IHI.org asked Lawrence Spergel, MD, FACS, about his work in the area of vascular access, and for his thoughts on what he'd like to see the website accomplish. Here is his reply.

Q:  What makes vascular access such an important issue for dialysis patients?

A:  First, end stage renal disease (ESRD) patients who are on hemodialysis need appropriate vascular access in order to connect their bloodstream to the dialysis machine that cleans their blood. It is truly their lifeline; without an adequate vascular access they cannot survive.  

Second, the population of patients with end stage renal disease has been growing rapidly. When I entered practice in the mid-1970s, there were fewer than 10,000 ESRD patients receiving hemodialysis. That number has increased to almost 300,000 patients today. In every community, there are patients whose lives depend on dialysis which, in turn, depends on well-functioning vascular access. This population will continue to grow because more and more of these patients are living longer. However, for hemodialysis patients to live long and productive lives, optimal vascular access and care are required.

Q:  With respect to vascular access, what is the gap between current practice and what we know to be best practice?

A:  Today, the best vascular access we can offer patients is a native arteriovenous fistula. This is where the patient's own vein is connected to an artery, instead of connecting a prosthetic tube (graft) to the artery or a plastic catheter into a vein. We now know that of all types of vascular access, fistulas are associated with the lowest failure and complication rates. 

In the United States, we have unfortunately gone in a different direction from our European and Japanese neighbors, in that we have predominantly used synthetic grafts and catheters for vascular access, while other countries have been using the native AV fistula in the majority of their patients. In the US, AV fistulas were widely used back in the 1960s and '70s. When the synthetic grafts became available in the mid-1970s, surgeons started to prefer them because they came in different sizes, were easy to place, and could be used almost immediately. However, we didn't realize all of the problems we would face over time with these artificial vessels and catheters. Now the medical community is faced with the challenge of reversing several decades' worth of medical practice and correcting this unfortunate practice pattern of excessive use of grafts and catheters. Although there are situations where a graft or catheter will be the appropriate vascular access for a given patient, the use of a graft or catheter should be avoided wherever an AV fistula is feasible. 

Q:  What is the "Fistula First" initiative?

A:  The purpose of the initiative is to ensure that every patient will have the best chance to receive a fistula as his or her vascular access - and to achieve and exceed the Kidney Disease Outcomes Quality Initiative Guidelines goal of AV fistula placement in 50 percent of incident (new) patients with the ultimate goal that 40 percent of prevalent (existing) patients will have a functioning fistula. The Fistula First initiative provides education, training, and resources to the medical professionals who care for dialysis patients to enable them to reach these goals. 

In medical circles, we have known for some time that we needed to tackle this challenging problem. What we've lacked is a way to provide not just information and guidelines, but actual strategies and the tools and resources needed to implement those strategies. Our aim is to help medical practitioners understand not just why it's so important to provide fistulas for patients, but how they can achieve this objective.

Through the Fistula First initiative, we can offer strategies, practices, algorithms, and protocols that have already worked in various settings. We can also connect interested practitioners to peers who have been successful in providing fistulas for their patients. This, to me, is the major goal of this website: to share collectively all of the experiences and best practices that have been identified by practitioners around the country and around the world.

Most practitioners want to do a better job, but they don't know where to obtain the necessary tools, resources, and assistance to get the job done. They face numerous barriers that, when added up, become overwhelming. We are seeking to make it easier by bringing everything we can to the practitioner's doorstep - in fact, not just to the doorstep but into the house and right to the computer.

Q:  What are the barriers to closing the gap between care as it is and care as it should be?

A:  Achieving these AV fistula goals for hemodialysis patients requires a multidisciplinary team effort, and there are barriers for each discipline involved in the patient's vascular access.

We have to make sure that primary care physicians are educated about how and when to respond when a patient starts to show signs of renal disease. The goal is to encourage primary care physicians to refer patients to nephrologists at an early stage of kidney disease. Timely referral plays an important role in being able to provide a patient with an AV fistula - to identify and preserve blood vessels suitable for an AV fistula, as well as to allow for the necessary time for the fistula to mature following surgery so that it will be ready for use when needed. 

Once the patient is in a nephrologist's care, it is the nephrologist's responsibility to assess the patient for vascular access and to make sure that the patient is promptly referred to a surgeon who knows how to provide, and actually will provide, the best vascular access for that patient - which, in most cases, will be a native AV fistula. The type and quality of the access will determine what kind of life the patient has and, in many cases, how long the patient survives. It is the nephrologist's responsibility to be proactive and involved, to learn about access, and to hold surgeons responsible and accountable for providing the best access and care for their patients.

Speaking as a surgeon, I can say that surgeons present a major barrier because most are not usually interested in vascular access surgery. Many surgical training programs do not include adequate training and education in hemodialysis vascular access, and continuing medical education programs rarely include this training either. However, surgeons performing vascular access procedures need to learn how to provide the best access for these patients, because when it comes down to it, the patient's life really depends on what the surgeon does. 

Many dialysis staff nurses and technicians present an additional barrier to AV fistula use. These staff are accustomed to using predominantly grafts and catheters, and often lack the proper cannulation training and other skills required to care for fistulas. Improper cannulation and management of fistulas can result in damage and loss of the fistula.

Another significant barrier in the United States is reimbursement. Fistula surgery, especially the more complicated, challenging procedures, are not reimbursed adequately considering the amount of time and effort involved in the surgery and preoperative care. In consideration of these factors, as well as in the inestimable benefits of AV fistulae for patients, efforts are underway to address and re-evaluate the reimbursement for AV fistula procedures. 

Q:  How do you envision the website accelerating improvement in this area?

A:  The Fistula First website can provide services and accessibility not otherwise possible using other educational tools. The website can reach out to the entire ESRD community, providing AV fistula-related resources, training and education to all practitioners, and interaction among practitioners. I envision the website as a wonderland of resources for practitioners seeking practical, helpful information.

For example, surgeons can obtain references and resources on specific surgery-related issues, problems and procedures, and can even view slide presentations on a number of topics. It is anticipated that the website will also provide interactive question-and-answer panels, and discussion groups where practitioners ask questions and have specialists in the same area provide feedback. This ability to interact on a real-time basis is ideal because it allows a cross-section of the entire world to provide education and resources for any problem or issue that comes up - and in a timely manner. 

We know that science and technology are always changing and always improving. I want to make sure that my clinical colleagues and I are constantly updating the site in our respective specialties.  My vision is that anyone going to the site for help - whether it's a nursing issue, a surgery issue, a radiology issue, or whatever  - is going to get the most current information and resources available to help them provide the best care and outcomes for our patients. After all, isn't that what is all about?