Barriers to Adopting a Fistula-First Policy in Europe: An International Survey among National Experts

Abstract

Purpose The purpose of this study is to explore how vascular access care was reimbursed, promoted, and organised at the national level in European and neighbouring countries. Methods An electronic survey among national experts to collect country-level data. Results Forty-seven experts (response rate, 76%) from 37 countries participated. Experts from 23 countries reported that 50% or less of patients received routine pre-operative imaging of vessels. Nephrologists placed catheters and created fistulas in 26 and 8 countries, respectively. Twenty-one countries had a fee per created access; the reported fee for catheter placement was never higher than for fistula creation. As the number of haemodialysis patients in a centre increased, more countries had a dedicated coordinator or multidisciplinary team responsible for vascular access maintenance at the centre-level; in 11 countries, responsibility was always with individual nephrologists, independent of a centre's size. In 23 countries, dialysis centres shared vascular access care resources, with facilitation from a service provider in 4. In most countries, national campaigns (n = 35) or educational programmes (n = 29) had addressed vascular access-related topics; 19 countries had some form of training for creating fistulas. Forty experts considered the current evidence base robust enough to justify a fistula-first policy, but only 13 believed that more than 80% of nephrologists in their country would attempt a fistula in a 75-year-old woman with comorbidities. Conclusions Suboptimal access to surgical resources, lack of dedicated training of clinicians, limited routine use of pre-operative diagnostic imaging and patient characteristics primarily emerged as potential barriers to adopting a fistula-first policy in Europe.