title: Barriers to adopting a fistula-first policy in Europe: an international survey among national experts.
abstract: OBJECTIVE
  The purpose of this study is to explore how vascular access care was reimbursed, promoted, and organised at the national level in European and neighbouring countries.
  
  
  METHODS
  An electronic survey among national experts to collect country-level data.
  
  
  RESULTS
  Forty-seven experts (response rate, 76%) from 37 countries participated. Experts from 23 countries reported that 50% or less of patients received routine preoperative imaging of vessels. Nephrologists placed catheters and created fistulas in 26 and 8 countries, respectively. Twenty-one countries had a fee per created access; the reported fee for catheter placement was never higher than for fistula creation. As the number of haemodialysis patients in a centre increased, more countries had a dedicated coordinator or multidisciplinary team responsible for vascular access maintenance at the centre-level; in 11 countries, responsibility was always with individual nephrologists, independent of a centre's size. In 23 countries, dialysis centres shared vascular access care resources, with facilitation from a service provider in 4. In most countries, national campaigns (n = 35) or educational programmes (n = 29) had addressed vascular access-related topics; 19 countries had some form of training for creating fistulas. Forty experts considered the current evidence base robust enough to justify a fistula-first policy, but only 13 believed that more than 80% of nephrologists in their country would attempt a fistula in a 75-year-old woman with comorbidities.
  
  
  CONCLUSIONS
  Suboptimal access to surgical resources, lack of dedicated training of clinicians, limited routine use of preoperative diagnostic imaging and patient characteristics primarily emerged as potential barriers to adopting a fistula-first policy in Europe.
authors.affiliation: 2 Department of Medical Informatics, Academic Medical Center, Amsterdam - The Netherlands.
authors.forename: Sabine N
authors.initials: SN
authors.lastname: van der Veer
authors.forename: Pietro
authors.initials: P
authors.lastname: Ravani
authors.forename: Luis
authors.initials: L
authors.lastname: Coentrão
authors.forename: Richard
authors.initials: R
authors.lastname: Fluck
authors.forename: Werner
authors.initials: W
authors.lastname: Kleophas
authors.forename: Laura
authors.initials: L
authors.lastname: Labriola
authors.forename: Susanne H
authors.initials: SH
authors.lastname: Hoischen
authors.forename: Marlies
authors.initials: M
authors.lastname: Noordzij
authors.forename: Kitty J
authors.initials: KJ
authors.lastname: Jager
authors.forename: Wim
authors.initials: W
authors.lastname: van Biesen
mesh_terms: D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000706:statistics & numerical data*; D062905:Central Venous Catheters / Q000706:statistics & numerical data*; D005060:Europe; D018588:Fee-for-Service Plans / Q000706:statistics & numerical data*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires