Medicare hopes to boost better option for dialysis

Initiative will seek help from primary care doctors to ensure that chronic kidney disease patients get timely referrals.

By Markian Hawryluk, amednews staff. May 17, 2004.

Washington -- Medicare is trying to fundamentally change the standard of care for patients with end-stage renal disease, and it is reaching out to primary care physicians and specialists for help.

The motivation for the initiative is both to improve the quality of patient care and to save Medicare money. The effort could have an enormous impact. About 270,000 Medicare beneficiaries currently receive dialysis treatment, and the number is expected to double by 2010. Because ESRD patients automatically qualify for Medicare, the program bears the brunt of dialysis costs.

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The plan, announced in April by the Centers for Medicare & Medicaid Services, focuses on the way doctors establish vascular access for dialysis patients. Most U.S. surgeons opt to use arteriovenous grafts or hemodialysis catheters, even though AV fistulas are typically a clinically superior method.

In the United Kingdom and Japan, where budgetary pressures forced physicians to turn to fistulas long ago, grafts are more the exception than the rule. But in the United States, fewer than a third of Medicare dialysis patients have an AV fistula.

The goal of the effort, called the Fistula First campaign, is use of fistulas in at least half of new dialysis patients.

"Fistulas are the gold standard for establishing access to a patient's circulatory system in order to provide life-sustaining dialysis," CMS Administrator Mark McClellan, MD, PhD, said in announcing the initiative. "They last longer, need less rework, and are associated with lower rates of infections, hospitalization and death for Medicare beneficiaries than other types of access."

270,000 Medicare beneficiaries receive dialysis treatment.

Fistulas also promise enormous savings. Using a graft instead of a fistula adds $4,500 in costs per patient per year. A catheter is $9,000 more expensive.

U.S. physicians have gotten used to using grafts because they were readily available in a variety of sizes and could be used within a couple of weeks, said the initiative's clinical chair, Lawrence Spergel, MD, who is a vascular surgeon from San Francisco.

Catheters are used when immediate access is needed.

Fistulas are created by joining a vein and an artery in the forearm. The high-pressure blood flow from the artery causes the vein to dilate and strengthen to a point where it can be punctured three times a week. But that process takes two to three months to mature.

"Everybody thinks it's somebody else's problem," Dr. Spergel said. "In order for the patient to get the optimum access, it requires timely referral so the surgeon can get it done, and have enough time for it to mature so it can be used before the patient needs dialysis."

Primary care has an essential role

That means primary care doctors must be able to identify those who may need the procedure in the future.

Dr. Spergel recommends that primary care physicians review the new guidelines from the National Kidney Foundation so that they can accurately identify the five stages of chronic kidney disease.

The number of Medicare beneficiaries requiring dialysis is expected to double by 2010.

"It is critical that we get out of the gate early with the patient that shows any evidence of chronic kidney disease," he said. "The primary care physician should be on the lookout in their diabetic patients and their hypertensive patients, and patients with a history of vascular disease, checking their blood, looking for any evidence of kidney disease."

Waiting until the patient reaches the fifth stage -- end-stage renal disease -- to refer to a nephrologist is too late, he said. Often the chronic kidney disease is so far along, the patient winds up in the emergency department, where doctors must opt for the quickest way to establish access to the bloodstream. As a result, patients get grafts or catheters.

CMS has contracted with the Institute for Healthcare Improvement to help its ESRD networks educate physicians and others on the clinical benefits of using fistulas, how to develop them in patients, and how to dialyze patients through fistulas.

"The CMS ESRD networks have historically worked with dialysis facilities to identify and remedy lapses in appropriate care for our dialysis beneficiaries," said Steve Jencks, MD, director of the agency's Quality Improvement Group. "But in this case, we need to involve caregivers outside of dialysis facilities, such as primary care physicians, nephrologists and vascular access surgeons, who play a major role in the timely placement of fistulas in eligible patients."

Proponents highlight models that have succeeded in increasing fistula use. One example they point to is Vo Nguyen, MD, a nephrologist from Olympia, Wash., who is now involved in the CMS effort. In 1996, he received a troubling letter from the Northwest Renal Network about the high rate of graft failure among ESRD patients.

Dr. Nguyen always had left vascular access decisions to the surgeons, and virtually all of his patients were dialyzed through grafts or catheters. Once the access was created, the surgeon's involvement with the patient generally ended -- until the graft failed. And when the surgeons complained of being dragged out of bed when the grafts thrombosed, Dr. Nguyen and his colleagues knew they had to do something.

Dr. Nguyen turned to local vascular surgeon Chris Griffith, MD. Together with other members of the dialysis team, the doctors came up with a strategy to shift from grafts to fistulas.

They opted for a multidisciplinary approach that relied on coordination of efforts between the primary care physician, the nephrologist and the vascular surgeon, as well as education of health professionals and patients. By 2001, the dialysis clinic had eliminated the use of AV grafts, except for patients who had transferred from other clinics with grafts in place.