EFFECTS OF IMPLEMENTING A TIMELY CATHETER REMOVAL PROGRAM IN HEMODIALYSIS PATIENTS

Background: Patients with kidney failure who progress to end stage renal disease (ESRD) require renal replacement therapy in the form of kidney transplantation or dialysis to sustain life. The most common modality of dialysis utilized is hemodialysis (HD), which includes routine treatments about three times per week to filter the blood via a central venous catheter (CVC) or permanent vascular access (i.e. arteriovenous fistula (AVF) or graft (AVG)). In the United States there are currently more than 420,000 prevalent HD patients, of which, about 63% use an AVF or AVG. It has been well established that CVC use is associated with major risks for worsened morbidities and mortality, as compared to AVFs or AVGs. In June of 2015, six Fresenius Medical Care North America (FMCNA) clinics implemented a Timely Catheter Removal Program (TCRP) aimed to reduce CVC use. In this study we investigated whether the TCRP impacted CVC utilization in HD patients. Methods: We analyzed data from all patients at six FMCNA clinics that piloted TCRP starting in June of 2015. This program includes care coordination between clinic staff, vascular access experts (VAEs), interventionalists, and surgeons. Weekly clinic reports were generated and included metrics regarding CVC status, time to VAE appointments, time to AVF/AVG surgeries, time to CVC removals, and CVC exposure time. Six treatment facilities were compared to six control clinics exactly matched for the level of CVC use 12 months prior to TCRP initiation, trend in CVC use a year before TCRP, and number of patients a month prior to initiation of TCRP. The monthly percent of patients without a CVC were collected for the clinics 12 months prior to TCRP (baseline) and 15 months after the start of TRCP. Segmented regression analysis of interrupted time series data was utilized to assess the effect of TCRP. Interactions between the level and trend of CVC use after TCRP and clinic grouping were included in the model. Results: We found significant differences in the trend of CVC use between patients in TCRP and control groups after initiation of the program (p=0.005). In TCRP group, we observed an unremarkable change of 0.0024% fewer patients with a CVCs per month during the 12 month baseline period (p=0.95), but found a significant change of 0.2% fewer patients with a CVC per month during the 15 month treatment period (p= 0.001). In the control clinics, we found a change of 0.05% fewer patients with a CVC per month during the treatment period (p=0.1). Conclusions: Our findings suggest that TCRP care coordination initiative is associated with reductions in the percent of patients that utilize a CVC access for HD.