According to the 2013 annual data report from the United States Renal Data System, the use of catheters is the largest risk factor for infections among hemodialysis patients, and infection rates have increased 43% since 1993. The report also notes that this strong association between the use of catheters and the rate of infections among dialysis patients is well known within the dialysis community.
Of course this association has been addressed by policy makers, and is the reason for the launch of the Fistula First Breakthrough initiative in 2003. And the initiative successfully increased the prevalence of arteriovenous fistulas in hemodialysis patients from 32% to 60%. But the use of central venous catheters in the first 90 days of dialysis initiation remains high, as do the infection rates in the same time period.
Shifting to catheter last
This dilemma is the subject of NN&I's latest article on the CMO Initiative. "The overall consensus is that, though the continued emphasis for improving fistula rates where clinically appropriate should be maintained, we advocate that the primary drive should be toward reduction of chronic CVC use, namely 'Catheter Last,'" the authors wrote.
According to the article, there are several barriers that lead to the overuse of catheters among dialysis patients, including the following:
1) Inadequate care of patients during CKD stages 3-5, not allowing early placement of permanent vascular access;
2) Patient resistance and denial;
3) Inadequate surgical results. Choosing surgeons without consideration of performance or accountability for outcomes;
4) Acute starts for dialysis therapies; and
5) Insufficient attention by nephrologists in demanding better permanent access placement prior to dialysis initiation.
So how does the dialysis community overcome these barriers? According to the authors, the first step is to create industry-wide methodology for reporting vascular access performance.
"In order to attack any clinical problem, including the overuse of catheters, it is essential that accurate data are available in order to understand current practice and to track the impact of any quality improvements initiatives," wrote DaVita CMO Allen R. Nissenson, MD, FACP in an accompanying editorial. "The CMO group unanimously agreed that defining key aspects of performance with development of associated performance measures was a necessary first step in driving improvements in this key area of patient care."
Read more recommendations for lowering catheter rates among hemodialysis patients from the CMO Initiative in the article "Vascular access in dialysis patients: improving outcomes."