The Centers for Medicare and Medicaid established an arteriovenous fistula (AVF) placement goal of 66% or greater for initial hemodialysis (HD) access, with a corresponding arteriovenous graft (AVG) placement goal of 34% or less. But 1 in 5 surgeons fall short of the “fistula first” targets, according to new study findings.

Of 85,320 Medicare patients (median age 70 years; 55.5% male) undergoing first-time HD access placement during 2016 to 2017, 77.9% had an AVF and 22.1% had an AVG, Caitlin Hicks, MD, MS, of Johns Hopkins University in Baltimore, and colleagues reported in JAMA Surgery. The team calculated the use rates of 2397 surgeons performing more than 10 access procedures annually. The median AVG use rate was 18.2%, well within best practices. But a subset of 498 surgeons (20.8%) had high AVG use rates exceeding the threshold of 34%.

Surgeon characteristics associated with high AVG use included having more than 30 years in practice and specialization in vascular surgery. Those practicing in the Northeast (vs South) and in rural locations were 17% and 20% less likely to use AVG, respectively.

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“Although referral for early hemodialysis access placement is important, the need for surgeons to practice responsibly and use AVF for initial access whenever possible is similarly important,” Dr Hicks and her coauthors wrote. “Fistulae have been associated with higher nonmaturation rates, a need for more early interventions to achieve function, and a longer time to achieve accessibility than AVG. These technical challenges may drive some surgeons to select AVG placement over AVF placement in certain patients.”

Variation in HD access experience and/or patient referral practices might also account for the differences, the team speculated. Data on patients’ arterial and venous diameters were missing, so they could not determine when AVGs were chosen over AVFs for anatomic reasons.

“The future of continuous quality improvement is an open access national program where all surgeons are required to participate, not just those who choose or can afford to,” Misty D. Humphries, MD, University of California, Davis, suggested in an accompanying editorial.

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Hicks CW, Wang P, Kernodle A, et al. Assessment of use of arteriovenous graft vs arteriovenous fistula for first-time permanent hemodialysis access. JAMA Surg. (Published online June 12, 2019.) doi:10.1001/jamasurg.2019.1736

Humphries MD. Refining how we identify high-value surgical care. JAMA Surg. (Published online June 12, 2019.) doi:10.1001/jamasurg.2019.1737