Many kidney failure patients continue to receive critical dialysis treatments through catheters, a vein access method that is widely known to increase the risk of serious infections, blood clots and even death.
The best method (an arteriovenous fistula) is not always the first resort, despite more than 20 years of evidence and national best-practice campaigns encouraging its use. It's a problem some associate with poor access to care, misaligned reimbursement incentives and geographic disparities.
It's a “massive failure,” said Dr. Mahmoud Malas, associate professor of surgery at the Johns Hopkins School of Medicine. He co-authored a study released Wednesday identifying geographic disparities in meeting target rates for AV fistula use.
“It's both surprising and disappointing,” Malas said. “We know fistula use is associated with the best outcomes—but we're still not doing a good job. It makes me think there's something wrong with the system."
To live, patients whose kidneys stop working require dialysis—a process to filter toxins from their body—three times a week for several hours at a time. The toxins are filtered through a vein, which can be accessed using a graft, catheter or an AV fistula. The fistula, created in the patient's arm by surgically stitching an artery to a vein, is recognized as the highest standard of care.
However, of the 400,000 hemodialysis patients in the U.S., approximately 25% are dialyzing with catheters, according to estimates. Each hospitalization for catheter-related infections costs an average of $23,000. Reducing catheter use by half could yield $1 billion a year in Medicare savings, according to a 2011 article in the Journal of the American Society of Nephrology (PDF).
The CMS began publicly rating dialysis providers on quality with a five-star system rolled out earlier this year as part of ongoing efforts to boost transparency for consumers. AV fistula and catheter use are among 11 quality measures that are now publicly reported through the CMS's Dialysis Facility Compare site and contribute to the ratings.
About 98% of facilities receiving five-stars had at least half their patients on a fistula, compared with 57% of the one-star locations, a Modern Healthcare analysis of the federal data finds. Only about a third of five-star facilities achieved 8 of 10 patients on a fistula. No one-star facility reached that rate.
A national campaign called “Fistula First, Catheter Last,” encourages facilities to reach the target rate of 68% of patients on fistulas. That's still low compared with other countries, where as many as 9 out of 10 patients use them, according to the CMS.
But, “it seems the goal is within reach,” an agency spokesperson said in response to the Modern Healthcare analysis. “There is substantial room for improvement.”
Kidney-care providers, surgeons, nephrologists and others interviewed by Modern Healthcare, however, cite several barriers.
One is that low-income patients with limited access to primary care are less likely to have warning signs of kidney disease detected early. As a result, they “crash into dialysis,” meaning the window between learning they have kidney failure and the need to start dialysis is only a few days.
That's problematic because it takes six to eight weeks after surgery for a fistula to be ready to use. It only takes one day for a catheter. “Catheter is the last resort. But that's all people have sometimes—a last resort,” said Dr. Mark Leischner, medical director of the 16-station Fresenius Northcenter Dialysis Facility in Chicago, which received four stars on the CMS' rating system.
Once a patient has crashed in with a catheter, the quality goal is to switch them to a fistula within 90 days. But many said that process can be laborious. It can take more than the allotted time to get insurance approved and schedule appointments with surgeons whose rosters may be packed. Patients may also be resistant to undergoing another surgery and want to stick to the method they already have.
“It's a major challenge; 90 days is not enough,” said Dr. Kam Kalantar-Zadeh, chief of the division of nephrology and hypertension at the University of California at Irvine School of Medicine. He is also medical director of the university's dialysis facility, which got three stars on the recent CMS rating. “A center that has an 80% fistula rate really deserves a five-star rating,” he said.
Researchers have attempted to identify what factors determine which dialysis patients get the best care and which do not, and they emphasize that providers should learn from the places getting it right.
The JAMA surgery study this week co-authored by Malas found some geographic regions are doing better than others. The study looked at 464,547 patients who began hemodialysis between January 2006 and December 2010.
Regional differences in the use of fistulas first ranged from 11% to 22%, the study found. Of the 18 end-stage renal disease networks, fistula rates were highest in New England (Network 1) and the Pacific Northwest (Network 16). Their rates were double the amount of those in Florida (Network 7) and Texas (Network 14).
Not surprisingly there were similar differences among networks in terms of the distribution of quality performance on the CMS star ratings, a Modern Healthcare analysis shows. For example of 342 dialysis facilities in Florida, 174 (19%) received four and five stars while of 214 facilities in the Northern California network, 97 (45%) achieved those high marks. Modern Healthcare also previously noted marked differences among the nation's two largest dialysis providers.
Such differences are troubling to Malas, who says opportunities to reduce catheter overuse are being overlooked. His current research focuses on patient education, specifically using peer-to-peer methods. “One of the biggest problems is trust,” he said. In surveys of dialysis patients, he has found patients tend to trust other patients more than they trust the physician.
DaVita leaders in May told providers who scored low on the CMS' controversial rating system to “stop being sour grapes” and work on known methods to improve outcomes.
That sentiment was shared by Dr. Wootaek Chang, chief of the nephrology division at the Brooklyn Hospital Center in New York. One of the first things he noticed when he joined the staff more than 27 years ago was that at least 70% of the patients receiving treatments had catheters.
“This was no good,” said Chang, who recalls being surprised by the high rates. "We made a concerted effort,” he said, by working with vascular surgeons to evaluate all new patients and ensure every patient whose veins were good enough would have a fistula created.
Those efforts seem to have paid off. One of the hospital's dialysis facilities had five stars and the other four, and both had fistula use rates above 80%, despite high poverty rates in the community.
Chang has some concerns with Medicare's ratings methodology but is optimistic it will at least renew focus on catheter use.
“There's no doubt it will give motivation for facilities to do something,” he said. “The goal should be to do what is right for the patient.”