Table 6.

Barriers to achieving KDOQI AV fistula targetsa

ProblemIssue
Inadequate pre-ESRD careA nephrologist often sees ESRD patients for the first time immediately before initiating long-term dialysis (29). In these cases, a PTFE graft often is constructed to avoid the 4- to 6-mo maturation time required for an AV fistula. Central venous catheter is the first mode of access for 61% of US ESRD patients compared with 15% for AV fistulas (30). The Medicare ESRD program currently lacks a formal coverage and reimbursement approach to promote pre-ESRD medical management and preventive services among people who are not already Medicare beneficiaries (31).
Relatively few surgeons perform the AV fistula procedureThere is a scarcity of surgeons in the United States with proficiency in constructing AV fistulas, resulting in shortage of capacity to establish this mode of access.
Reimbursement for the AV fistula procedure is relatively lowConstruction of an AV fistula is more technically challenging than other access modalities and reimbursement is lower. Medicare-allowable payment for the placement of PTFE graft in 2005 was 25% greater than reimbursement for AV fistula ($610 for CPT 36821).
Diagnostic imaging is not used adequately to construct AV fistulaKDOQI guidelines call for preoperative imaging to assess appropriateness of AV fistula and facilitate construction. Preoperative imaging involves use of Doppler ultrasound or low-concentration contrast that allows for venous mapping. Use of preoperative imaging carries the potential to increase rates of AV fistula construction as surgeons are able to gain a better understanding of the patient’s vasculature before surgery (32).
Surveillance of established AV fistula is spotty, leading to higher than necessary rates of failurePayment for surveillance is bundled as a component of the composite reimbursement for hemodialysis. Only one manufacturer (Fresenius Medical Care) makes vascular access flow monitoring available as part of routine hemodialysis therapy. For the majority of patients, flow surveillance will be performed only if the cost is absorbed by the provider.
  • a AV, arteriovenous; KDOQI, Kidney Disease Outcomes Quality Initiative.