Recent Progress and Current Trends in AV Access
An interview with Howard Katzman, MD, of VASA, regarding the role of the society, achieving viable access sites, and what the US can learn from Europe and Japan.
Endovascular Today: The Vascular Access Society of the Americas (VASA) is a multidisciplinary society merging clinical education and expertise in vascular access and dialysis for the advancement of patient care. What is your role with VASA, and what can you tell us about the society?
Dr. Katzman: I am one of the founding members of VASA and a member of the current board of directors. The idea of such an organization began about 4 years ago, and we are in our second year of soliciting membership. There are 350 active members today, and our long-term goal is to have 1,000 active members. The society was founded to provide a forum for individuals interested in and dedicated to the provision of the highest level of vascular access services and to share common needs and concerns. To achieve this purpose, it became evident that the organization would need to provide CME, guidance in scientific and economic areas, and a voice for the multiple specialties that deal with patients requiring these services. Currently, membership is open to vascular surgeons, general surgeons, nephrologists, interventional radiologists, and interventional nephrologists, along with dialysis nursing specialists.
The ultimate goal is to help shape and define the best practices for dialysis and special access needs, how to evaluate patients, provide service, and perform follow-up management. In so doing, the patients will require fewer procedures, have fewer complications, and the cost of care will diminish considerably. Our members will have access to various hands-on seminars, a biannual national meeting, the opportunity to publish in the International Journal of Vascular Access, and benefit from efforts to improve coding and reimbursement as we work with CMS.
Endovascular Today: There seems to be some controversy regarding whether Fistula First has gone too far and whether physicians are creating fistulas when they should not be. What is your opinion?
Dr. Katzman: There are two ways to look at that. One perspective is that perhaps we are going overboard and creating fistulas that probably are not going to work. However, although you might create a fistula that fails, over the time that the fistula functioned, you may have helped other collateral portions of the venous circulation develop, enabling you to do a subsequent fistula successfully. Also, the program is beneficial because it is driving us to evaluate people and be thoughtful about the initial access, which may have not been the dynamic before. Fistula First is still a good initiative.
Endovascular Today: Do you feel the current National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines target of 66% prevalence by 2009 will be met?
Dr. Katzman: We probably will not make that goal, but we will be far better than we were before the recommendations. We know that given all patients and circumstances, there is a 30% failure rate of primary fistulas; therefore, the best you could hope for would be a 70% prevalence of fistulas. In the US, we had a prevalence rate of 30% for many years, which has now improved to 50%, and in my opinion, represents significant progress. We may not make the 66% target, but we are clearly improving.
Endovascular Today: How and why have US patients been treated differently than those in Europe or Japan, where fistulas have always been more predominant?
Dr. Katzman: The European healthcare system allows people to be seen earlier, whereas in the US, people are seen too late. We know that many of our patients are indigent, economically disadvantaged, do not have insurance, and do not go to a doctor until they are very sick. Also, for a long time, there was a disconnect between the primary care physicians and the nephrologists, and the patient did not get to a nephrologist until late. The end result was a poor setting for fistula creation. There is a strong effort for family practice, and primary care doctors to refer these patients earlier. In the past, too many start-up patients were of an emergent nature requiring immediate access (ie, a catheter). It is well known that catheter usage in Europe and Japan is far less than the US.
Endovascular Today: Is there anything the US can do to catch up?
Dr. Katzman: Yes, we can continue developing the kinds of initiatives such as Fistula First, improving reimbursement by assigning appropriate values to appropriate codes, and to continue emphasizing the need for the patient to be seen earlier and prepared more effectively for long-term therapy.
Endovascular Today: There is a current trend of new freestanding arteriovenous access centers opening across the US. Is there a formal certification program for training physicians who have not performed interventional procedures before?
Dr. Katzman: You are correct, there is a trend to establish freestanding arteriovenous access centers. Some do an outstanding job. There are no formal certifying processes today, and the leadership of such units may be by vascular surgeons, interventional radiologists, or nephrologists. Perhaps designing and implementing a program to standardize professional and technical components of such centers should be one of the goals of VASA.
Endovascular Today: What is driving this trend? Has reimbursement policy had an effect?
Dr. Katzman: Yes, without question. When the procedure is done in the hospital, the hospital gets the facility fee and the operator gets the professional fee. At freestanding units, the facility fee remains with the unit, which is a financial incentive. These units are also very efficient. Patients in need of access service become ill when treatments are missed. This then overloads the hospital system. If you can manage these patients quickly and efficiently on an outpatient basis, it is much better for the patient. On a national level, it is better because the dialysis centers are not hurt by patients missing treatment, and the patients are kept out of the hospital where the in-hospital costs are enormous. It is a good thing. The trend toward access procedures and maintenance taking place in freestanding centers is a positive development.
Endovascular Today: What role do you think nephrologists will play in arteriovenous access 5 years from now?
Dr. Katzman: They play a very significant role today, and that will continue. They are the front line for identifying the problem and getting the patient seen. It is much too early to know if the interventional nephrologists will play a significant role in performing access procedures and care.
Endovascular Today: What has had the largest impact on patient care during the last year or so?
Dr. Katzman: Frankly, I think emphasizing awareness, preventing infections by the decreased use of catheters, and developing reliable subcutaneous access have already made an impact. The mission of VASA is to help drive the processes to further improve the results of procedures and, in turn, the lives of those dependent on vascular access.
Howard E. Katzman, MD, is a vascular surgeon with the Surgical Group of Miami in Miami, Florida, and is on the board of VASA. Dr. Katzman may be reached at (305) 324-4840; firstname.lastname@example.org.
To learn more about VASA, go to www.vasamd.org or contact VASA at (978) 745-8331; email@example.com.