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A multidisciplinary approach to hemodialysis access: prospective evaluation
1Department of Radiology, University of Alabama at Birmingham, USA. mallon@nrtc.dom.uab.edu
Insights
A multidisciplinary team improved hemodialysis access by reducing complications and hospitalizations. This approach enhanced graft declot success, decreased surgical issues, and increased fistula use, leading to significant cost savings.
Area of Science:
- Nephrology
- Vascular Surgery
- Radiology
Background:
- Dialysis access complications cause significant morbidity, hospitalization, and costs in chronic dialysis patients.
- Current approaches to hemodialysis access require optimization for better patient outcomes and reduced healthcare expenditure.
Purpose of the Study:
- To evaluate the impact of an integrated multidisciplinary approach on hemodialysis access outcomes and costs.
- To improve the management of vascular access for hemodialysis patients through collaborative care.
Main Methods:
- Implementation of a multidisciplinary team including nephrologists, access surgeons, and radiologists.
- Establishment of a dedicated dialysis access coordinator and a computerized database for outcome tracking.
- Periodic confidential analyses and recommendations provided to surgical and radiology teams.
Main Results:
- Increased immediate technical success rate for graft declots from 48% to 69%.
- Shifted elective arteriovenous (A-V) graft placement from inpatient to outpatient procedures, increasing same-day/outpatient placement from 16% to 81%.
- Reduced surgical complications of new A-V graft surgery from 25% to 11% and decreased graft thrombosis incidence by 60%.
- Increased the proportion of native A-V fistula construction from 33% to 69% for new dialysis patients.
Conclusions:
- An integrated multidisciplinary approach significantly reduced surgical complications and access failures in hemodialysis patients.
- The improved outcomes were achieved despite reduced hospitalizations for access procedures, resulting in substantial cost savings.
- This collaborative model enhances patient care and optimizes resource utilization in hemodialysis vascular access management.
Abstract:
Dialysis access procedures and complications represent a major cause of morbidity, hospitalization and cost for chronic dialysis patients. To improve outcomes and reduce the cost of hemodialysis access procedures we developed a multidisciplinary approach, involving nephrologists, access surgeons, and radiologists. A full-time dialysis access coordinator scheduled all access procedures with the surgeons and radiologists, and tracked outcomes. A computerized database was developed for prospective documentation of procedures and complications. Confidential, detailed analyses and recommendations for improvements were provided periodically to the surgeons and radiologists. The major changes arising from the multidisciplinary approach were as follows: (1) The approach to clotted grafts evolved from an inpatient surgical procedure to an outpatient radiologic procedure. The immediate technical success rate of graft declots increased from 48% to 69%. (2) Elective placement of arteriovenous (A-V) grafts evolved from a three-day inpatient hospitalization to a largely outpatient procedure. The proportion of A-V grafts placed as same day surgery or outpatient surgery increased from 16% to 81%. (3) Surgical complications of new A-V graft surgery decreased from 25% to 11%. (4) Aggressive detection and correction of graft stenosis decreased the incidence of graft thrombosis by 60%, from 0.70 to 0.28 events per patient-year. (5) The proportion of native A-V fistula construction in new dialysis patients increased from 33% to 69%. In conclusion, an integrated multidisciplinary approach markedly reduced surgical complications of access surgery and decreased access failures. These improvements occurred despite a marked decrease in hospitalization for access procedures, with a substantial cost saving.