One in Five Surgeons Still Using Low-Value Arteriovenous Graft for Dialysis Access

By Marilynn Larkin

June 20, 2019

NEW YORK (Reuters Health) - One in five surgeons who do hemodialysis access procedures continue to use arteriovenous grafts (AVG) instead of the recommended best practice of arteriovenous fistula (AVF), researchers say.

"Physicians are performing more AVF than AVG than they were doing in the past, but there is still substantial room for improvement," Dr. Caitlin Hicks of Johns Hopkins University School of Medicine in Baltimore told Reuters Health by email.

In 2009, the US Centers for Medicare and Medicaid Services and end-stage renal disease treatment networks across the US set a goal to increase the use of AVF to 66% of vascular access surgeries, in an effort to match the 60% to 90% rates in Europe and Asia.

To document progress toward that goal, Dr. Hicks and colleagues reviewed all Medicare claims from 2016 through 2017 for patients undergoing initial permanent hemodialysis access placement with an AVF or AVG. Data from all surgeons performing more than 10 hemodialysis access placement procedures during the period were also analyzed, and a surgeon-level AVG (vs. AVF) use rate was calculated.

As reported online June 12 in JAMA Surgery, 85,320 patients (median age, 70; 55.5% men) underwent first-time hemodialysis access placement; 77.9% had an AVF and 22.1% had an AVG.

Among the 2,397 included surgeons (92.4% men), the median number of first-time access procedures performed during the study period was 24 and the median surgeon-level AVG use rate was 18.2%; however, 20.8% had an AVG use rate greater than 34%.

After accounting for patient characteristics, surgeon factors independently associated with AVG use included more than 30 years of clinical practice versus 21-30 years (odds ratio, 0.85), metropolitan setting (OR, 1.25), and vascular versus general surgery specialty (OR, 0.77).

Surgeons in the Northeast region of the U.S. had the lowest AVG use rate (OR, 0.83 versus the South).

The team created benchmarking reports for individual surgeons for potential distribution, noting that "sharing benchmarked performance data with surgeons could be an actionable step in achieving more high-value care in hemodialysis access surgery."

Dr. Hicks elaborated, "Targeted physician-specific benchmarking reports could be utilized to provide feedback to outlier physicians and improve their education and performance in AV access creation, ultimately improving the quality of care for patients. We have a team at Johns Hopkins...who could do this, or other quality initiatives such as the Vascular Quality Initiative ( "

Dr. Misty Humphries of the University of California Davis in Sacramento, author of a related editorial, commented by email, "For the last decade healthcare has been focused on quality improvement, but we are now moving towards 'value-based care.' Essentially, this is quality care with the consideration of cost."

"The (study) highlights providers who are not working within the accepted guidelines of care," she told Reuters Health. "And it raises the question of who should be setting appropriate use criteria for procedures and who is responsible for ensuring providers are actually adhering to those criteria."

"Overall, the system is broken and people on the high road have committed to joining expensive quality-improvement programs hoping to set standards for providers not on that road," she said by email.

"These programs are voluntary and...expensive, and who pays for them is always a challenge," she said. "Small practices cannot afford them and hospitals are not required to have them in place. Until there is a mandate that forces providers to objectively look at tier work and their outcomes, we will see many interventional providers continuing to do what they have always done: perform more procedures to generate their relative value units (RVUs) and make money for the hospital."


JAMA Surg 2019.