ABSTRACT
Stenosis in the anastomotic site or venous limb of an arteriovenous fistula (AVF) is the most frequent cause of AVF failure. Percutaneous angioplasty with a standard or high-pressure balloon is the first-line treatment for AVF stenosis due to its higher technical success rate (90%) and lower complication rate (4%). Almost 20% of stenosis cases are resistant or undilatable by regular-pressure balloon angioplasty due to fibrosis, leading to technical failure or restenosis. Alternative therapies, such as atherectomy devices or cutting balloons, are expensive and difficult to obtain in low-income developing countries. We successfully treated resistant AVF stenosis with a coronary OPN-NC® ultra-high-pressure balloon and produced a good angiographic result with technical success. Coronary hardware is easily available and relatively cheaper compared to dedicated peripheral balloons or devices in our country due to reuse, which can be a boon in such type of cases. According to the standard hospital protocol, Cathlab hardware was reused.
Subject(s)
Angioplasty, Balloon , Arteriovenous Shunt, Surgical , Cost-Benefit Analysis , Humans , Arteriovenous Shunt, Surgical/adverse effects , Angioplasty, Balloon/economics , Graft Occlusion, Vascular/therapy , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/etiology , Male , Renal Dialysis , Female , Poverty , Middle Aged , Constriction, PathologicABSTRACT
BACKGROUND: Arteriovenous fistula is the ideal hemodialysis access, but most patients start with tunneled dialysis catheter. Arteriovenous fistula and arteriovenous graft surgery may reduce tunneled dialysis catheter use and also increase procedural expenses. We compared Medicare costs associated with arteriovenous fistula, arteriovenous graft, and tunneled dialysis catheter. METHODS: Using the US Renal Data System, we identified incident hemodialysis patients in 2008 who started with tunneled dialysis catheter, survived at least 90 days, and had adequate Medicare records for analysis. We followed them until death or end of 2011; access modality was based on billing evidence of arteriovenous fistula or arteriovenous graft creation. We assumed patients without such records remained with tunneled dialysis catheter. We generated multivariate linear regression models predicting Medicare expenditures, censoring costs when patients died; we included all payments to physicians and institutions. We also created algorithms to identify access-related costs. RESULTS: There were 113,505 patients in the US Renal Data System who started hemodialysis in 2008, of whom 51,002 Medicare patients met inclusion criteria. Of that group, 41,532 (81%) began with tunneled dialysis catheter; 27,064 patients were in the final analysis file. In the first 90 days after hemodialysis initiation, 6100 (22.5%) received arteriovenous fistula, 1813 (6.7%) arteriovenous graft, and 19,151 (70.8%) stayed with tunneled dialysis catheter. Annualized access costs by modality were tunneled dialysis catheter US$13,625 (95% confidence interval: US$13,426-US$13,285); arteriovenous fistula US$16,864 (95% confidence interval: US$16,533-US$17,194); and arteriovenous graft US$20,961 (95% confidence interval: US$20,967-US$21,654; p < .001). Multivariate linear regression demonstrated that staying with tunneled dialysis catheter had lowest access-related costs, arteriovenous fistula was intermediate, and those who underwent arteriovenous graft surgery were highest (p < .021). Access type was not significantly associated with total costs. Additional arteriovenous fistula and arteriovenous graft creation (US$3525 and US$3804 per access per year, respectively) and open and endovascular access-related interventions (US$3102 and US$3569 per procedure per year, respectively; all p < .001) were important predictors of increased cost. CONCLUSIONS: Among patients starting hemodialysis with tunneled dialysis catheter, continued tunneled dialysis catheter use is associated with lowest access-related cost. Both endovascular and open interventions are associated with significant additional costs. Further investigation is warranted to develop efficient patient-centered strategies for hemodialysis access.
Subject(s)
Arteriovenous Shunt, Surgical/economics , Blood Vessel Prosthesis Implantation/economics , Catheterization, Central Venous/economics , Health Care Costs , Medicare/economics , Outcome and Process Assessment, Health Care/economics , Renal Dialysis/economics , Aged , Arteriovenous Shunt, Surgical/adverse effects , Blood Vessel Prosthesis Implantation/adverse effects , Catheterization, Central Venous/adverse effects , Databases, Factual , Female , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/etiology , Graft Occlusion, Vascular/therapy , Humans , Male , Middle Aged , Retrospective Studies , Risk Factors , Time Factors , Treatment Outcome , United StatesABSTRACT
OBJECTIVE: Arteriovenous fistulas (AVFs) used for hemodialysis commonly undergo multiple percutaneous and open interventions to maintain functional patency, but it is unclear whether this strategy is cost-effective. The aim of this study was to evaluate the clinical effectiveness and cost-effectiveness of performing repeated interventions vs starting a new AVF. METHODS: We reviewed all patients with mature radiocephalic, brachiocephalic, and brachiobasilic AVFs at a single academic institution between 2007 and 2015 and assessed the clinical effectiveness of each open and percutaneous intervention to maintain functional patency after the fistula was created. These data were used to parameterize a Markov simulation model to determine the cost-effectiveness for performing an open or percutaneous intervention vs creating an AVF at a new anatomic location. This model compared strategies of creating a new AVF after the first to fourth reintervention within a 1-year time window, with the reference being creation of a new AVF on the fourth reintervention. Costs were measured from Medicare's perspective, and effectiveness was measured as quality-adjusted life-years (QALYs) and time in functional access. Incremental cost-effectiveness ratios (ICERs) were calculated by taking the ratio of the difference in cost and the difference in effectiveness between two strategies. RESULTS: A total of 720 AVFs that were created during the 8-year period reached maturity, and 407 (56%) underwent at least one intervention to maintain functional patency, with the median (interquartile range) time to first reintervention of 12.6 (10-17) months. For the strategies of creating a new AVF after the first versus the fourth reintervention, payer costs ranged from $3519 to $3922 for open procedures and $2134 to $3922 for percutaneous procedures. The ICERs for open interventions on failing AVFs were $357,143/QALY after the first reintervention and $95,876/QALY after the second reintervention. The ICERs for percutaneous interventions on failing AVFs ranged from $1,522,078/QALY after the first reintervention to $443,243/QALY after the third reintervention. CONCLUSIONS: Whereas the clinical effectiveness of performing percutaneous interventions on failing AVFs diminishes after each reintervention, they are nevertheless less costly than creating a new AVF. In comparison, our data show that creating a new AVF is cost-effective after the second open reintervention procedure.
Subject(s)
Arteriovenous Shunt, Surgical/adverse effects , Cost-Benefit Analysis , Graft Occlusion, Vascular/surgery , Models, Economic , Reoperation/economics , Adult , Aged , Arteriovenous Shunt, Surgical/economics , Computer Simulation , Female , Graft Occlusion, Vascular/diagnosis , Graft Occlusion, Vascular/economics , Humans , Kidney Failure, Chronic/economics , Kidney Failure, Chronic/therapy , Male , Markov Chains , Medicare/economics , Middle Aged , Quality-Adjusted Life Years , Renal Dialysis/economics , Renal Dialysis/methods , Retrospective Studies , Treatment Outcome , Ultrasonography, Doppler, Duplex , United States , Vascular PatencyABSTRACT
BACKGROUND: Almost 80% of patients with end-stage renal disease (ESRD) initiate dialysis via a central venous catheter (CVC). CVCs are associated with multiple complications and a high cost of care. The purpose of our project is to determine the impact of early cannulation arteriovenous grafts (ECAVGs) on quality of care and costs. METHODS: The dialysis access modality, complications, secondary interventions, hospital outcomes, and detailed costs were tracked for 397 sequential patients who underwent access creation between July 2014 and October 2018. Complications were grouped into deep vein thrombosis, line infections, sepsis, pneumothorax, and other. Secondary interventions included angioplasty, angioplasty and stent grafting, thrombectomy, surgical revision, and explantation. Hospital outcomes included length of stay, inpatient mortality, 30-day readmission, and discharge disposition. Costs included supplies, medications, laboratory tests, labor, and other direct costs. All variables were measured at the time of the index procedure, 30 days, 90 days, 180 days, 270 days, 1 year, 18 months, and 2 years. RESULTS: There were 131 patients who underwent arteriovenous fistula (AVF) and 266 who received ECAVG for dialysis access. The total cost of care per patient was $17,523 for AVF and $5,894 for ECAVG at 1 year (P < 0.01). Primary-assisted patency for AVF was 49.3% versus 81.4% for ECAVG (P = 0.027), and secondary-assisted patency for AVF was 63.8% versus 85.4% for ECAVG at 1 year (P = 0.011). There was a survival advantage for ECAVGs at 1 year (78.6% for AVF vs 85.0% for ECAVG, P = 0.034). Patients who received ECAVG had fewer CVC days (2.3% vs 19.1% for AVF, P < 0.001), fewer complications (1.6% vs. 21.5% for AVF, P < 0.001), and fewer secondary interventions (17.0% vs 52.5% for AVF, P < 0.001). CONCLUSIONS: This is the first study on patients with ESRD to report detailed outcomes and cost analysis as it relates to AVF versus ECAVG. ECAVGs have an advantage over AVFs due to lower overall cost and better clinical outcomes at 1 year. Implementation of an urgent start dialysis access program centered around ECAVGs may help achieve the national goal of better health care at a lower cost for patients with ESRD.
Subject(s)
Arteriovenous Shunt, Surgical , Catheterization , Kidney Failure, Chronic/therapy , Outcome and Process Assessment, Health Care , Renal Dialysis , Vascular Grafting , Arteriovenous Shunt, Surgical/adverse effects , Arteriovenous Shunt, Surgical/economics , Arteriovenous Shunt, Surgical/mortality , Arteriovenous Shunt, Surgical/standards , Catheterization/adverse effects , Catheterization/economics , Catheterization/mortality , Catheterization/standards , Cost Savings , Cost-Benefit Analysis , Female , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/therapy , Health Care Costs , Hospital Mortality , Hospitalization , Humans , Kidney Failure, Chronic/diagnosis , Kidney Failure, Chronic/economics , Kidney Failure, Chronic/mortality , Male , Middle Aged , Outcome and Process Assessment, Health Care/economics , Outcome and Process Assessment, Health Care/standards , Quality Indicators, Health Care , Renal Dialysis/adverse effects , Renal Dialysis/economics , Renal Dialysis/mortality , Renal Dialysis/standards , Retreatment , Time Factors , Treatment Outcome , Vascular Grafting/adverse effects , Vascular Grafting/economics , Vascular Grafting/mortality , Vascular Grafting/standardsABSTRACT
PURPOSE: To compare reinterventions and associated costs to maintain arteriovenous graft hemodialysis access circuits after rescue with percutaneous transluminal angioplasty (PTA), with or without concurrent Viabahn stent grafts, over 24 months. MATERIALS AND METHODS: This multicenter (n = 30 sites) study evaluated reintervention number, type, and cost in 269 patients randomized to undergo placement of stent grafts or PTA alone. Outcomes were 24-month average cumulative number of reinterventions, associated costs, and total costs for all patients and in 4 groups based on index treatment and clinical presentation (thrombosed or dysfunctional). RESULTS: Over 24 months, the patients in the stent graft arm had a 27% significant reduction in the average number of reinterventions within the circuit compared to the PTA arm (3.7 stent graft vs 5.1 PTA; P = .005) and similar total costs ($27,483 vs $28,664; P = .49). In thrombosed grafts, stent grafts significantly reduced the number of reinterventions (3.7 stent graft vs 6.2 PTA; P = .022) and had significantly lower total costs compared to the PTA arm ($30,329 vs $37,206; P = .027). In dysfunctional grafts, no statistical difference was observed in the number of reinterventions or total costs (3.7 stent graft vs 4.4 PTA; P = .12, and $25,421 stent graft and $22,610 PTA; P = .14). CONCLUSIONS: Over 24 months, the use of stent grafts significantly reduced the number of reinterventions for all patients, driven by patients presenting with thrombosed grafts. Compared to PTA, stent grafts reduced overall treatment costs for patients presenting with thrombosed grafts and had similar costs for stenotic grafts.
Subject(s)
Angioplasty, Balloon , Arteriovenous Shunt, Surgical/adverse effects , Blood Vessel Prosthesis Implantation/instrumentation , Blood Vessel Prosthesis , Graft Occlusion, Vascular/surgery , Renal Dialysis , Stents , Thrombosis/surgery , Angioplasty, Balloon/adverse effects , Angioplasty, Balloon/economics , Arteriovenous Shunt, Surgical/economics , Blood Vessel Prosthesis/economics , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/economics , Cost Savings , Cost-Benefit Analysis , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/etiology , Graft Occlusion, Vascular/physiopathology , Health Care Costs , Humans , Prospective Studies , Renal Dialysis/economics , Reoperation , Risk Factors , Stents/economics , Thrombosis/economics , Thrombosis/etiology , Thrombosis/physiopathology , Time Factors , Treatment Outcome , United StatesABSTRACT
Due to the implementation of the National Health Insurance system in 1995, the number of patients receiving maintenance dialysis has increased rapidly. This contributed to Taiwan to be in an unfortunate position of possessing the highest prevalence of end-stage renal disease globally. Although the age-standardized incidence of end-stage renal disease gradually decreased to -1.1% in 2014, the huge economic burden that comes with dialysis is detrimental to the quality of dialysis treatment. To achieve a balance between economy and quality of care requires multidisciplinary cooperation. Through a variety of chronic kidney disease-related care projects, we have gradually reversed this situation and achieved good results. Further promotion of kidney transplantation and hospice care for terminal patients will improve the situation. With respect to vascular access, the "fistula first" policy is carried out and percutaneous transluminal angioplasty is the mainstay of treatment to resolve vascular access dysfunction. The medical expenses for dialysis and vascular access management are both fully paid for by the National Health Insurance, and patients do not have to worry about the medical expenses. However, the statistics and vascular access monitoring are relatively insufficient in the past. The comprehensive integration of vascular access management into public policy related to kidney disease will complete the missing piece of the puzzle of overall care.
Subject(s)
Arteriovenous Shunt, Surgical/trends , Blood Vessel Prosthesis Implantation/trends , Catheterization, Central Venous/trends , Kidney Failure, Chronic/therapy , Renal Dialysis/trends , Arteriovenous Shunt, Surgical/adverse effects , Arteriovenous Shunt, Surgical/economics , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/economics , Catheterization, Central Venous/adverse effects , Catheterization, Central Venous/economics , Databases, Factual , Endovascular Procedures/trends , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/epidemiology , Graft Occlusion, Vascular/physiopathology , Graft Occlusion, Vascular/surgery , Health Care Costs/trends , Health Expenditures/trends , Humans , Incidence , Insurance, Health, Reimbursement/trends , Kidney Failure, Chronic/diagnosis , Kidney Failure, Chronic/economics , Kidney Failure, Chronic/epidemiology , Kidney Transplantation/trends , Prevalence , Renal Dialysis/adverse effects , Renal Dialysis/economics , Risk Factors , Taiwan/epidemiology , Time Factors , Treatment Outcome , Vascular PatencyABSTRACT
OBJECTIVE: We aimed to compare routine preoperative color-coded duplex ultrasound (DUS) to clinical examination (CE) alone in surgery for arteriovenous fistula (AVF) with special emphasis on long-term outcomes and cost effectiveness. METHODS: All patients undergoing an AVF formation or revision between January 1, 2011, and December 31, 2016, at our tertiary referral center were subject to analysis. Routine DUS was performed in 114 patients and CE alone in 217 patients. Primary and secondary patency, the need for revision or reintervention to obtain patency, and individual as well as overall costs were analyzed. RESULTS: Primary patency rate was higher in AVF after DUS compared with CE alone at 62% vs 26% (P < .05), respectively. Patients receiving DUS had significantly lower rates of revision and revisions per patient when compared with CE (25.4% vs 59.4% [P < .0001]; 0.36 ± 0.71 vs 1.06 ± 1.55 [P < .0001], respectively). Costs per patient were significantly lower in the DUS group compared with CE at 4074 vs 6078 (P < .0001). CONCLUSIONS: We were able to show that patients receiving preoperative DUS showed higher patency rates and needed fewer revisions. Standard preoperative ultrasound examination is an easy tool to improve outcomes and cost effectiveness in AVF surgery.
Subject(s)
Arteriovenous Shunt, Surgical/economics , Health Care Costs , Preoperative Care/economics , Renal Dialysis/economics , Ultrasonography, Doppler, Color/economics , Vascular Patency , Aged , Arteriovenous Shunt, Surgical/adverse effects , Cost Savings , Cost-Benefit Analysis , Female , Graft Occlusion, Vascular/diagnostic imaging , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/etiology , Graft Occlusion, Vascular/surgery , Humans , Male , Middle Aged , Preoperative Care/adverse effects , Reoperation/economics , Retrospective Studies , Tertiary Care Centers , Time Factors , Treatment Outcome , Ultrasonography, Doppler, Color/adverse effectsABSTRACT
PURPOSE: To conduct an economic analysis on the impact of increased stent graft (SG) use for treatment of arteriovenous graft (AVG) anastomotic stenosis or arteriovenous fistula (AVF)/AVG in-stent restenosis (ISR) from United States point-of-care (POC) and Medicare perspectives. MATERIALS AND METHODS: The analyses compared initial device and reintervention costs over 2 years between current and projected treatment mixes, including percutaneous transluminal angioplasty (PTA), bare metal stents (BMSs), and SGs. In projected scenarios, the absolute increase in SG use was approximately 3%. Costs included procedure reimbursement rates (Medicare) and device list prices (POC) for index procedures and reinterventions. Reintervention rates and types were informed by the RENOVA and RESCUE randomized trials. Reinterventions were primarily PTA only; however, stent use occurred a proportion of the time. BMS reintervention rates were assumed to be identical to PTA based on observational data. A population size of 1,000 patients was assumed. RESULTS: To the POC (n = 1,000), increased SG use was predicted to result in cost savings ranging from $4,106 to $34,420 for AVG anastomotic stenosis. For AVF/AVG ISR, increased SG use was predicted to result in either a cost increase of $17,187 or a cost savings of $13,159. To Medicare (n = 1,000), increased SG use was predicted to save costs for both populations, with savings ranging from $57,401 to $169,544. CONCLUSIONS: The use of SG for treatment of AVG anastomotic stenosis and AVF/AVG ISR appears to be economically favorable for POC providers and Medicare. Further data on reintervention rates are required from other SG trials to validate findings.
Subject(s)
Blood Vessel Prosthesis/economics , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/therapy , Point-of-Care Systems/economics , Stents/economics , Angioplasty/economics , Constriction, Pathologic , Costs and Cost Analysis , Humans , Medicare/economics , Retreatment/economics , United States , Vascular PatencyABSTRACT
BACKGROUND: Percutaneous transluminal angioplasty (PTA) and fistula reconstruction surgery are therapeutic options for vascular access occlusion in hemodialysis patients. However, owing to its convenience, PTA has gradually become the preferred therapeutic option for fistula stenosis or occlusion. This study investigated the effects of the two therapeutic methods on the vascular access maintenance duration (number of days) and maintenance costs of fistula in dialysis patients from different dialysis units. METHODOLOGY: In this study, 544 hemodialysis patients from 2 dialysis units in a teaching hospital in the southern area of Taiwan were included in the analysis of the frequency of PTA or revascularization surgery and the use of related medical resources by conducting a retrospective chart review. RESULTS: The frequency of PTA in the patients undergoing long-term hemodialysis was not significantly associated with their demographic characteristics. The efficacy of PTA has declined with shorter maintenance duration with increasing PTA frequency. The cost profile of PTA was more expensive than that of fistula revascularization surgery. CONCLUSIONS: In this study, PTA was found to be just a temporary solution for fistula thrombosis, whereas fistula reconstruction surgery is inexpensive and improves survival time. Therefore, dialysis units should establish an appropriate standard of care to avoid over-reliance on PTA in order to reduce the fistula failure rate, improve the dialysis efficacy, and reduce the psychological stress in patients, as well as to reduce the maintenance costs and rationalize the medical expenses.
Subject(s)
Angioplasty, Balloon , Arteriovenous Shunt, Surgical/adverse effects , Blood Vessel Prosthesis Implantation , Graft Occlusion, Vascular/therapy , Renal Dialysis , Thrombosis/therapy , Aged , Angioplasty, Balloon/adverse effects , Angioplasty, Balloon/economics , Arteriovenous Shunt, Surgical/economics , Blood Vessel Prosthesis , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/economics , Blood Vessel Prosthesis Implantation/instrumentation , Cost-Benefit Analysis , Female , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/etiology , Graft Occlusion, Vascular/physiopathology , Hospital Costs , Hospitals, Teaching , Humans , Male , Middle Aged , Retrospective Studies , Taiwan , Thrombosis/economics , Thrombosis/etiology , Thrombosis/physiopathology , Time Factors , Treatment Outcome , Vascular PatencyABSTRACT
BACKGROUND: Establishment and maintenance of vascular access for hemodialysis is life-sustaining for patients needing renal-replacement therapy. Arteriovenous fistulas (AVFs) are the preferred type of access, but the costs associated with creation and maintenance are poorly characterized, especially with respect to patient characteristics. METHODS: A prospectively maintained registry has been established at The Mount Sinai Hospital for patients undergoing access procedures since 2007. We studied 163 patients undergoing successfully placed and cannulated AVFs as their first permanent ipsilateral access and for whom 3-year follow-up was available, including 18 patients with failed contralateral AVFs. Records were analyzed for institutional inpatient and outpatient procedures related to access maturation, imaging, catheter-related procedures, and revisions. We determined hospital costs for 3 AVF locations, assessing the contribution of various factors to variation in costs and patency. RESULTS: The median first-year cost of patent AVFs was $8,662, with $4,754 attributable to initial creation. For fistulas remaining patent for at least 3 years, median cumulative 36-month costs were $11,639, with $1,343 attributable to imaging and $10,478 to creation and interventions. Fistulas with patent lifetimes of 19-30 months (3.7%) had median cumulative costs of $26,035. Those with patent lifetimes of 6 months or shorter (6.7%) had median cumulative costs of $17,526. Right-sided fistulas were associated with 41% higher 1-year costs and 38% higher 3-year costs when compared with left-sided fistulas. Human Immunodeficiency Virus (HIV) status and prior history of complex contralateral access were also associated with higher 1-year and 3-year costs. CONCLUSIONS: Hemodialysis access maintenance contributes significantly to the healthcare burden of renal disease. Our data suggest that particular patient characteristics factor into patency and costs. Short-term mounting costs associated with AVF maintenance may portend poor long-term patency. Rising healthcare costs cannot be easily controlled without understanding the clinical factors driving them.
Subject(s)
Arteriovenous Shunt, Surgical/economics , Hospital Costs , Kidney Failure, Chronic/economics , Kidney Failure, Chronic/therapy , Renal Dialysis/economics , Vascular Patency , Aged , Arteriovenous Shunt, Surgical/adverse effects , Cost Control , Cost-Benefit Analysis , Female , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/etiology , Graft Occlusion, Vascular/therapy , Humans , Kidney Failure, Chronic/diagnosis , Male , Middle Aged , New York City , Registries , Retreatment/economics , Retrospective Studies , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: In end-stage renal disease patients with central venous obstruction, who have limited vascular access options, the Hemodialysis Reliable Outflow (HeRO) Graft is a new alternative with a lower incidence of complications and longer effective device life compared to tunneled dialysis catheters (TDCs). We undertook an economic analysis of introducing the HeRO Graft in the UK. METHODS: A 1-year cost-consequence decision analytic model was developed comparing management with the HeRO Graft to TDCs from the perspective of the National Health Service in England. The model comprises four 3-month cycles during which the vascular access option either remains functional for hemodialysis or fails, patients can experience access-related infection and device thrombosis, and they can also accrue associated costs. Clinical input data were sourced from published studies and unit cost data from National Health Service 2014-15 Reference Costs. RESULTS: In the base case, a 100-patient cohort managed with the HeRO Graft experienced 6 fewer failed devices, 53 fewer access-related infections, and 67 fewer device thromboses compared to patients managed with TDCs. Although the initial device and placement costs for the HeRO Graft are greater than those for TDCs, savings from the lower incidence of device complications and longer effective device patency reduces these costs. Overall net annual costs are £2600 for each HeRO Graft-managed patient compared to TDC-managed patients. If the National Health Service were to reimburse hemodialysis at a uniform rate regardless of the type of vascular access, net 1-year savings of £1200 per patient are estimated for individuals managed with the HeRO Graft. CONCLUSIONS: The base case results showed a marginal net positive cost associated with vascular access with the HeRO Graft compared with TDCs for the incremental clinical benefit of reductions in patency failures, device-related thrombosis, and access-related infection events in a patient population with limited options for dialysis vascular access.
Subject(s)
Blood Vessel Prosthesis Implantation/economics , Blood Vessel Prosthesis/economics , Catheterization, Central Venous/economics , Catheters, Indwelling/economics , Central Venous Catheters , Health Care Costs , Kidney Failure, Chronic/economics , Kidney Failure, Chronic/therapy , Renal Dialysis/economics , Blood Vessel Prosthesis/adverse effects , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/instrumentation , Catheter Obstruction/economics , Catheter Obstruction/etiology , Catheter-Related Infections/economics , Catheter-Related Infections/microbiology , Catheter-Related Infections/therapy , Catheterization, Central Venous/adverse effects , Catheterization, Central Venous/instrumentation , Catheters, Indwelling/adverse effects , Cost-Benefit Analysis , Decision Support Techniques , England , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/etiology , Graft Occlusion, Vascular/therapy , Humans , Kidney Failure, Chronic/diagnosis , Models, Economic , Prosthesis Design , Prosthesis Failure , Prosthesis-Related Infections/economics , Prosthesis-Related Infections/microbiology , Prosthesis-Related Infections/therapy , State Medicine/economics , Thrombosis/economics , Thrombosis/etiology , Thrombosis/therapy , Time Factors , Treatment Outcome , Vascular PatencyABSTRACT
This study compared costs and clinical outcomes of invasive versus non-invasive diagnostic evaluations for patients with suspected in-stent restenosis (ISR) after percutaneous coronary intervention. We developed a decision model to compare 2 year diagnosis-related costs for patients who presented with suspected ISR and were evaluated by: (1) invasive coronary angiography (ICA); (2) non-invasive stress testing strategy of myocardial perfusion imaging (MPI) with referral to ICA based on MPI; (3) coronary CT angiography-based testing strategy with referral to ICA based on CCTA. Costs were modeled from the payer's perspective using 2014 Medicare rates. 56 % of patients underwent follow-up diagnostic testing over 2 years. Compared to ICA, MPI (98.6 %) and CCTA (98.1 %) exhibited lower rates of correct diagnoses. Non-invasive strategies were associated with reduced referrals to ICA and costs compared to an ICA-based strategy, with diagnostic costs lower for CCTA than MPI. Overall 2-year costs were highest for ICA for both metallic as well as BVS stents ($1656 and $1656, respectively) when compared to MPI ($1444 and $1411) and CCTA. CCTA costs differed based upon stent size and type, and were highest for metallic stents >3.0 mm followed by metallic stents <3.0 mm, BVS < 3.0 mm and BVS > 3.0 mm ($1466 vs. $1242 vs. $855 vs. $490, respectively). MPI for suspected ISR results in lower costs and rates of complications than invasive strategies using ICA while maintaining high diagnostic performance. Depending upon stent size and type, CCTA results in lower costs than MPI.
Subject(s)
Costs and Cost Analysis/statistics & numerical data , Graft Occlusion, Vascular/diagnosis , Graft Occlusion, Vascular/economics , Stents/economics , Coronary Angiography/economics , Exercise Test/economics , Humans , Myocardial Perfusion Imaging/economics , Percutaneous Coronary Intervention , Tomography, Emission-Computed, Single-Photon , Tomography, X-Ray Computed/economics , Treatment OutcomeABSTRACT
BACKGROUND: The Hemodialysis Reliable Outflow (HeRO) vascular access device is a hybrid polytetrafluoroethylene graft-stent construct designed to address central venous occlusive disease. Although initial experience has demonstrated excellent mid-term patency rates, subsequent studies have led to external validity questions. The purpose of this study was to examine a single center experience with this vascular access device in challenging access cases with associated costs. METHODS: A retrospective study representing the authors' cumulative HeRO vascular access device experience was undertaken. The primary endpoint was graft failure or death, with secondary endpoints including secondary intervention rates and cost. RESULTS: Forty-one patients with 15,579 HeRO days and a mean of 12.7 ± 1.5 mo with the vascular access device were available for analysis. Secondary patency was 81.6% at 6 mo and 53.7% at 12 mo. The reintervention rate was 2.84 procedures per HeRO vascular access device year. Associated HeRO costs related to subsequent procedures were estimated at $34,713.63 per patient/y. CONCLUSIONS: These data on the patency and primary outcome data diverge significantly from initial multicenter studies and represent a real-world application of this technology. It is costly to maintain patency. Use of HeRO vascular access devices should be judicious with outcome expectations reduced.
Subject(s)
Arteriovenous Shunt, Surgical/standards , Graft Occlusion, Vascular/prevention & control , Kidney Failure, Chronic/therapy , Renal Dialysis/instrumentation , Vascular Access Devices/standards , Arteriovenous Shunt, Surgical/economics , Female , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/mortality , Health Expenditures/statistics & numerical data , Humans , Kaplan-Meier Estimate , Kidney Failure, Chronic/economics , Kidney Failure, Chronic/mortality , Length of Stay/statistics & numerical data , Male , Middle Aged , Outcome Assessment, Health Care/economics , Renal Dialysis/economics , Renal Dialysis/mortality , Retrospective Studies , Vascular Access Devices/economicsABSTRACT
Drug-eluting stent (DES) deployment during percutaneous coronary intervention (PCI) has reduced target-vessel revascularisation rates (TVR). The selective use of DES in patients at highest risk of restenosis may allay concerns about universal compliance of dual antiplatelet therapy for one year, and potentially reduce costs. If this strategy achieved acceptably low TVR rates, such an approach could be attractive. Late clinical outcomes were examined in 2115 consecutive patients (mean age 63±12 years, 75% male, 22% diabetics) who underwent PCI in the first three years from October 2003, after commencing the following selective criteria for DES use: left main stenosis; ostial lesions of major epicardial arteries; proximal LAD lesions; lesions≥20mm in length with vessel diameter≤3.0mm; lesions in vessels≤2.5mm; diabetics with vessel(s)≤3.0mm; and in-stent restenosis. Among patients undergoing PCI, 2075 (98%) patients received stents (29%≥1 DES and 71% bare metal stent [BMS]), and among those who received DES, there was a 92% compliance with these criteria. There were no differences in clinical outcomes between the two stent groups except for definite stent thrombosis, which occurred in 2% after DES, and 0.6% after BMS at one year (p=0.002). With BMS, large coronary arteries (≥3.5mm), intermediate (3-3.49mm) and small arteries (<3mm) in diameter had a TVR rate at one year of 3.6%, 7.2% and 8.2% respectively (p=0.005). It is possible to use selective criteria for DES while maintaining low TVR rates. The TVR rate with BMS was low in those with stent diameters≥3.5mm. The higher DES stent thrombosis rate reflects first generation DES use, though whether routine second generation DES use reduces these rates needs confirmation.
Subject(s)
Drug-Eluting Stents/standards , Graft Occlusion, Vascular/prevention & control , Percutaneous Coronary Intervention/methods , Percutaneous Coronary Intervention/standards , Policy Making , Adult , Aged , Aged, 80 and over , Coronary Vessels/surgery , Costs and Cost Analysis , Female , Graft Occlusion, Vascular/economics , Humans , Male , Middle Aged , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/economics , Platelet Aggregation Inhibitors/administration & dosageABSTRACT
The creation and maintenance of vascular access for hemodialysis patients is responsible for a significant amount of morbidity and hospital expenses which continue to escalate with increasing population of ESRD patients. A retrospective review of patient charts were performed from 2008 to May 2011 at an academic tertiary care center who had a diagnosis of vascular access failure based on ICD 9 coding. Data regarding demographic information, length of stay (LOS), source of insurance, hospital expenses, and discharge status were obtained. Based on strict inclusion criteria we identified 172 total patients. The mean age among all patients was 60.53 ± 15.35 years and the majority of patients were Hispanic (n = 81). The Mean LOS was 5.30 ± 4.64 days. Mean hospital costs were 41,896 ± 20,318 US$. Patients admitted for tunneled dialysis placement had greater length of stay (p-value = 0.011) as did patients with hypertension (p-value = 0.030). Hospital expenses were significantly higher for patients admitted for arterio-venous fistula complications (55,456 ± 23,779 US$) compared with admissions for catheter or dialysis graft related complications (p-value = 0.004). Patients on Medicare had significantly lower length of stay (3.98 ± 3.32 days) compared with patients with Medicare/Medical (6.59 ± 5.69 days), p-value = 0.047. Inpatient management of vascular access failure is associated with increased length of stay, and significant hospital expenses. Timely referral to vascular access centers can prevent unnecessary hospitalizations and provide cost-saving benefits.
Subject(s)
Graft Occlusion, Vascular/therapy , Hospital Costs/trends , Inpatients , Renal Dialysis/economics , Vascular Surgical Procedures/economics , Adult , Aged , Arteriovenous Shunt, Surgical/adverse effects , Female , Graft Occlusion, Vascular/economics , Humans , Kidney Failure, Chronic/economics , Kidney Failure, Chronic/therapy , Length of Stay/economics , Length of Stay/trends , Male , Medicare/economics , Middle Aged , Retrospective Studies , United States , Vascular Surgical Procedures/methods , Young AdultABSTRACT
BACKGROUND: The use of an arteriovenous fistula (AVF) for haemodialysis treatment may be associated with a high early failure rate, but usually good long-term patency, while using an arteriovenous graft (AVG) yields a lower early failure rate with worse long-term patency. The aim of this study was to calculate and compare the costs and outcome of AVF and AVG surgery in terms of early and long-term patencies. METHODS: A decision tree and a Markov model were constructed to calculate costs and performance of AVFs and AVGs. The model was populated with a retrospective cohort of HD patients receiving their first VA. The outcomes were determined probabilistically with a 5-year follow-up. RESULTS: AVFs were usable for a mean (95% CI) of 28.5 months (24.6-32.5 months), while AVGs showed a patency of 25.5 months (20.0-31.2 months). The use of AVFs was the dominant type of VA and 631 could be saved per patient/per month patency compared to AVG use. Regardless of the willingness to pay, the use of AVFs yielded a higher probability of being cost-effective compared to AVGs. CONCLUSIONS: AVFs are more cost-effective than AVGs. Nonetheless, early failure rates significantly influence AVF performance and initiatives to reduce early failure can improve its cost-effectiveness.
Subject(s)
Arteriovenous Shunt, Surgical/economics , Blood Vessel Prosthesis Implantation/economics , Health Care Costs , Kidney Failure, Chronic/therapy , Renal Dialysis/economics , Arteriovenous Shunt, Surgical/adverse effects , Blood Vessel Prosthesis Implantation/adverse effects , Cost-Benefit Analysis , Decision Support Techniques , Decision Trees , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/etiology , Graft Occlusion, Vascular/therapy , Humans , Kidney Failure, Chronic/economics , Markov Chains , Models, Economic , Postoperative Complications/economics , Postoperative Complications/therapy , Retrospective Studies , Time Factors , Treatment Outcome , Vascular PatencyABSTRACT
Expenditures on dialysis vascular access now exceed $2.5 Billion annually in the US. Studies suggest that significant savings could be achieved by increasing arteriovenous fistula (AVF) prevalence to >65%. It is common but unsubstantiated opinion that AVF have lower maintenance costs than arteriovenous grafts (AVG). This manuscript tests this hypothesis by direct comparison. Equipment utilization time and supply utilization on 110 thrombectomy procedures on AVF and 258 on AVG were compared. Procedures techniques were standardized within one facility and procedures performed by a multiple but limited number of operators. There were no significant differences in demographic variables and comorbid factors between groups. Time to complete AVF thrombectomy was 1.7 times that for AVG. In addition, major supplies used such as wires and balloons were also significantly greater. Interventionists who took longer than average to thrombectomize AVF took longer than average to thrombectomize AVG. The prevalence of arterial inflow lesions was 1.5 greater in thrombosed AVF versus Thrombosed AVG. Procedure costs when analyzed in terms of procedure time, room utilization, staff, and equipment are significantly greater for thrombosed AVF than thrombosed AVG.
Subject(s)
Arteriovenous Shunt, Surgical/economics , Blood Vessel Prosthesis/economics , Graft Occlusion, Vascular/therapy , Thrombectomy/economics , Comorbidity , Female , Graft Occlusion, Vascular/economics , Humans , Kidney Failure, Chronic/therapy , Male , Middle Aged , Renal DialysisABSTRACT
PURPOSE: Endovascular procedures have been increasingly used for salvage of failing vascular access with conflicting results. The aim of this study was to assess the mid-term patency and complication rates of angioplasty procedures performed in a single center for treatment of stenosis compromising vascular accesses. METHODS: A prospective database of vascular accesses performed in 2006-2010 was investigated. The endovascular approach was applied following a standardized protocol by a dedicated team. A total of 531 consecutive procedures were reviewed (326 men; mean age 70.94 years). Patency rates were estimated using the Kaplan-Meier method. RESULTS: There were 199 procedures for failing access: 135 were surgical and 64 angioplasties performed for anastomosis (n=27), venous (n=45) or arterial (n=7) stenosis. Immediate technical success of endovascular procedures was 95.3%(61/64); complication rate was 6.3% (4/64). Primary patency rates were 55% at six months, 49% at 12 months, and 21% at 24 months. In the concurrent group of 135 open procedures, primary patency rates were 80% at six months and 67% at 12 months (P=.002); nevertheless, at 24 months, patency was as low as 49%. Cost estimates for angioplasty revealed additional fees ranging from 411.34 to 446.34 Euro with respect to open surgical procedures. CONCLUSIONS: Most dysfunctional vascular accesses can be successfully and safely treated by the endovascular route. In spite of poor mid-term durability, the angioplasty balloon might be considered as a bridge, effective, and repeatable solution with reasonable costs to prolong access survival avoiding additional surgery. The failure rate in the mid-term for dysfunctional vascular access may also be high after surgical reintervention.
Subject(s)
Angioplasty, Balloon , Arteriovenous Shunt, Surgical/adverse effects , Graft Occlusion, Vascular/therapy , Renal Dialysis , Adult , Aged , Aged, 80 and over , Angioplasty, Balloon/adverse effects , Angioplasty, Balloon/economics , Arteriovenous Shunt, Surgical/economics , Constriction, Pathologic , Female , Graft Occlusion, Vascular/diagnostic imaging , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/etiology , Graft Occlusion, Vascular/physiopathology , Health Care Costs , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Prospective Studies , Radiography , Renal Dialysis/economics , Reoperation , Time Factors , Treatment Outcome , Vascular Patency , Young AdultABSTRACT
Drug-eluting stents have dramatically reduced the risk of restenosis, but concerns of an increased risk of stent thrombosis have provided uncertainty about their use. Recent studies have continued to show improved procedural and clinical outcomes with drug-eluting stents both in the setting of acute coronary syndromes and stable coronary artery disease. Newer generation drug-eluting stents (especially everolimus-eluting stents) have been shown to be not only efficacious but also safe with reduced risk of stent thrombosis when compared with bare-metal stents, potentially changing the benchmark for stent safety from bare-metal stents to everolimus-eluting stents. While much progress is being made in the development of bioabsorbable polymer stents, nonpolymer stents and bioabsorbable stent technology, it remains to be seen whether these stents will have superior safety and efficacy outcomes compared with the already much improved rates of revascularization and stent thrombosis seen with newer generation stents (everolimus-eluting stents and resolute zotarolimus-eluting stents).
Subject(s)
Coronary Restenosis/prevention & control , Stents/trends , Absorbable Implants , Angioplasty, Balloon, Coronary/methods , Coronary Restenosis/economics , Cost-Benefit Analysis , Drug Combinations , Drug-Eluting Stents/economics , Drug-Eluting Stents/trends , Forecasting , Graft Occlusion, Vascular/economics , Graft Occlusion, Vascular/etiology , Humans , Myocardial Infarction/economics , Myocardial Infarction/therapy , Myocardial Revascularization/economics , Myocardial Revascularization/methods , Percutaneous Coronary Intervention/economics , Percutaneous Coronary Intervention/methods , Platelet Aggregation Inhibitors/economics , Platelet Aggregation Inhibitors/therapeutic use , Polymers/therapeutic use , Stents/economics , Thrombosis/economics , Thrombosis/etiologyABSTRACT
OBJECTIVE: To determine the cost-effectiveness of 2 different vascular access strategies among incident dialysis patients. BACKGROUND: Vascular access is a principal cause of morbidity and cost in hemodialysis patients. Recent guidelines and initiatives are intended to increase the proportion of patients with a fistula. However, there is growing awareness of the high prevalence of fistula failures and attendant complications. METHODS: A decision analysis using a Markov model was implemented to compare 2 different vascular access strategies among incident dialysis patients: (1) placing an arteriovenous fistula (AVF1st) as the initial access followed by a synthetic vascular access if the AVF did not mature compared to (2) placing a synthetic vascular access (SVA1st) as the initial access device. The cost-utility was evaluated across a range of the risk of complications from temporary catheters and SVA. RESULTS: Under base case assumptions, the AVF1st strategy yielded 2.19 quality-adjusted life years (QALYs) compared with 2.06 QALYs from the SVA1st strategy. The incremental cost-effectiveness was $9389 per QALY for AVF1st compared to SVA1st and was less than $50,000 per QALY as long as the probability of maturation is 36% or greater. AVF1st was the dominant strategy when the AVF maturation rate was 69% or greater. CONCLUSION: The high risk of complications of temporary catheters and the overall low AVF maturation rate explain why a universal policy of AVF1st for all incident dialysis patients may not optimize clinical outcomes. Strong consideration should be given to a more patient-centered approach taking into account the likelihood of AVF maturation.