Controversial vascular access surveillance mandate

The Centers for Medicare and Medicaid Services (CMS) recently revised the requirements that end-stage renal disease (ESRD) dialysis facilities must meet to be certified under Medicare. The CMS ESRD Interpretive Guidance Update states that the dialysis facility must now have an ongoing program of hemodialysis vascular access surveillance. Surveillance usually refers to monthly access blood flow or static dialysis venous pressure measurements combined with preemptive correction of stenosis. However, surveillance as currently practiced does not accurately predict synthetic graft thrombosis or prolong graft life. There is limited evidence that monthly surveillance may reduce native arteriovenous fistula thrombosis without prolonging fistula life, but the effect on thrombosis awaits further confirmation. Thus, the CMS surveillance requirement is not evidence based. We recommend the following changes to the ESRD Interpretive Guidance Update: only monitoring (e.g., physical examination) is required, whereas the proper role of surveillance awaits the results of further research. Such changes would allow nephrologists to apply the clinical judgment and individualized care that is most beneficial to their patients.