“Fistula First” as a CMS Breakthrough Initiative:
Improving Vascular Access Through Collaboration
Vickie J. Peters
Gina Clemons
Brady Augustine

Vickie J. Peters, MSN, MAEd, RN, CPHQ, is National Project Director, Fistula First. She was formerly the Quality Improvement Director, ESRD Network 18, Los Angeles, CA. She is a member of the Chumash Chapter of ANNA.

Gina Clemons, MHA, is Director, ESRD Program, Center for Medicare & Medicaid Services, Baltimore, MD.

Brady Augustine, MS, is Senior Quality Advisor, Center for Medicare & Medicaid Services, Baltimore, MD.

On March 17, 2005, the Centers for Medicare & Medicaid (CMS) officially announced the launch of its first formal “Breakthrough Initiative” on vascular access, “Fistula First.” It is the first of a series of collaborative CMS Breakthrough Initiatives targeting critical areas of opportunity for rapid health care improvements resulting in better health care for millions of Medicare beneficiaries and lower costs for the Medicare program. “Fistulas are the ‘gold standard’ for establishing access to a patient’s circulatory system in order to provide life-sustaining dialysis, with good reason,” stated CMS Administrator Mark McClellan, MD, PhD. “Now we’re going to work together to make them the standard of care for Medicare beneficiaries.”

Major Criteria
To qualify as a Breakthrough Initiative, a project must meet two major criteria: a) demonstrate a substantial gap between recognized good practice and actual practice, and b) provide a possibility of substantial improvement in performance. Many medical studies have documented the morbidity and mortality problems associated with catheters and grafts, forming the basis of the Kidney Disease Outcomes Quality Initiative (K-DOQI) recommendations for a prevalent arteriovenous fistula (AVF) rate of 40%. In December 2002, several regions of the country had AVF rates below 26%, opening the door to improvement opportunities.

This new initiative is actually building on work that has been going on through the ESRD Networks since early 2003. At that time, a multi-disciplinary team chaired by Dr. Lawrence Spergel and including representatives from CMS, the ESRD Networks, the Institute for Healthcare Improvement (IHI), and various renal stakeholder groups convened to develop a firm and broad understanding of the challenges and successes for arteriovenous fistula (AVF) placement within the dialysis and surgical communities. Based on this initial work, a formal set of improvement recommendations known as a “change package” was produced, consisting of 11 successful activities that health care practitioners can employ in their care settings to produce results. Based on the efforts by the ESRD Networks, large dialysis organizations, and many renal practitioners, the national rate of AVF had moved from 32.4% in December 2002 to 36.4% by September 2004. In recognition of this achievement, the CMS Administrator and the CMS Quality Council adopted Fistula First as the first agency-wide Breakthrough Initiative in November 2004.


CMS Strategies to Increase National AVF Rate

The outcome goal of the original ESRD Network-based Fistula First project was to meet the K-DOQI recommendation for a national AVF rate of 40% by June 2006. The new Breakthrough Initiative goal is to increase the national AVF rate to 66% by June 2009. To meet this challenge, CMS has adopted a series of multifaceted strategies designed to address many of the key issues identified by the renal community partners:

1.  Strengthen existing partnerships and create new partnerships with professional, patient, trade organizations, and other stakeholders, resulting in a coalition that can have a real impact on how clinical decisions are made. CMS recognized that the most critical component to make Fistula First a success is the partnership of the entire renal community in a collaborative environment. In November 2004 and March 2005, two renal stakeholder meetings were held to discuss key issues and potential barriers related to AVF outcomes. In response, a formal coalition was formed, and five Task Forces were set up to address the complex health care system and the myriad of issues surrounding successful AVF placement. Along with ANNA, other professional organizations such as the National Kidney Foundation, the American Association of Kidney Patients, the Medical Education Institute, Renal Physicians Association and the Society for Vascular Surgery have stepped forward to provide leadership for the five national Task Force groups.

2. Measure and track progress. As part of the ESRD Network Fistula First project, standard vascular access definitions and data collection forms/methods were compiled. A national database of computerized facility-specific data on vascular access types was developed as part of the CMS Standardized Information Management System (SIMS), and a real-time, Network-specific summary of the data “Dashboard” is posted monthly on a website. That data has provided the basis for tracking the significant results of the ESRD Network portion of the Fistula First initiative to date, and will continue to be monitored accordingly. As part of the Breakthrough Initiative, however, a task force on Quality Measurement and Information was convened to evaluate what other measures currently exist outside of Network and SIMS data, and what additional measures will be needed to supplement the Dashboard data as this initiative evolves. Examples include surgeon-specific AVF rates and Quality Improvement Organization (QIO) hospitalization data. Public information sites like the CMS “Dialysis Facilities Compare” website are being updated or developed to include information on AVF for patients and other interested parties.

3. Provide information and education to support care for renal failure patients who may be candidates for AVF placement. Education has played a major role in the success of the ESRD Network Fistula First project, through multiple cannulation training courses offered for nurses and technicians throughout the country, to a formal CD/DVD training series for surgeons focusing on different types of surgical techniques for AVF placement. In the expanded Breakthrough Initiative, a Clinical Practice task force began work to further market this educational tool to their professional community and to medical training programs. In addition, a Beneficiary Education task force and a Practitioner Education task force have begun work to review other educational resources for patients and caregivers, eventually expanding out to non-renal medical and health care professionals. Work is currently underway to produce a cannulation training program on CD/DVD similar to the surgical series, and patient education materials already in existence are being updated to reflect the new focus on AV fistulas. Marketing educational and informational exchanges with non-renal groups will also help expand the Fistula First initiative into the chronic kidney disease (CKD) arena.

4. Seek ways to align financial incentives with medical practice recommendations. One of the key issues brought up by both the ESRD Networks and the renal community as a whole involves the problem of catheters and grafts traditionally being reimbursed at higher rates than the recommended AV fistulae. As part of the Breakthrough Initiative, a task force on Program Operations (delivery systems) was formed to examine all aspects of payment, reimbursement, and policies that can be revised to support the Fistula First initiative throughout the health care system.

Conclusion
The level of interest and cooperation so far among and between the various stakeholders and task forces connected with this initiative has been outstanding. Considerable work needs to be done to meet the ambitious new goal of a 66% AVF rate by 2009. As part of its internal quality improvement plan, CMS will announce additional Breakthrough Initiatives in the future, but Fistula First has paved the way and provided a collaborative model for these other initiatives.

References/Readings
Centers for Medicare & Medicaid Services. (2004, November). Fistula First, questions and answers. Handout material from Renal Stakeholder’s Meeting, Baltimore, MD.

Centers for Medicare & Medicaid Services. (2005). CMS launches breakthrough initiative for major improvement in care for kidney patients, Press release. Office of Media Affairs.

McClellan, M. (2005, March). The Fistula First breakthrough initiative. Presentation at CMS/ESRD Network Forum Meeting, Baltimore, MD.