Increasing the placement of native veins arteriovenous fistulae: the role of access surgeons' education and profiling

Background: The utilization of native veins arteriovenous (AV) fistulae in the US remains low despite their superiority over other types of hemodialysis access. Methods: A nephrologist-driven, quality improvement project that concentrated on access surgeons was utilized to increase fistulae placement. Period I of the project (1998 - 2000) entailed surgeons' education about advantages of fistulae and methods to increase their placement. During period II (2001 - 2002),referral patterns to surgeons were altered according to their performance, and surgeons out of the area were utilized. Data on patient characteristics, type of access placed and access complications were measured. Results: Fistulae constituted 45% of AV access placed in period I and 79% of those placed in period II. Fistulae prevalence, which was 15% at the end of the pre-project period, increased to 27% at the end of period I and 49% at the end of period II. All changes were statistically significant. Complication rates did not increase. Fistulae placement by surgeons operating in both periods increased in period II. The distribution of types of access placed and outcomes differed significantly among surgeons. Conclusions: Fistulae placement could be increased when the nephrologist works with access surgeons and monitors their performance. Profiling of access surgeons by policy-makers could be a useful method for the identification of surgeons with better skill.