4/15/2016 Objectives: Debate: We Are Not Using Early Access Grafts Enough and it is � To try to convince you that: Costing us in Catheter-Related 1. Hemodialysis catheters (CVCs) can be costly - patient health outcomes and healthcare resources Days: PRO 1. Early cannulation grafts can spare catheter days Charmaine Lok, MD, MSc, FRCPC 2. Early cannulation grafts have similar outcomes as “standard Professor of Medicine, University of Toronto grafts” Medical Director of Hemodialysis, University Health Network 3. Grafts have similar outcomes as fistulas Friday April 15, 2016 UCSF Vascular Symposium 2016 4. Early cannulation grafts can be cost effective San Francisco 1. HD catheters can be costly: Patient Worldwide… Inflammation � Incident or Prevalent patients… Poor flows � Regardless of AGE, SEX, DIABETES Central Stenosis status or many other factors: Inadequate Dialysis Catheters = Thrombosis SPAIN: Praga, M et al. Nephron Clin Practice, 2013 inferior survival Malnourishment Catheter Use Catheter CANADA: Moist, L. et. al, CJASN, 2008 Fibrin Sheath Infection DEATH Interventions SCOTLAND/UK: Bray, B. et al. QJM, Bleeding risk AUSTRALIA/NEW ZEALAND: Polkinghorne K. et al, 2012 JASN, 2004ra 1
4/15/2016 Reduce Patient Mortality: Convert to AV-Access What about… in First Y ear of HD DOPPS (1996-2004) Change catheter to AV Adjusted HR for mortality access (95% CI) Catheter to AV fistula 0.64 (0.47-0.87) Catheter to AV graft 0.71 (0.55-0.92) Bradbury. AJKD, 2009 Catheters Last YES THEY SHOULD BE IF WE CAN! 5 Recall: “Urgent Starts” to dialysis 2. Early cannulation grafts (eAVG) can spare catheter days Little or no planning Inadequate time for: • Referral to surgeon • Pre-creation corrective interventions , if required 20-40% • Post-creation facilitative interventions , if required • Concept first introduced in 1997 “Perma-Seal” • Fistula maturation to • Multi-laminated structure • Allows cannulation < 72 hours use when needed • Examples: Vectra graft, Flixene graft, Acuseal graft, Avflo graft, Rapidax graft <72 hrs is <3 days… how urgent is urgent? Other situations exist where eAVG may be useful For real emergency dialysis - a temporary CVC = in/out once only! 2
4/15/2016 Sparing a lot of catheter days eAVG can spare catheter days � Report USRDS 2015: � 103,337 incident HD patients (2013) � 80.2% start dialysis with a catheter (N=82,876) � At 90 days after HD start, 68.3% still using catheter (N=56,604) � 5,094,404 catheter days � if 40% were “urgent start”; N=33,150 (2,037,755 CVC days at 90 days if 68.3% still using CVC) � if used eAVG and CVC use * 1 � 33,150 catheter days (spare 2,004,605 catheter days by 90 days) � if used eAVG and CVC use *3 � 99,451 catheter days (spare 1,938,304 catheter days) � if 20% were “urgent start”: N=16,575 (1,018,865 catheter days) (spare 969,140-1,002,290 catheter days) � Spare more if used eAVG in non-urgent start situations e.g. elderly <72 hrs is <3 days… how urgent is urgent? patients with limited life expectancy, high risk patients for fistula failure For real emergency dialysis - a temporary CVC = in/out once only! 3. eAVG have similar outcomes to standard AVG Real Life at UHN 43 eAVG 37 6 Urgent Start Non-urgent 30 7 Not Yet On Already on Dialysis Dialysis 90% without a CVC! 3 started 27 started using eAVG With CVC Primary and secondary patency at 12 months 3
4/15/2016 4. Grafts have similar outcomes to fistulas Grafts have similar outcomes to fistulas Lok, C.E. and Moist, L. et. al, CJASN, � Similar sepsis rate compared with a fistula and lower 8: 810; 2013 infection rates compared with a catheter • Retrospective review (3 years) • 494 patients, 655 8 accesses 7 • 390 AVF, 265 AVG 2.5 6 Incident • AVG fared worse in 2 5 Prevalent assisted primary patency BUT % 4 1.5 superior secondary 3 patency as 2 1 compared to AVF A 1 Snyder, D.. et al. Am J Surgery; 196:641; 2008 0.5 Lee, T. et al. J Am Soc Nephrol 0 18:1936; 2007 AVF AVG CVC 0 AVF AVG CVC Vascular Access Type Series1 USRDS 2012 Allemang et al. American Journal of Surgery 2014 5. Early cannulation grafts can be cost effective 5. Early cannulation grafts can be cost effective � UK study; Aitken E. et al; J Vasc Access; 2016 � US study; Desai, S. et al; J Am Coll Surg; 2015 (abstract) Prospective: CVC pts followed * 6mos (v. mapping, CVC wait times,/delays, • complications etc tracked; eAVG acceptance surveys baseline + 6 mos) ESRD pts followed * 6mos (tracked infection, re-intervention, hospitalization) • Data used to model “standard practices” for VA types Budget impact model created (hosp perspective) • Cost per pt-yr (actual costs projected to 1 yr, using propensity score matching) 4
4/15/2016 Summary & Conclusion: Thank You! � Hemodialysis catheters (CVCs) can be costly - patient health outcomes and healthcare resources - we use them too much which means we are not using eAVG � Early cannulation grafts (eAVG) can spare catheter days � eAVG have similar outcomes as “standard grafts” DOC � Grafts have similar outcomes as fistulas DOC HARLAND LOK PRETTY ROCKS! � eAVG grafts can be cost effective GREAT TOO! Conclusion: YES, we are not using eAVG enough (despite good reason to use them) and it is costing us in catheter days! Questions? 5
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