Re-envisioning Fistula First in a patient-centered culture

Amanda Gomes, Rebecca Schmidt, Jay Wish
Clinical Journal of the American Society of Nephrology: CJASN 2013, 8 (10): 1791-7
The main options for vascular access in hemodialysis patients are arteriovenous fistulas (AVFs), arteriovenous grafts, and tunneled cuffed central venous catheters. AVFs have the lowest complication rate and require the fewest interventions and lowest cost to maintain. There has been a dramatic national increase in prevalent AVFs among patients with ESRD in the United States driven, in part, by the Fistula First Breakthrough Initiative. The Fistula First Breakthrough Initiative has engaged stakeholders in the dialysis community to disseminate best practices and quality improvement activities to increase AVF prevalence in suitable candidates. In the pursuit of maximizing AVF placement and prevalence, less emphasis has been placed on the individual patient context. An AVF may not be the best access choice in a subset of patients, particularly those with poor long-term prognoses or comorbid chronic diseases with a short life expectancy, those patients more likely to die than to have their CKD progress to ESRD requiring dialysis, and those with vascular anatomy not amenable to successful AVF placement. Placement of an AVF in these patients subjects them to uncomfortable and likely unnecessary and/or unsuccessful surgeries at an expense, while doing little to improve their clinical outcome or their individual experience of care. AVF prevalence as a pay-for-performance measure without the appropriate case-mix adjustment may penalize providers for accepting higher-risk patients. Although a functioning AVF that provides reliable hemodialysis remains the gold standard for vascular access for most patients, it may not be the most suitable option for every patient.

Full Text Links

Find Full Text Links for this Article


You are not logged in. Sign Up or Log In to join the discussion.

Related Papers

Remove bar
Read by QxMD icon Read

Save your favorite articles in one place with a free QxMD account.


Search Tips

Use Boolean operators: AND/OR

diabetic AND foot
diabetes OR diabetic

Exclude a word using the 'minus' sign

Virchow -triad

Use Parentheses

water AND (cup OR glass)

Add an asterisk (*) at end of a word to include word stems

Neuro* will search for Neurology, Neuroscientist, Neurological, and so on

Use quotes to search for an exact phrase

"primary prevention of cancer"
(heart or cardiac or cardio*) AND arrest -"American Heart Association"

We want to hear from doctors like you!

Take a second to answer a survey question.