AV fistula creation coupled with systematic catheter reduction offers the promise of improved patient outcomes with decreased overall expenditures. The success in increasing AV fistula prevalence in the US to 42.9% in June 2006 with regional rates as high as 59.5% is evidence of a significant change in practice patterns. Educating patients, the use of clearly defined protocols and updating payment systems to include CKD care are crucial to continued progress. Current data demonstrate that these increases in AV fistula prevalence have occurred in conjunction with decreased graft use. Although it is still too early to define the clinical and cost impacts, this should decrease access procedures but may not fully realize the potential reductions in mortality and cost possible if combined with catheter reduction. Successful catheter reduction requires sustained efforts with similar requirements (education, mapping and referral) and barriers (fi nancial, process and clinical) as the current Fistula First program. Expansion of the Fistula First program to include a 'Catheter Out' initiative with the focus on decreasing catheter prevalence and complications should be considered as requirement in the push toward the break through targets of 66% AV fistula prevalence. Pay-for-performance should include a combination of increasing AV fistula and decreasing catheter prevalence. In summary, the issue is not 'Fistula First' or 'Catheter Out'; both are possible and absolutely necessary.

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