A multidisciplinary approach to hemodialysis access: prospective evaluation

Abstract

Dialysis access procedures and complications represent a major cause of morbidity, hospitalization and cost for chronic dialysis patients. To improve outcomes and reduce the cost of hemodialysis access procedures we developed a multidisciplinary approach, involving nephrologists, access surgeons, and radiologists. A full-time dialysis access coordinator scheduled all access procedures with the surgeons and radiologists, and tracked outcomes. A computerized database was developed for prospective documentation of procedures and complications. Confidential, detailed analyses and recommendations for improvements were provided periodically to the surgeons and radiologists. The major changes arising from the multidisciplinary approach were as follows: (1) The approach to clotted grafts evolved from an inpatient surgical procedure to an outpatient radiologic procedure. The immediate technical success rate of graft declots increased from 48% to 69%. (2) Elective placement of arteriovenous (A-V) grafts evolved from a three-day inpatient hospitalization to a largely outpatient procedure. The proportion of A-V grafts placed as same day surgery or outpatient surgery increased from 16% to 81%. (3) Surgical complications of new A-V graft surgery decreased from 25% to 11%. (4) Aggressive detection and correction of graft stenosis decreased the incidence of graft thrombosis by 60%, from 0.70 to 0.28 events per patient-year. (5) The proportion of native A-V fistula construction in new dialysis patients increased from 33% to 69%. In conclusion, an integrated multidisciplinary approach markedly reduced surgical complications of access surgery and decreased access failures. These improvements occurred despite a marked decrease in hospitalization for access procedures, with a substantial cost saving.