PC142. Quality Review of Veterans Administration Dialysis Access

Abstract

Hemodialysis is the primary mode of renal replacement therapy for patients with end-stage renal disease. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative, specifically the “Fistula First Catheter Last” initiative, has improved dialysis access outcomes by advocating for arteriovenous fistula (AVF) placement for primary access in >68% of end-stage renal disease patients while reducing the percentage of patients with catheter-dependent dialysis >90 days to < 10%. To identify trends in dialysis quality end points for the Veterans Health Administration, we reviewed the Department of Veterans Affairs (VA) Dialysis Dashboard data for 2017-2018. We retrospectively analyzed the VA Dialysis Dashboard data from January 2017 through October 2018. Average percentage of patients with catheters >90 days and those with AVF for primary access were assessed across all 18 Veterans Integrated Service Networks (VISNs). Averages were calculated within each VISN, and then a weighted average was calculated for the VISN overall. VA-sponsored freestanding dialysis centers were also evaluated separately as a group. In 2017, VISNs 1 and 19 met Fistula First Catheter Last benchmarks of 68% or greater for AVF access, with VISN 1 also achieving the mark in 2018. VISN 20 met the catheter benchmark in 2017. None of the VISNs met the catheter benchmark in 2018. Ten freestanding VA-sponsored dialysis clinics overall had better compliance rates than the hospital-based dialysis centers. Performance within a VISN varied widely. Our home institution’s catheter rates decreased from 16% in 2017 to 11% in 2018 in part because of a concerted multidisciplinary approach to dialysis access. Developing a goal-oriented team is critical to expedite permanent access placement to meet or to exceed national guidelines and to ensure quality care. Our team includes a vascular surgeon, nephrologist, interventional radiologist, and anesthesiologist, all of whom collaborate to optimize patient care and outcomes. Further analysis of VISN data may identify other modifiable factors that could improve outcomes for dialysis patients.