Root causes of low AVF rates

Taken from the CMS QIP template for Increasing AVFs in Hemodialysis Patients

	Root Cause	Potential to change
Patient Factors
Awareness/ knowledge	· Lack awareness of long-term risks of catheters as opposed to fistulas · Lack awareness of benefit of fistulas compared with grafts	Yes Yes
Physical factors that make a fistula more challenging or difficult**	· Obesity · Diabetes · Other disease affecting vasculature (e.g. scleroderma) · Vascular abnormalities that predispose to steal syndrome · Smoking · Long-term steroid use^d · History of or active drug abuse · Medical instability · Hypotension, severe cardiomyopathy with poor cardiac output that precludes keeping a fistula patent. · Recent bacteremia or other infection causing deferral of any surgical procedure* · Suitable veins (especially superficial veins) thrombosed or stenosed by years of IVs and lab draws^d · Prior failed accesses, especially grafts, which may be associated with venous damage above the graft · Repeated catheter failures (infections, poor flows, bad dialysis) that make a working arm access more urgent, thus increasing the likelihood that a graft will be placed which has a shorter maturation^d	No No No No No No No No No No No No Yes/No
Communication/ Education	· Failure to inform healthcare professionals of pre-ESRD or ESRD status	Yes
Social	· Patient misses surgery appointments out of fear, lack of support (e.g. transportation)* · No insurance*	Yes No
Other	· Preference for catheters since catheters do not require a “stick” · Preference for grafts because they are easier to stick than fistulas · Reluctance to self-cannulate · Plan for transplant (scheduled or hopeful) soon. · Plan for peritoneal dialysis · Prior bad experiences · Fear of pain, including pain of needlesticks, surgery, etc. · Unsightly body image · Patient complacency	Yes Yes Yes Yes Yes Yes Yes No Yes
Nephrologist Factors
General	· Total reliance on surgeon decision. · Failure to act as Vascular Access Team Coordinator (includes making recommendations to vascular surgeon, assisting in vein preservation and mapping, and working closely with HD unit staff to assure knowledge and skills re: access and cannulation) · Late referral to surgery for access placement · Sense of urgency to have a working arm access · Waiting for completion of transplant evaluation before making access plans*	Yes Yes Yes Yes Yes
Awareness/ knowledge	· Lack awareness that placement of catheters at certain sites may limit future access options · Lack of valid information about the benefit of AV fistulas in the long-term · Failure to recognize that peritoneal dialysis (PD) may be used while awaiting AVF · Failure to recognize the value of PD as an alternative to HD · Lack of awareness that even patients awaiting transplant and patients undergoing PD may need access placement	Yes Yes Yes Yes Yes
Communication/ Education	· Failure to communicate to the surgeon their preference to have an AVF placed · Failure to educate patients re: vascular access options, protecting potential access sites (e.g. no IV lines and no blood draws from non-dominant arm in patients with impending renal failure).	Yes Yes
Training/experience	· Lack of training re: vascular access (residency-based or postgraduate CME)	Yes
Facility Factors
Awareness/ knowledge	· Lack awareness of long-term risks of catheters as opposed to fistulas · Lack awareness of benefit of fistulas compared with grafts · Lack awareness that episodes of hypotension need to be avoided, especially in patients with fresh or immature fistulas	Yes Yes Yes
Communication/ Education	· Inadequate communication between facility and nephrologist, surgeon, radiologist	Yes
Training/experience	· Techs and nurses may lack adequate training/experience in accessing fistulas and grafts (including the rotation of needle sites), development of immature fistulas, preservation of fistulas, and maintenance of fistulas leading to premature access failure and patient fear or reluctance · Staff preference for grafts because they are easier to cannulate than fistulas, thus requiring less time to initiate a dialysis treatment · Impatience with the slow-to-develop fistula	Yes Yes Yes
Administrative	· Lack of and/or failure to use a Quality Improvement program to monitor vascular access · Lack of and/or failure to use a stenosis monitoring program · Lack of and/or failure to use protocols for fistula development, preservation, and maintenance; clamp management; and dressing management · Lack of and/or failure to use protocols for management of new or fragile fistulas (e.g. rest the fistula following infiltration) · Lack of and/or failure to use protocols for tunneled catheter management, such that failing or infected catheters lead to more urgent permanent access placement · Lack of and/or failure to use an educational program to instruct patients about post-op care, signs and symptoms of problems, etc · Lack of and/or failure to use a policy to request/demand/receive surgical reports regarding access placements and revisions. · Lack of support for self-cannulation	Yes Yes Yes Yes Yes Yes Yes Yes
Other facility factors	· Inadequate dialysis related to facility factors may increase the urgency for a working arm access, thus increasing the likelihood that a graft will be placed which has a shorter maturation · Lack of flexibility in patient scheduling making it difficult to accommodate patients who desire to self-cannulate and patients who require longer for staff to cannulate	Yes Yes

Vascular Surgeon Factors
Awareness/ knowledge	· Misconception that the need to dialyze immediately (or very soon) requires that a graft be placed. · Belief that a patient’s lifespan is so limited that a successful graft will be more useful and less problematic than a fistula that may develop slowly ^14 · Belief that sonography is not helpful for mapping vasculature prior to access placement · Lack of recognition of the requirements for success, e.g., fistula lengths must be adequate for cannulation, minimum blood flows that are necessary for dialysis must be achievable (not just a dopplerable blood flow), positions need to allow for appropriate needle placement during dialysis, etc. · Failure to recognize importance of Vascular Access Team and surgeon’s and nephrologist’s roles on it. · Failure to recognize the importance of routinely providing a dialysis unit with the operative report for access placements and revisions	Yes Yes Yes Yes Yes Yes
Communication/ Education	· Failure to educate the patient on post-op care and monitoring of a fistula · Failure to provide the patient with a pictorial description of the access for their own records, and for sharing with other care providers	Yes Yes
Training/experience	· Lack of training re: AVFs (includes mapping and surgical techniques). Surgical training programs place little emphasis on vascular access approaches, techniques and troubleshooting, especially for the more complicated procedures · Graft is technically less difficult than a brachial cephalic or transposition fistula · Lack of experience with placement of tunneled cuffed catheters or PD for short-term use while a fistula is maturing such that a graft is placed instead, especially if the surgeon has a perceived sense of urgency to have an arm access in place. · Surgeon may lack the patience, training, or commitment to manage the fistula that is not maturing properly—may be quick to convert to a graft if a fistula is not maturing quickly or they are experiencing difficulties with it.	Yes No Yes Yes
Business	· Lack of tools &/or reimbursement to fully assess patients as to whether or not they are suitable candidates for AVFs (e.g. sonography units not available, not funded, or lack expertise related to mapping). · Lack of surgeons that are interested in access, lack of O.R. availability – some excellent vascular surgeons choose not to do access work · Access work is seen as cumbersome due to the complicated patient population involved. The surgical procedure itself may not take long, but getting medication lists, problem lists, H&P, other necessary steps in getting to the OR takes a lot of extra time. · Reimbursement by Medicare for placement of a graft is higher than the reimbursement for fistula placement.	No No No No
Social	· Surgeons may prefer grafts due to their shorter maturation period which allows them to complete the “episode of care” for a difficult, challenging patient more quickly (i.e. they do not have to continue to care for the patient as long). · Unlike transplant surgeons, access surgeons get little or no recognition from patients or colleagues for great access results.