A journey in reversing practice patterns: a multidisciplinary experience in implementing DOQI guidelines for vascular access

• Published in: Nephrology, dialysis, transplantation Vol. 20; no. 7; pp. 1450 - 1455
• Main Authors: Ackad, Alexandre, Simonian, Gregory T., Steel, Knight, Parisi, Christopher, Mancini, Sharon, Douglas, Claudia, Buckner, Darrell
• Format: Journal Article
• Language: English
• Published: Oxford Oxford University Press 01.07.2005; Oxford Publishing Limited (England)
• Subjects: Aged; Analysis. Health state; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Arteriovenous Anastomosis; Arteriovenous Shunt, Surgical - standards; Biological and medical sciences; Catheters, Indwelling; DOQI guidelines; Emergency and intensive care: renal failure. Dialysis management; Epidemiology; Female; General aspects; haemodialysis vascular access; Humans; Intensive care medicine; Kidney Failure, Chronic - therapy; Male; Medical sciences; Middle Aged; native arteriovenous fistulae; Practice Guidelines as Topic; practice pattern; Practice Patterns, Physicians' - standards; Program Evaluation; PTFE graft; Public health. Hygiene; Public health. Hygiene-occupational medicine; Renal Dialysis - standards; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; tunnelled haemodialysis catheter; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels; Kidney disease; Urinary system disease; PTFE graft; Hemodialysis; DOQI guidelines; practice pattern; Catheter; haemodialysis vascular access; Extrarenal dialysis; Renal failure; Graft; tunnelled haemodialysis catheter; native arteriovenous fistulae
• ISSN: 0931-0509; 1460-2385
• DOI: 10.1093/ndt/gfh818

Background. The National Kidney Foundation has established detailed guidelines due to increasing morbidity and costs related to haemodialysis vascular access in the end-stage renal disease population. Methods. A quality assurance multidisciplinary committee was formed to implement the Dialysis Outcome Quality Initiative (DOQI) guidelines in September, 1999. Beginning January 2000, a ‘Save the Vein Programme’ was implemented and native fistulae became the angioaccess of first choice for new patients. In addition, an effort was made to replace failed non-autogenous vascular accesses with autogenous fistulae. Shortly after, pre-operative evaluation of the vascular anatomy of the arm by Doppler ultrasound became the standard of care. The 1 year period prior to January 2000 was used for comparison. Results. Total fistula creation in the year 1999 was 48. In the first year after the Save the Vein Programme was begun, 77 new fistulae were created and 96 fistulae in the following year. Concurrently, 50 grafts were constructed in 1999; this number decreased to 46 in 2000 and to 15 in 2001. The percentage of functional fistulae in incident patients increased from 20 to 60% (P<0.001). Similarly, in prevalent patients, functional fistulae increased from 24 to 44% (P<0.004). For all patients, there was a reduction in the hospitalization rate from 98 to 79% (P<0.001) and of vascular-related admissions from 67 to 53%. Conclusion. A reversal in practice pattern from graft to fistulae creation was achieved by the successful implementation of DOQI guidelines. This also resulted in a reduction in morbidity.