Vascular access technique is strongly associated with major clinical outcomes in dialysis patients, and arteriovenous fistulas are widely regarded as the access modality of choice. The use of central venous catheters, moreover, is associated with increased risk of infection.
Although dialysis facilities do not create accesses, the delivery of dialysis — by way of cannulation technique, blood flow rates, and infection control practices — may strongly influence access patency and the incidence of access complications.
Another alternative approach to the rating of dialysis facilities is to assign all weight to vascular access technique, rather than major clinical outcomes or process outcomes.
Here, we use public data from the July 2014 release of Dialysis Facility Compare to compile 5-star ratings according to the CMS methodology and to an alternative methodology in which the percentage of patients receiving hemodialysis with an arteriovenous fistula and the percentage receiving hemodialysis with a venous catheter for more than 90 days are each assigned a weight of 50 percent.
In this scenario, slightly more than 43 percent of facilities are assigned equal numbers of stars by the contrasting approaches.
Among facilities assigned one star by the CMS methodology, over 53 percent are assigned two or more stars by the alternative rating. On the other hand, among facilities assigned five stars by the CMS methodology, nearly 58 percent are assigned four or fewer stars by the alternative rating.
Among facilities assigned two, three, or four stars by the CMS methodology, revisions by a margin of either one or two stars with the alternative rating are common.
Comparison of rating from CMS methodology vs. rating based exclusively on fistula & catheter metrics
Number of facilities
(Alternative facility score in rows; CMS rating in columns)
Movement from CMS rating
(Movement in rows; CMS rating in columns)