Accelerated increase of arteriovenous fistula use in haemodialysis centres: results of the multicentre CIMINO initiative

Background. In the Netherlands, arteriovenous fistulas (AVFs) are used in 60-65% of the haemodialysis patients and this compares poorly with the European average. A multicentre guidelines implementation programme, CIMINO, was initiated aiming at increasing the use of AVFs. Methods. Physicians and dialysis staff in 11 participating centres (N = 1092 vascular accesses) were strongly and repeatedly advised to adhere to current guidelines with extra attention for pre-operative duplex examination and salvaging of failing and failed fistulae. Specially appointed access nurses prospectively registered all created vascular accesses using an internet-linked database. In 22 other centres (N 1566 accesses), the CIMINO programme was not offered and they were considered the control group. Results. On 1 January 2006, average follow-up time of the CIMINO group and the control group were 13.3 months and 34.1 months, respectively. A total of 598 new vascular accesses (77% AVFs) were created in the CIMINO group. Prevalent AVF use increased from 58.5% (range: 31-79%) to 62.7% (range: 45-83%) in the CIMINO group and from 65.5% (range: 31-91%) to 67.3% (range: 42-91%) in the control group. The increase in AVF use per year was significantly quicker than in the control group (P < 0.05). Use of untunnelled catheters decreased whereas that of tunnelled catheters increased. Conclusions. This initiative shows that a multicentre guidelines implementation programme results in an accelerated increase of AVF use in comparison with a time control group. These data suggest that the choice of access placement depends predominantly on centre specific factors.