1. Fistula First A Seminar for The Nephrology Community Corpus Christi, Texas July 31, 2004 Alamo City & Heart of Texas Chapters of The American Nephrology Nurses Association Co Provided By:

2. Agenda Noon Welcome & Introductions: Alan Saltarelli, RN, ANNA Alamo City Chapter -President Balbi Godwin, RN, ANNA Heart of Texas Chapter -President 12:15 Fistula First Overview: Alex Rosenblum, RN, CNN 12:45 Vascular Access Surgery 101: Pho DO, MD {Supported with a unrestricted educational grant from Bard } 1:30 Interventional Techniques 101: Anwar Gerges, MD {Supported with a unrestricted educational grant from Cordis } 2:15 Break/Exhibits 2:45 The ABCs of AV Fistulas: Janet Holland, RN, CNN 4:00 Nurse to Nurse: Moderators-Janet Holland, Alex Rosenblum &Bobbie Knotek A special opportunity to listen, learn and ask questions of nurses from facilities who have met the Fistula First Goals of attaining 40% + AVF rates at their dialysis facility. 4:45 Adjourn

3. Goals of Today’s Conference Expand awareness of the Centers for Medicare & Medicaid Services sponsored Fistula First Quality Improvement Initiative. Review advanced surgical/endovascular techniques for placement and/or rescue of the AVF. Share practice experiences that appear to positively impact of AVF placement and patency rates. Empower participants to have confidence that they can & do play an active role in meeting project goals. Reminder: Fistula First Resources in the Back of the Room

4. What are the ESRD Networks? 18 regional agencies under contract with the Centers for Medicare & Medicaid Services Developed in 1978 to assess/improve quality of care for ESRD patients

5. Who does the ESRD Network of Texas serve? Quality Improvement Information Management Consumer Services 26,397 patients (2/2004)  24,254 In-Center HD patients  84 Home HD patients  2,055 PD patients  ~ 7,000 Transplant patients

6. Nephrologists Robert Hootkins, MD, Chair Jim Cotton, MD Stuart Goldstein, MD Denise Hart, MD Donald Molony, MD Fernando Raudales, MD Mouin Seikaly, MD Ruben Velez, MD Patients Cynthia Hays Transplant Surgeons Ingemar Davidson, MD Charles Van Buren, MD Executive Committee Richard Gibney, MD, Chair Dionicio Alvarez, MD John Bell, MD Pat Dubose, RN Amy Hackney, MBA Robert Hootkins, MD Melvin Laski, MD Marlon Levy, MD Susan Raulie, RN Nurses Molly Itty, RN, CNN Jeanne Nishioka, RN, CNN Dietitians Alice Chan, RD, LD Eileen Mauk, PhD Social Workers Mary Beth Callahan, LMSW Linda Schacht, LMSW Medical Review Board End Stage Renal Disease Network of Texas Committees

7. Project Surgical/Interventional Radiology Advisory Committee  Gerald Beathard, MD  Mary Brandt, MD  Ronald Blumoff, MD  Ingemar Davidson, MD  Hector Diaz-Luna, MD  Greg Jaffers, MD  Edward Gomez, MD  Cary Munschauer  George Nassar, MD  Greg Pearl, MD  Eric Peden, MD  Wade Rosenberg, MD  Stephen Settle, MD  Michael Silva, MD Alan Lumsden, MD, Chair

8. Fewer infectious complications:  AVFs: 4.4 - 12 x less infection rates than AVGs Fewer interventional procedures to keep patency:  AVFs: 2.4 - 7.1 x less salvage procedures than AVGs Better 1 year primary patency in incident HD patients:  68% for AVFs & 49% for AVGs Allon and Robbin. Kidney Int. 62:1109-1124, 2002. Nassar and Ayus. Kidney Int. 60:1-13, 2001. Pisoni RL, et al. Kidney Int. 61:305-316, 2002. Why is CMS Focusing on Hemodialysis Vascular Access? Quality of Care/Public Health Concerns:

9. Why is CMS Focusing on Hemodialysis Vascular Access? Cost Containment: Estimated costs for VA related complications = $1-2 billion (~8k per patient) 200-250K procedures per year 20% of hospitalizations related to VA dysfunction ESRD = ~0.5% of Medicare population & 5% of budget Doubling of dialysis population by 2010 (50k in Texas) VA Practice variations: AVF variation between states, Networks and countries (80% AVF in Europe/Asia)

10. Why only AV Fistulas? Message for the Surgeon - By a Surgeon Why only AV Fistulas? You should do this because: Patients with AVFs live longer Patients with AVFs have 8x fewer access complications You will like: High patient and nephrologist satisfaction Simple, safe outpatient procedures Avoid or markedly decrease hospital admissions and emergency operations for infection, bleeding, steal syndrome, and thrombosis. William Jennings, MD, Tulsa Vascular Access Surgeon

11. What Do We Know About Hemodialysis Vascular Access Utilization in the US?

12. Percent of Prevalent Patients with AV Fistula As of Feb 2004 CMS FF Dashboard

13. What Do We Know About Hemodialysis Vascular Access Utilization in the World?

14. Top 10 City AVF Prevalent Rates As of April 2004 New York 44% Los Angeles41% ChicagoNR Houston25.7% Philadelphia28.5% Phoenix37.5% San Diego39.1% San Antonio22.1% Dallas 36.9% Detroit18% Data Source: Network #14 Data base collected informally from regional ESRD Networks

15. AVF Utilization Among Prevalent HD Patients By Country As of Sept. 2003

16. AVF Utilization Among Incident HD Patients By Country As of Sept. 2003

17. What Do We Know About Hemodialysis Vascular Access Utilization in Texas?

18. Vascular Access Utilization Texas Prevalence Trends: December 2000-May 2004

19. Percent Fistula Utilization By County as of March 2004

20. Percent Fistula Utilization By City as of March 2004 Cities with less than 80 patients excluded

23. Suggested Strategies to Increase AVF Rates

24. Fistula First Change Concepts 1.Routine CQI review of vascular access 2.Early referral to nephrologist 3.Early referral to surgeon for “AVF only” 4.Surgeon selection 5.Full range of appropriate surgical approaches 6.Secondary AVFs in AVG patients 7.AVF placement in catheter patients 8.Cannulation training 9.Monitoring and surveillance 10.Continuing education: staff and patient 11.Outcomes feedback Please refer to handouts

26. Welcome to the ESRD Network of Texas Inc. (#14) Website. Mission: Support quality dialysis and kidney transplant healthcare through patient services, education, quality improvement and data exchange. www.esrdnetwork.org The ESRD Network of Texas Web Site

27. ESRD Network Web Resources Fistula First Video and CEU form Hemodialysis Access Referral Form To Surgery/Radiology Procedure Report Form From Radiology/Surgeon to Dialysis Clinic Recommended AVF Cannulation Recommended Protocol Use of Clamps on AVFs Recommended Protocol Secondary AVF Procedures “Sleeves Up Recommended Protocol” Local Medical Review Policy Related to Vascular Access List of Facilities with 40% AVF Rate and Associated Surgeon or Surgical Group Physical Examination of the AVF Article

28. What We Have Learned From the Project So Far! Without a Medical Director/Nephrologist taking an active role in improving vascular access process, the facility will struggle and patients may receive sub par care. You must have access to one or more surgeons with the experience, willingness & tenacity to place AVFs in appropriate patients. Pre-surgery blood vessel mapping greatly improves the chances of successful AVF placements. Early referral of patients for mapping and surgery improve AVF placement opportunities.

29. Comprehensive cannulation training is a necessity Delegating a staff member to be responsible for monitoring access rates and planned procedures is very helpful. Educate and motivate patients and their families that AVFs may help keep them out of the hospital or worse Very complicated project! What We Have Learned From the Project So Far!

30. “We have just begun to fight” Planned initiatives formally begun in March/April 2004  Distribution of Resources  Distribution of Facility Specific Charts  Distribution of Surgeon Specific Charts  Surgeon Conferences  Nurse Conferences

31. Next Steps!  Continued  Nurse Educational Conferences/Awareness Campaign  Distributing charts and statewide report highlighting benchmark facilities, county rates & facility distribution.  Highlighting names of surgeons associated with “Benchmark” facilities  Distributing resource updates and reminders of availability  Seeking opportunities to assist/support/encourage use of Change Package strategies.

32. Next Steps! New  Seek input from EC, MRB, Committees  Market information on Revised Mapping Policy  Focus on largest cities (Houston, San Antonio)  Initiate “collaboratives” with LDOs to mentor laggard facilities  Nephrologist seminar in Houston  Partnering/educating hospitals to review policy