Achieving the goal: results from the Fistula First Breakthrough Initiative

This review summarizes the background and implementation of the Fistula First Breakthrough Initiative (FFBI), published information about changes in vascular access practice since its inception, and several issues raised by the program.

The FFBI is a surveillance system using the End-Stage Renal Disease (ESRD) Networks to spread improvement ideas. Concomitant with implementation of the program, prevalent arteriovenous fistula use has increased an average of 3.3% annually since 2003, an incremental improvement of 1.3% over the preexisting trend. At the same time, long-term central venous catheter (CVC) use declined among the prevalent population. Increasingly, individual facilities are achieving the FFBI goal of 66% prevalent arteriovenous fistula use; however, results vary across geographic regions and are not explained by patient demographic and clinical characteristics alone.

ESRD Network interventions as a function of the FFBI are associated with increasing arteriovenous fistula use and likely contributed to improvement, but improvement cannot be unequivocally attributed to the Networks due to lack of rigorous research design. Questions and opportunities remain. It is not yet clear how to identify patients who may not be appropriate candidates for an arteriovenous fistula. The ultimate impact of the FFBI on patient mortality is yet to be determined. The FFBI must continue to identify variations in use and the contributing causes, and implement strategies to address these causes if the FFBI goal is to be fully achieved.