The Dialysis Outcome Quality Initiative (DOQI):A Regional Update On Arteriovenous Fistula Prevalence

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Britt H. Tonnessen, MD¹, Jamie L. Ross, M.D.¹, Linda Duval, RN, BSN², Niloufar Hedrick, MS², Patricia Philliber, M.D.², W. Charles Sternbergh, III, M.D.¹, Samuel R. Money, M.D.¹.
¹Ochsner Clinic Foundation, New Orleans, LA, USA, ²End Stage Renal Disease Network 13, Oklahoma City, OK, USA.

Background: Maximizing arteriovenous fistula (AVF) placement and utilization in hemodialysis (HD) patients should be a priority for access surgeons and nephrologists. DOQI guidelines emphasize a target minimum 40% AVF utilization in the prevalent HD community. AVFs are the preferred mode of HD due to better long-term patency and lower infection rates compared to catheters or arteriovenous grafts.
Methods: The 2003-2006 “Fistula First” National Vascular Access Improvement Initiative has specific goals to increase AVF placement and utilization. Network 13 collects facility-specific data on modes of HD from Arkansas, Louisiana, and Oklahoma. Data over 3 month periods from 10/03-6/04 were averaged and analyzed by parametric and non-parametric statistics.
Results: Examining nearly 12,000 HD patients, the overall prevalence of AVF utilization was 28.2%. A 2.3% increase in AVF prevalence over this period was statistically significant (27.2% to 29.5%; p<0.0001). The prevalence of catheter utilization during this period was 29.7% (DOQI target <10%). 13.6%-18.5% (n=33-45) of dialysis facilities achieved greater than 40% AVFs. To assess the effect of facility size on AVF prevalence, 243 dialysis facilities were divided into quartiles based on number of HD patients (median=73.5). The first, second, third, and fourth quartiles contained 96, 104, 35, and 8 dialysis facilities, respectively. The largest facilities (fourth quartile, >110 patients) had a higher prevalence of AVF usage (40.7%, p<0.001) compared to the first (26.4%), second (27.1%), and third (27.1%) quartiles. Evaluating the effect of time, AVF utilization increased significantly over the 9-month period in the first (2.3%, p<0.04), second (2.1%, p<0.005), and third quartiles (3.1%, p<0.001). In the fourth quartile, there was a slight but not significant increase of 1.8% in AVF utilization over time (p= 0.67).
Conclusions: The strikingly low prevalence of AVFs and high rate of catheter usage among the majority of dialysis centers in our region is cause for concern. Although larger centers fared better overall, facilities below the 75^th percentile by size did demonstrate modest increases in AVF usage over time. Hopefully, the trend of increased AVF usage will continue and DOQI guidelines will be reached.