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The Centers for Medicare & Medicaid Services (CMS), the ESRD Networks, the Institute for Healthcare Improvement (IHI), and the kidney community joined together in a partnership in launching the National Vascular Access Improvement Initiative (NVAII) in 2003. Based on this early work, a Fistula First Change Package (see below), a set of improvement recommendations and tools was developed and is available for download. In March of 2005, CMS formally expanded its commitment by elevating the initiative into the Agency's first breakthrough initiative, "Fistula First."The purpose of the initiative is to increase the use of fistulas when Medicare beneficiaries with kidney failure require hemodialysis. Kidney failure is also known as end-stage renal disease (ESRD). Hemodialysis is the most common treatment for ESRD. About 330,000 Medicare beneficiaries currently receive this treatment. During hemodialysis, tubes are used to carry the blood between the body and the dialysis machine. This requires the patient to have an access to the bloodstream. For most patients the best access is a fistula. An arteriovenous (AV) fistula is the surgical joining of a vein and an artery usually in the forearm in order to provide an access for dialysis. Fistulas are considered to be the "gold standard" for establishing access to a patient's circulatory system. Fistulas last longer, need less rework or repairs, and are associated with lower rates of infections, hospitalization, and death. The goal of the Fistula First Breakthrough Initiative is to increase the use of fistulas which is one of the objectives of the Department of Health and Human Services' Healthy People 2010. The current goal is to have fistulas placed in at least half of all new hemodialysis patients and to have a minimum of 66 percent of all existing patients who continue dialysis to use a fistula. At the end of 2005, 41 percent of prevalent patients on hemodialysis were dialyzed with a fistula, a 24% improvement from the 33% rate in 2003. This translates into improved and extended lives for thousands of people who suffer from kidney disease. Eventually, CMS would like to improve fistula use rates to levels seen in Europe and Asia, on average 70% and 80% respectively. The Breakthrough Initiative has convened a broad renal coalition, the Fistula First Coalition, to ensure that many more hemodialysis patients have the opportunity to receive a fistula. This renal coalition includes the CMS ESRD Network program providing technical assistance, dialysis providers, primary care physicians, nephrologists, vascular access surgeons, interventional radiologists/nephrologists, professional societies, quality improvement organizations, networks, and patient advocacy groups. This Coalition is spreading the word and developing a firm and broad understanding of the challenges and successes for fistula placement within the dialysis and surgical communities. It has employed task forces, training packages, marketing, position papers, and a dedicated webpage for the initiative. Although progress is being made, there is room for improvement. In order to increase the chance we reach the stretch goal of 66%, CMS has included an expectation in the ESRD Networks Scope of Work starting in July 2006 that there must be a reduction in the "quality deficit", that is, the difference between where we are and where we want to be, by 20% each year for the next 5 years. To further support the Initiative, CMS has taken or is interested in taking various actions which can improve the appropriate use of fistulas, including: - aligning payment systems with improved patient outcomes through two demonstration projects that incentivise the appropriate use of fistulas for ESRD beneficiaries.
- Updating the ESRD facility Conditions for Coverage. CMS is currently reviewing comments on a proposed rule and the Agency is required to publish a corresponding final rule by February 2008.
- Evaluating and introducing payment codes to support the appropriate use of fistulas. In January 2005, based on input from the kidney community, CMS implemented new procedure codes for vessel mapping and fistula transposition procedures.
Through collaboration with our kidney partners, the Coalition continues to grow in membership and further positive achievements are expected because of this. We can be proud of the successes while we acknowledge and work together to address the challenges.
Page Last Modified: 02/12/2009 7:53:54 AM
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