title: The impact of a community-wide vascular access program on the management of graft thromboses in a dialysis population of 495 patients.
abstract: BACKGROUND
  The unpredictability of prosthetic vascular access thrombosis precludes the scheduling of elective graft thrombectomy. This results in inconsistent dialysis for patients, as well as logistical challenges for dialysis clinics and surgeons, and increased cost. In an effort to solve this problem a community-wide, prospective vascular access program (VAP) was established. This study evaluates the impact of the VAP by comparing the operative procedures and outcomes of vascular access surgery performed in the community before and after establishment of the program.
  
  
  METHODS
  All 17 surgeons who perform vascular access, representing five independent practice groups in Greenville, South Carolina, formed a VAP in November 1996. Dialysis patients were pooled, and all graft thrombectomies were managed on a rotational basis by a surgeon assigned daily to a specifically designated access thrombectomy operating room. The hospital records of all patients undergoing vascular access procedures from November 1, 1995, through October 31, 1996 (pre-VAP), and November 1, 1996, through October 31, 1997 (post-VAP), were reviewed.
  
  
  RESULTS
  Comparison of the pre-VAP and post-VAP groups showed no significant difference in the number of patients undergoing vascular access procedures (391 versus 378), number of vascular access procedures performed (1034 versus 1,048), or average number of vascular access procedures performed per patient (2.64 versus 2.79). There was no statistical difference in the number of thrombectomies and revisions (786 versus 765; P = 0.114) or thrombectomies alone (248 versus 283; P = 0.114) in the pre-VAP and post-VAP groups. There was a significant increase in the number of procedures performed on an outpatient basis in the post-VAP group (757; 73%) compared with the pre-VAP group (575; 56%); P <0.001. There was also a significant difference in the percentage of cases performed after 6:00 PM in the pre-VAP group (262; 25%) compared with the post-VAP group (48; 4.5%; P = 0.001).
  
  
  CONCLUSIONS
  Dialysis graft thrombosis, occurring in 75% of our patients annually, represents a substantial logistical dilemma necessitating the incorporation of 1,000 additional operations into a busy elective surgery schedule. An organized VAP reduces inpatient hospitalization, minimizes expensive after hours surgery, and enhances patient and physician convenience while providing a mechanism to monitor clinical outcomes and assure timely dialysis.
authors.affiliation: Department of Surgical Education, Greenville Hospital System, South Carolina 29605, USA.
authors.forename: D L
authors.initials: DL
authors.lastname: Cull
authors.forename: S M
authors.initials: SM
authors.lastname: Taylor
authors.forename: H E
authors.initials: HE
authors.lastname: Russell
authors.forename: E M
authors.initials: EM
authors.lastname: Langan
authors.forename: B A
authors.initials: BA
authors.lastname: Snyder
authors.forename: T M
authors.initials: TM
authors.lastname: Sullivan
mesh_terms: D000556:Ambulatory Surgical Procedures; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D002408:Catheters, Indwelling / Q000009:adverse effects; D016009:Chi-Square Distribution; D015331:Cohort Studies; D017558:Elective Surgical Procedures; D006083:Graft Occlusion, Vascular / Q000601:surgery*; D017048:Health Care Costs; D006760:Hospitalization; D006801:Humans; D011446:Prospective Studies; D006435:Renal Dialysis / Q000191:economics / Q000295:instrumentation*; D012086:Reoperation; D013022:South Carolina; D017131:Thrombectomy; D013927:Thrombosis / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome