Nephrologists Weigh in on “Fistula First” Strategy

Nephrologist as a leader is the number one strategy listed in the new CMS Fistula First Breakthrough Initative (FFBI) Strategic Plan. The FFBI promotes the placement of an arteriovenous fistula (AV fistula), the gold standard for vascular access in dialysis patients because of factors that include lower costs, fewer complications and decreased mortality rates. CMS’ End Stage Renal Disease Networks and the 11 QIOs conducting the CKD sub-national project are partnering to increase AV fistula rates.

Supporting Nephrologist Accountability

The new FFBI Strategic Plan places the nephrologist at the forefront of the healthcare team with responsibility to ensure patients are prepared for dialysis, prescriptions are appropriate, and quality outcomes are achieved. The plan acknowledges that nephrologists will need encouragement and support to assume a leadership role in vascular access management for all hemodialysis patients. FFBI supporting tactics for the nephrologist as a leader strategy include:

• Greater collaboration with the American Society of Nephrology as the primary provider of nephrology continuing education;
• Expansion of nephrology fellowship programs to include such skills as leadership training and quality improvement; and
• Accountability through the development and use of nephrology and surgeon profiles of care for benchmarking and quality improvement.

Two Perspectives on Leadership

Two practicing nephrologists recently offered their viewpoints on the FFBI strategy: John Sadler, M.D., a Baltimore nephrologist with three decades of experience, and Nathan Hellman, M.D., a nephrology fellow currently completing his training at Massachusetts General Hospital in Boston.

For more than 30 years, Dr. Sadler has been an active participant and leader in the renal dialysis community. “Over the years, we haven’t seen a great leap in nephrologists becoming leaders,” said Dr. Sadler. “Only small steps… today’s nephrologists are not the CKD patient’s primary physician, which creates a degree of separation.”

Dr. Sadler notes that most patients today receive dialysis at a freestanding center. While this setting usually increases patient convenience, it can create opportunities for “disconnects” in communication between the nephrologist and other health professionals involved in CKD treatment. “It’s all about the patients. This is a human problem, not a systems problem, and that makes it a lot harder,” he said.

Dr. Hellman emphasizes the importance of collaboration as nephrologists take on a leadership role in promoting AV fistula placement. He notes that he and his colleagues are spread thin, typically spending ore than 90 percent of the day caring for patients — and this trend is likely to continue.

“There are less than 7,000 actively practicing nephrologists in the United States,” he said. “We need more to meet the projected demand.”

To increase adoption of the nephrologist as leader strategy, Dr. Hellman recommends reaching out to young nephrologists as a logical starting point. The nephrology community is leveraging social media to stay connected and collaborate with one another. Blogs like the Renal Fellow Network (www.renalfellow.blogspot.com) create a communication forum for nephrology fellows across the country to share successes and lessons learned.

For more information on the Fistula First Breakthrough Initiative, visit www.fistulafirst.org. To learn how QIOs are improving care for CKD patients, download the CKD fact sheet at http://tinyurl.com/CKDfactsheet.