 to 15.
• The percentage of functional fistulae in incident patients rose from 20% to 60% (P<0.001), and in prevalent patients from 24% to 44% (P<0.004).
• Overall hospitalization rates decreased from 98% to 79% (P<0.001), and vascular-related admissions reduced from 67% to 53%.

Conclusions:

• Successful implementation of DOQI guidelines led to a significant reversal in practice patterns, favoring fistula creation over grafts.
• This shift in vascular access strategy resulted in a demonstrable reduction in patient morbidity and hospitalizations.