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Fistula First: myth vs. fact
1Case Western Reserve University, USA.
Insights
Improving care for advanced chronic kidney disease (CKD) patients not on dialysis requires timely nephrology referral. System changes can increase arteriovenous fistula (AVF) placement rates, improving patient outcomes.
Area of Science:
- Nephrology
- Public Health
- Healthcare Systems
Background:
- Millions of patients have advanced chronic kidney disease (CKD) stages 4 and 5, often managed for comorbidities like diabetes and hypertension.
- Many patients with advanced CKD lack consistent nephrology care, highlighting a gap in referral pathways.
- Current arteriovenous fistula (AVF) creation rates before dialysis initiation are suboptimal, even among patients with existing nephrology care.
Purpose of the Study:
- To identify system-level changes needed to improve nephrology referral for advanced CKD patients.
- To increase the rate of timely AVF placement prior to dialysis initiation.
- To establish nephrologists as leaders in driving system improvements for CKD patient care.
Main Methods:
- Analysis of current patient encounters and healthcare system interactions for advanced CKD.
- Proposal of system-level triggers for nephrology referral.
- Evaluation of the impact of system changes on AVF creation rates.
Main Results:
- Implementing system-level referral triggers can increase nephrology care access for advanced CKD patients.
- A 25% incident AVF rate is observed, even with pre-dialysis nephrology care.
- System changes can realistically double the incident AVF rate to 50%, leading to a 66% prevalent AVF rate.
Conclusions:
- System-level interventions are crucial for optimizing nephrology referrals and AVF placement in advanced CKD.
- Nephrologists can lead initiatives to improve AVF rates through effective system change.
- Achieving higher AVF rates is attainable and essential for better patient outcomes before dialysis.
Abstract:
It is estimated that there are fewer than one million patients with Stages 4 and 5 CKD not on dialysis. Most of these patients have regular encounters with the health care system because of diabetes, hypertension, and other diseases of aging. Many of these patients are not under the ongoing care of a nephrologist, but could be if the appropriate triggers for nephrology referral are established at the system level. Even among patients who have been cared for by a nephrologist for >12 months prior to the onset of dialysis, the incident AVF rate is only around 25%. This is an embarrassingly low rate and reflects an opportunity for the nephrologist to emerge as a leader to drive the system changes that will promote timely referral and AVF placement. A doubling of the incident AVF rate to 50%, achievable with effective system change, is the best path to reach a prevalent AVF rate of 66%.
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