Catheter Reduction & Healthy People 2030: Improving Dialysis Access Survival
The United States continues to face significant challenges in chronic kidney disease care, particularly for the nearly 500,000 Americans undergoing dialysis. A recent spotlight from the Healthy People 2030 initiative highlights a critical, often overlooked aspect of patient survival: vascular access for dialysis. Specifically, the initiative’s goals related to reducing central venous catheter use and associated mortality are currently trending in the wrong direction, signaling an urgent need for systemic improvements.
The Central Line Conundrum
For decades, arteriovenous fistulas (AVFs) have been recognized as the gold standard for vascular access in dialysis patients. Yet, a concerning trend reveals that 85% of patients initiate dialysis with a central venous catheter – a temporary access point – rather than the preferred AVF. This reliance on catheters carries a significantly higher risk of mortality, with rates four times greater compared to permanent access methods like fistulas or grafts. Beyond the increased mortality risk, catheters are associated with lifestyle restrictions and a heightened susceptibility to infections.
The Dialysis Vascular Access Coalition believes that achieving the Healthy People 2030 goals isn’t merely about meeting benchmarks; it’s about saving lives. The two metrics related to kidney disease – catheter use and mortality – are inextricably linked. The COVID-19 pandemic exacerbated this issue, leading to a marked deterioration in vascular access outcomes across the United States.
A Post-Pandemic Setback
Data from the United States Renal Data System (USRDS) from 2025 paints a troubling picture. The central venous catheter rate has climbed from 16% to over 22%. This increase is particularly alarming given the known risks associated with catheter use. The shift towards catheter-first access isn’t simply a clinical preference; it reflects systemic pressures and vulnerabilities within the healthcare system.
During the height of the pandemic, dialysis patients experienced some of the highest mortality rates among all comorbidities, even facing triage to palliative care due to ventilator shortages. This crisis resulted in the first decline in the dialysis patient population in half a century, underscoring the fragility of care during times of extreme stress.
Systemic Strain and Economic Factors
The challenges extend beyond clinical considerations. The USRDS data also reveals a correlation between Medicare rate cuts to dialysis vascular access centers and the rise in catheter rates. Current Medicare Advantage plan policies often fail to recognize the time-sensitive nature of dialysis access creation, repair and maintenance. With Medicare spending approximately $53 billion on dialysis care in 2023, the economic and human costs of suboptimal vascular access are substantial and unsustainable.
The importance of specialized vascular access centers cannot be overstated. These centers offer expert interventions and have demonstrated improved outcomes, often at a cost savings to the healthcare system. Protecting these freestanding centers is crucial for ensuring timely and appropriate access for dialysis patients.
A Path Forward: Realigning Incentives and Prioritizing Access
To effectively address the challenges and achieve the Healthy People 2030 targets, a multi-pronged approach is necessary. This includes:
- Improving Medicare Reimbursement: Protecting freestanding vascular access centers is paramount. Adequate reimbursement ensures patients receive timely, specialized care.
- Updating Medicare Advantage Policies: Recognizing vascular access as a clinical priority, rather than an elective procedure, is essential for ensuring prompt access to care.
- Prioritizing Infection Control: Transitioning patients away from catheters is the most effective way to reduce dialysis-related deaths from catheter-related infections and sepsis.
The success of the Medicare “Fistula First” initiative in the early 2000s provides a valuable blueprint. By prioritizing AVFs over catheters and grafts, fistula utilization increased from roughly 30% to over 60% within a decade. This initiative recognized the critical role of specialized vascular access centers in reducing infections, hospitalizations, and overall costs.
Replicating the spirit of “Fistula First” and aligning with the catheter reduction goals of Healthy People 2030 can assist regain lost ground and improve the long-term survival of patients on dialysis. This requires a concerted effort from policymakers, healthcare providers, and advocacy groups to prioritize vascular access as a cornerstone of quality kidney care.
Terry F. Litchfield, MPA, CPC, is president of Access Solutions and can be reached at [email protected].
Learn more about kidney disease and dialysis: The National Kidney Foundation (https://www.kidney.org/) provides comprehensive information and resources for patients, families, and healthcare professionals. The Centers for Disease Control and Prevention (CDC) also offers information on chronic kidney disease (https://www.cdc.gov/kidneydisease/index.html), including risk factors and prevention strategies. For details on the Healthy People 2030 initiative, visit the Department of Health and Human Services website (https://www.healthypeople.gov/).