In 2003, the Centers for Medicare and Medicaid Services (CMS) made an increase in arteriovenous fistula (AVF) prevalence and a decrease in catheter prevalence a priority, initiating a project known since 2005 as the Fistula First Breakthrough Initiative (FFBI). From 2003 to June 2010, the prevalent AVF in use rate has increased from 32.2% to 55.8% according to CMS data, a remarkable achievement yet short of CMS’s 66% prevalent AVF goal. The prevalent catheter rate decreased from 26.9% to 23.8% during this same period. Although an effort to augment AVF placement has resulted in issues of nonmaturation, the primary contributor to the 23.8% prevalent catheter rate is the 82% incident catheter rate, which has not declined significantly. Future efforts to decrease the prevalent catheter rate and increase the prevalent AVF rate must be directed at patients with stages 4 and 5 chronic kidney disease and the healthcare providers and practitioners involved in their care, including hospital systems, surgeons, referring physicians, and nephrologists. The nephrologist plays a key role in providing guidance to those providers and holding them accountable for improved vascular access outcomes.