A debate regarding the optimal place for vascular access creation and management to take place—specialised units or high-volume centres—saw Suresh Mathavakkannan (East and North Hertfordshire NHS Trust, Stevenage, UK) and David Kingsmore (Queen Elizabeth University Hospital Trust, Glasgow, UK) go head-to-head at this year’s Vascular Access Society of Britain and Ireland (VASBI) annual scientific meeting (29–30 September, Glasgow, UK).
Arguing in favour of specialist centres, Mathavakkannan began by noting the importance of multidisciplinary teams—ideally a trinity of nephrologists, vascular/transplant surgeons and interventional radiologists (IRs) who all have a particular interest in vascular access. He also opined that the “holy grail” is getting 60% of all patients started on incident dialysis with a ‘definitive’ access solution rather than a tunnelled catheter. And, among prevalent dialysis patients, this target rises to 80%.
Citing the UK Renal Registry (UKRR) report, and moving onto his “biggest pitch” for specialised vascular access, the speaker said that only a handful of units reached these targets in 2019, and the majority of those that did were specialist centres—predominantly transplant centres. Here, Mathavakkannan conceded that, even in smaller-scale units, it is difficult to create and maintain a vascular access service because it is “a very resource-intensive exercise” involving a patient population that has always been “very complex”, but is now getting older, frailer and more comorbid over time.
However, while there is a degree of resource constraint for specialised centres, and many units need to perform more procedures and target improved outcomes to meet current demands moving forward, these challenges are even harder for high-volume centres to contend with, he continued. He further claimed this negatively impacts their ability to be both proactive and reactive in access creation, potentially increasing their numbers of unplanned starters, who will likely begin dialysis with a line.
“You need to have the ability to get it right first time, but you also need to have the ability to intervene [later], if necessary,” Mathavakkannan said. Referencing previous UK Renal Association vascular access guidelines, which emphasise the need for centres to have surgical and radiological intervention facilities for prompt and timely treatment of arteriovenous fistula/graft (AVF/G) stenosis, he added: “Again, that is predicated on having enough resources to do that on a daily basis—and I would argue that is only available in a specialist centre.”
Mathavakkannan concluded by reiterating that specialised centres tend to produce better patient experiences and quality, adding: “We can deliver dialysis pretty close to home, but vascular access probably needs to be done in a unit that can comprehensively manage all the service needs of the patient.”
Kingsmore’s presentation in favour of keeping vascular access ‘non-centralised’ focused on the current evidence supporting specialised/centralised care—or lack thereof. The basis of his argument centred around three key points: Firstly, the UK can be either geographically disadvantaged in remote rural areas or already has close access to larger centres due to high population density. Secondly, the rationale behind specialisation is well matured. “Vascular access does not meet the logical requirements for specialisation [large teams, rare conditions or technically unforgiving anastomoses in inaccessible locations],” he claimed, “and there is no evidence for it whatsoever. In fact, it may even be harmful.”
The speaker noted that the centralisation of care is “not even a modern argument”, highlighting an article from as far back as 1945 in The Lancet that warned of “narrowness and monotony”, and limitations around “the cross-fertilisation of ideas” and collaborative work, as well as a focus on “the self-serving needs of the clinician—rather than the needs of patients”, in the UK National Health Service (NHS).
Challenging his opponent’s assertions that specialised centres are associated with a higher level of quality, Kingsmore said that quality of care can be broken down into the healthcare setting, its processes, and the subsequent outcomes, but pointed out the flaws in directly associating certain types of centres with certain outcomes. “Some smaller units do fantastic work, and some bigger ones—not quite so much, but it is not about the nomenclature,” he stated. “It is about the quality of care they actually deliver.” Here, he also chose to refer to the UKRR report and the fact that, in order of unit size, better outcomes were reported in terms of lower catheter use in smaller units.
And, while he corroborated Mathavakkannan’s views on the importance of a multidisciplinary team, and the role of collaborative working, Kingsmore also reported the difficulties of achieving these ideals despite working in a large centre with all the facets required.
Finally, and thirdly, he noted that the concept of centralisation is “absolutely meaningless”, as vascular access care is already centralised, and improved organisation of existing systems—i.e. through a multidisciplinary team-based approach—is more likely to be successful in providing more comprehensive services and overcoming issues like resource constraints at high-volume centres. “[Centralisation] is impractical, it is not logical, and it may even lead to poorer outcomes,” he concluded.
In a brief discussion following the debate, both speakers agreed that it is not necessarily the size of a given vascular access centre that matters, but rather the right level of investment and collaboration to provide a good-quality service. A straw poll of the VASBI audience, conducted by session moderator Peter Thomson (Queen Elizabeth University Hospital, Glasgow, UK), revealed a near-50/50 split in support for specialised and high-volume vascular access centres, leaving the issue open to further discussions.