History of the Fistula First Project

Arteriovenous fistulas (AV fistulas) are considered the gold standard for hemodialysis vascular access based on their superior patency, low complication rates, improved adequacy, lower cost to the healthcare system, and decreased risk of patient mortality. As part of the End Stage Renal Disease (ESRD) Networks Statement of Work (SOW) beginning in July 2003, the Centers for Medicare & Medicaid Services (CMS), the ESRD Networks, and key provider representatives jointly recommended adoption of a National Vascular Access Improvement Initiative (NVAII). The primary goal of this Continuous Quality Improvement (CQI) project was to increase the appropriate use of AV fistulas for hemodialysis access and to reach or exceed the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K-DOQI) practice guidelines of 50% in incident patients and 40% in prevalent patients. Due to the implementation of this quality improvement initiative, this goal was reached in August 2005, 10 months earlier than anticipated.

The focus of the original NVAII was to address clinical and organizational improvements that would lead to placement and use of AV fistulas. ESRD Networks, dialysis providers, medical specialists, hospitals, and clinics all share responsibility for improving dialysis care by increasing appropriate and successful AV fistula placement. The ESRD Networks played a major role in catalyzing change, creating efficient ways to share knowledge and resources and building strong alliances with the facilities and medical professionals in their regions.

An interdisciplinary working group supported by a team from the Institute for Healthcare Improvement (IHI) identified and developed 11 major Change Concepts. The Change Concepts focused on modifications that could be made immediately to give all eligible hemodialysis patients the opportunity to receive an AV fistula.

In 2005, the NVAII was recognized by CMS as a breakthrough initiative and became known as the Fistula First Breakthrough Initiative (FFBI); the national prevalent AV fistula goal was increased to 66%. As part of the initiative, the FFBI Coalition was formed and remains active today.