Less than 40% of dialysis patients have a fistula—the result of a simple surgical procedure to attach an artery to a vein, usually near a patient’s wrist. Two needles are placed in the fistula to remove and return blood during the dialysis process. According to Gilbert M. Gaul’s article in today’s Washington Post, fistulas are not the majority option for dialysis patients “despite overwhelming evidence that they are safer, cheaper and more effective than grafts and catheters.” Research indicates that patients with fistulas are “far less likely to develop life-threatening infections.”
Seems that whether or not you get a fistula depends on whether or not you’re insured and your zipcode. In the DC area, for example, “patients in the District, West Virginia and much of Maryland have just a 1-in-4 chance of getting a fistula data show. Patients in Northern Virginia: a 1-in-2 chance.” The District of Columbia has the lowest use of fistulas in the country: 24.5% as of August 2005.
Doctors and surgeons are also a large part of the problem. According to the Washington Post account, “on average, a surgeon receives $714 for a graft but only $560 for a simple fistula, data show. Catheters and grafts are also prone to clogging, generating more fees for surgeons doing repairs. ‘You not only get paid more for the actual procedure, a graft is also a kind of annuity [for surgeons] because you know you have to clean it out regularly,’ said Brady Augustine, a senior quality advisor at the Centers for Medicare and Medicaid Services (CMS) and a former executive at a for-profit dialysis chain.” The Washington Post cites one estimate that Medicare spends about US$1 billion annually repairing grafts and catheters.
In my own case, my kidney failure came on too fast for a fistula to mature. I had to begin dialysis with a catheter or die. Within months, however, I saw a vascular surgeon for fistula surgery and began using it for dialysis within a few months. Meanwhile, I almost died anyway when my catheter became infected and I became septic. According to the Washington Post account, I was lucky: “Patients with grafts and catheters also have a 20 to 70 percent greater chance of dying in the first year of treatment, according to CMS.” Within a few months my fistula was mature enough to use (not without problems of its own) and I’ve been using it ever since. Knock wood, only once have I been hospitalized to clear a clot in the fistula.
Medicare has begun a program, Fistula First, that aims to have fistulas in 66% of all dialysis patients by 2010.
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