Economic evaluation of suture versus clip anastomosis in arteriovenous fistula creation.

OBJECTIVE: Techniques such as the use of nonpenetrating vascular clips for arteriovenous fistula (AVF) anastomotic creation have been developed in an effort to reduce fistula-related complications. However, the outcomes data for the use of clips have remained equivocal, and the cost evaluations to support their use have been largely theoretical. Therefore, the present study aimed to determine both the clinical and the cost outcomes of AVFs created with nonpenetrating vascular clips compared with the continuous suture technique during a 10-year period at a single institution. METHODS: All patients undergoing AVF creation in the upper extremity from 2009 through 2018 were retrospectively analyzed. The patient demographics and AVF outcomes were collected and compared stratified by the surgical technique used. A cost analysis was performed of a subgroup of patients from 2013 to 2018. RESULTS: During the 10-year study period, 916 AVFs were created (79% using the continuous suture technique and 21% using nonpenetrating vascular clips). Patient demographics and comorbid conditions did not differ between the two groups, and no differences were present in maturation, primary patency, assisted primary patency, or complication rates between the two groups at 1 year. The suture group had a shorter time to maturation (4.3 months vs 5.5 months; P < .01) and improved secondary patency compared with the clip group (77.13% vs 69.59%; P = .03) The cost analysis of the procedures revealed a significant difference in direct costs (suture, $1389.26 vs clip, $1716.51; P < .01) and contribution margin (suture, $1770.19 vs clip, $1128.36; P < .01) for the two groups. CONCLUSIONS: Both suture and clip techniques in AVF creation demonstrated equivalent rates of maturation, primary patency, assisted primary patency, and complications at 1 year with higher expense associated with the use of clips. Thus, in an effort to reduce the economic burden of healthcare in the United States, the findings from the present study support the preferential use of the standard polypropylene suture technique when creating upper extremity AVFs.

Cost-effectiveness analysis of immediate access arteriovenous grafts versus standard grafts for hemodialysis.

OBJECTIVE: Immediate-access arteriovenous grafts (IAAVGs), or early cannulation arteriovenous grafts (AVGs), are more expensive than standard grafts (sAVGs) but can be used immediately after placement, reducing the need for a tunneled dialysis catheter (TDC). We hypothesized that a decrease in TDC-related complications would make IAAVGs a cost-effective alternative to sAVGs. METHODS: We constructed a Markov state-transition model in which patients initially received either an IAAVG or an sAVG and a TDC until graft usability; patients were followed through multiple subsequent access procedures for a 60-month time horizon. The model simulated mortality and typical graft- and TDC-related complications, with parameter estimates including probabilities, costs, and utilities derived from previous literature. A key parameter was median time to TDC removal after graft placement, which was studied under both real-world (7 days for IAAVG and 70 days for sAVG) and ideal (no TDC placed with IAAVG and 1 month for sAVG) conditions. Costs were based on current Medicare reimbursement rates and reflect a payer perspective. Both microsimulation (10,000 trials) and probabilistic sensitivity analysis (10,000 samples) were performed. The willingness-to-pay threshold was set at $100,000 per quality-adjusted life-year (QALY). RESULTS: IAAVG placement is a dominant strategy under both real-world ($1201.16 less expensive and 0.03 QALY more effective) and ideal ($1457.97 less expensive and 0.03 QALY more effective) conditions. Under real-world parameters, the result was most sensitive to the time to TDC removal; IAAVGs are cost-effective if a TDC is maintained for ≥23 days after sAVG placement. The mean catheter time was lower with IAAVG (3.9 vs 8.7 months; P < .0001), as was the mean number of access-related infections (0.55 vs 0.74; P < .0001). Median survival in the model was 29 months. Overall mortality was similar between groups (76.3% vs 76.7% at 5 years; P = .33), but access-related mortality trended toward improvement with IAAVG (6.1% vs 6.8% at 5 years; P = .052). CONCLUSIONS: The Markov decision analysis model supported our hypothesis that IAAVGs come with added initial cost but are ultimately cost-saving and more effective. This apparent benefit is due to our prediction that a decreased number of catheter days per patient would lead to a decreased number of access-related infections.

Quantifying The Costs of Creating and Maintaining Hemodialysis Access in An All-Payer Rate-Controlled Health System.

OBJECTIVES: The creation and maintenance of durable hemodialysis access is critically important for reducing patient morbidity and controlling overall costs within health systems. Our objective was to quantify the costs associated with hemodialysis access creation and its maintenance over time within a rate-controlled health system where charges equate to payments. METHODS: The Maryland Health Services Cost Review Commission administrative claims database was used to identify patients who underwent first-time access creation from 2012-2020. Patients were identified using CPT codes for access creation, and costs were accrued for the initial encounter and all subsequent outpatient access-related encounters. T-tests and Wilcoxon tests were used to compare reinterventions and access-related costs ($USD) between arteriovenous fistulae (AVF) and arteriovenous grafts (AVG). Multivariable modeling was used to quantify the association of access type with charge variation. RESULTS: Overall, 12,716 patients underwent first-time access creation (69.3% AVF vs. 30.7% AVG). There was no difference in freedom from reintervention between the two access types at any point following creation (HR: 1.03, 95%CI: 0.97-1.10); however, AVF were associated with a lower number of cumulative reinterventions (1.50 vs. 2.24) compared to AVG (P<0.0001). AVF was associated with lower overall costs in the year of creation ($9,388 vs. $13,539, P<0.0001), a difference that remained significant over the subsequent 3 years. The lower costs associated with AVF were present both in the costs associated with creation and subsequent maintenance. On multivariable analysis, AVF was associated with a $3,557 reduction in total access-related costs versus AVG (95%CI -$3828, -3287). CONCLUSION: AVF require fewer interventions and are associated with lower costs at placement and over the first three years of maintenance compared to AVG. The use of AVF for first-time hemodialysis access represents an opportunity for healthcare savings in appropriately selected patients with a high preoperative likelihood of AVF maturation.

Vascular Surgeons Are Not Adequately Valued by Traditional Productivity Metrics.

BACKGROUND: Reimbursements for professional services performed by clinicians are under constant scrutiny. The value of a vascular surgeon's services as measured by work relative value units (wRVUs) and professional reimbursement has decreased for some of the most common procedures performed. Hospital reimbursements, however, often remain stable or increases. We sought to evaluate fistulagrams as a case study and hypothesized that while wRVUs and professional reimbursements decrease, hospital reimbursements for these services increased over the same time period. METHODS: Medicare 5% claims data were reviewed to identify all fistulagrams with or without angioplasty or stenting performed between 2015 and 2018 using current procedural terminology codes. Reimbursements were classified into 3 categories: medical center (reimbursements made to a hospital for a fistulagram performed as an outpatient procedure), professional (reimbursement for fistulagrams based on compensation for procedures: work RVUs, practice expense RVU, malpractice expense RVU), and office-based laboratory (OBL, reimbursement for fistulagrams performed in an OBL setting). Medicare's Physician Fee Schedule was used to calculate wRVU and professional reimbursement. Medicare's Hospital Outpatient Prospective Payment System-Ambulatory Payment Classification was used to calculate hospital outpatient reimbursement. RESULTS: From 2015 to 2018, we identified 1,326,993 fistulagrams. During this study period, vascular surgeons experienced a 25% increase in market share for diagnostic fistulagrams. Compared with 2015, total professional reimbursements from 2017 to 2018 for all fistulagram procedures decreased by 41% (-$10.3 million) while OBL reimbursement decreased 29% (-$42.5 million) and wRVU decreased 36%. During the same period, medical center reimbursement increased by 6.6% (+$14.1 million). CONCLUSIONS: Vascular surgeons' contribution to a hospital may not be accurately reflected through traditional RVU metrics alone. Vascular surgeons performed an increasing volume of fistulagram procedures while experiencing marked reductions in wRVU and reimbursement. Medical centers, on the other hand, experienced an overall increase in reimbursement during the same time period. This study highlights that professional reimbursements, taken in isolation and without consideration of medical center reimbursement, undervalues the services and contributions provided by vascular surgeons.

Long-Term Functional Patency and Cost-Effectiveness of Arteriovenous Fistula Creation under Regional Anesthesia: a Randomized Controlled Trial.

BACKGROUND: Regional anesthesia improves short-term blood flow through arteriovenous fistulas (AVFs). We previously demonstrated that, compared with local anesthesia, regional anesthesia improves primary AVF patency at 3 months. METHODS: To study the effects of regional versus local anesthesia on longer-term AVF patency, we performed an observer-blinded randomized controlled trial at three university hospitals in Glasgow, United Kingdom. We randomly assigned 126 patients undergoing primary radiocephalic or brachiocephalic AVF creation to receive regional anesthesia (brachial plexus block; 0.5% L-bupivacaine and 1.5% lidocaine with epinephrine) or local anesthesia (0.5% L-bupivacaine and 1% lidocaine). This report includes findings on primary, functional, and secondary patency at 12 months; reinterventions; and additional access procedures (primary outcome measures were previously reported). We analyzed data by intention to treat, and also performed cost-effectiveness analyses. RESULTS: At 12 months, we found higher primary patency among patients receiving regional versus local anesthesia (50 of 63 [79%] versus 37 of 63 [59%] patients; odds ratio [OR], 2.7; 95% confidence interval [95% CI], 1.6 to 3.8; P=0.02) as well as higher functional patency (43 of 63 [68%] versus 31 of 63 [49%] patients; OR, 2.1; 95% CI, 1.5 to 2.7; P=0.008). In 12 months, 21 revisional procedures, 53 new AVFs, and 50 temporary dialysis catheters were required. Regional anesthesia resulted in net savings of £195.10 (US$237.36) per patient at 1 year, and an incremental cost-effectiveness ratio of approximately £12,900 (US$15,694.20) per quality-adjusted life years over a 5-year time horizon. Results were robust after extensive sensitivity and scenario analyses. CONCLUSIONS: Compared with local anesthesia, regional anesthesia significantly improved both primary and functional AVF patency at 1 year and is cost-effective. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: Local Anaesthesia versus Regional Block for Arteriovenous Fistulae, NCT01706354.

Site of service influence on stent use for hemodialysis access interventions.

OBJECTIVE: With rising health care spending in the United States, the Centers for Medicare and Medicaid Services (CMS) in recent years attempted to use reimbursement rates to influence use of less expensive care sites for covered patients, such as ambulatory surgery centers (ASCs) and office-based laboratories (OBLs), in lieu of hospital service sites. It has been suggested that cost savings have not been realized because of more procedures being performed by physicians with ownership interests in nonhospital facilities. CMS adopted massive reimbursement changes for 2019 OBL and ASC-based procedures, which reduced dialysis access angioplasty reimbursement in the ASC setting by 50%, whereas facility reimbursement for stenting increased by 33% above prior levels. The clinical utility of adjunctive stenting in treating dialysis access stenosis remains controversial and highly discretionary. As a vascular group performing such procedures in both a hospital and nonhospital facility in which we have equity interest, we reviewed our use of stents in dialysis access procedures both in the hospital and in the ASC/OBL to determine whether site of service affected stent use. METHODS: A retrospective review of a prospectively maintained database was performed from 2014 to 2018. All patients undergoing dialysis access angiography with angioplasty and adjunctive stent placement at our OBL (later ASC) and our primary hospital were included in the study. RESULTS: There were 961 angioplasty or stent procedures performed for dialysis accesses between the two sites, 564 (58.7%) in the hospital setting and 397 (41.3%) at the OBL/ASC. There was a significant difference in race and age between the two sites, with younger, minority patients more frequently being treated in the hospital and older, white patients more likely to be treated in the ambulatory setting; 153 (27.1%) underwent adjunctive stent placement in the hospital and 127 (32.0%) in the ambulatory setting (P = .09). CONCLUSIONS: Whereas financial incentives have not yet had an appreciable influence on stent use for dialysis access within previous reimbursement paradigms, the dramatic changes recently adopted by CMS may well alter this dynamic and could lead to substantially higher overall costs without proven clinical advantage. Interventionalists may be incentivized to add stents when performing balloon angioplasty in ASCs. With high failure and reintervention rates and increasingly expensive adjuncts (drug-coated balloons and stents, covered stents), the cost implications of attempts to incentivize interventionalists toward a specific type of procedure or site of care are substantial, and unintended negative consequences are likely to occur.

Bundled Medicare Payments: Trends in Utilization and Physician Payments for Dialysis Arteriovenous Fistula and Graft Maintenance Procedures From 2010 to 2018.

OBJECTIVE. The purposes of this study were to evaluate the volume of and payments for dialysis arteriovenous fistula and arteriovenous graft maintenance procedures among Medicare beneficiaries from 2010 to 2018 and analyze trends by physician specialty and practice setting after the introduction of bundled Current Procedural Terminology (CPT) codes in 2017. MATERIALS AND METHODS. Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File for the years 2010 through 2018 were extracted by use of the CPT codes for arteriovenous fistula and arteriovenous graft maintenance procedures. Total volumes, payment amounts (professional component), and trends were analyzed by physician specialty and practice setting. RESULTS. From 2010 to 2018, the volume of dialysis circuit maintenance procedures increased 25%, from 308,140 to 385,440 procedures. This increase was driven by increased volumes among nephrologists (30.0%) and surgeons (30.5%) with only a modest increase for interventional radiologists (1.5%). Total physician payments increased 20%, from $333.8 million to $399.5 million. After the introduction of bundled CPT codes in 2017, per-procedure physician payment decreased from $1073 in 2016 to $1025 in 2017 (4.5%). The true decrease in per-procedure payment was underestimated owing to inclusion of higher-cost stenting and embolization procedures in the dialysis-specific codes beginning in 2017. CONCLUSION. The volume of dialysis access maintenance procedures and total physician payments increased from 2010 to 2018 in keeping with the Centers for Medicare & Medicaid Services Fistula First Breakthrough Initiative. Introduction of bundled CPT codes in 2017, designed to reduce redundant payments, correlated with a decrease in average per-procedure physician payment.

Preoperative ultrasound improves patency and cost effectiveness in arteriovenous fistula surgery.

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.

Cost-effectiveness of repeated interventions on failing arteriovenous fistulas.

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.

Clinical Outcomes and Economic Impact of Starting Hemodialysis with a Catheter after Predialysis Arteriovenous Fistula Creation.

BACKGROUND: Patients with advanced chronic kidney disease frequently undergo arteriovenous fistula creation prior to reaching end-stage renal disease (ESRD), but some initiate hemodialysis with a central vein catheter, if their fistula is not yet usable. The clinical consequences of the delay in fistula use have not been quantified in such patients. We compared patients with pre-ESRD fistula surgery who initiated dialysis with a catheter versus a fistula in terms of the frequency of post-dialysis vascular access procedures and complications and their economic impact. METHODS: We identified 205 patients with predialysis fistula creation from 2006 to 2012 at a large dialysis center who started hemodialysis within the ensuing 2 years. Of these, 91 (44%) initiated dialysis with a catheter and 114 (56%) with a fistula. We compared these 2 groups in terms of their annual frequency of percutaneous vascular access procedures, surgical access procedures, total access procedures, hospitalizations due to catheter-related bacteremia, and overall cost of vascular access management. RESULTS: The 2 groups were similar in demographics, comorbidities, and fistula type. As compared to patients initiating dialysis with a fistula, those initiating with a catheter had a significantly greater annual frequency of percutaneous access procedures (1.29 [1.19-1.40] vs. 0.75 [0.68-0.82]), surgical access procedures (0.69 [0.61-0.76] vs. 0.59 [0.53-0.66]), total access procedures (1.98 [1.86-2.11] vs. 1.34 [1.26-1.44]), and hospitalizations due to catheter-related bacteremia (0.09 [0.07-0.12] vs. 0.02 [0.01-0.03]). Patients initiating dialysis with a catheter incurred a median overall annual cost of access management that was USD 2,669 higher (USD 6,372 [3,121-12,242) vs. USD 3,703 [1,867-6,953], p = 0.0001). CONCLUSION: Among patients with predialysis fistula creation, those initiating dialysis with a catheter versus a fistula had substantially more frequent percutaneous, surgical, and total vascular access procedures, as well as hospitalizations due to catheter-related bacteremia. The annual cost of access management was substantially higher in those initiating dialysis with a catheter.

Costs Attributable to Arteriovenous Fistula and Arteriovenous Graft Placements in Hemodialysis Patients with Medicare coverage.

INTRODUCTION: Hemodialysis (HD) in end-stage renal disease (ESRD) patients requires vascular access (VA) through an arteriovenous fistula (AVF), a prosthetic arteriovenous graft (AVG), or a central venous catheter. While AVF or AVG is commonly used for HD, the economic implications of AVF versus AVG use have not been fully established. We describe the healthcare resource utilization and costs of AVF and AVG use for incident ESRD patients in the United States. METHODS: This observational cohort study of AVF and AVG placements used data from the United States Renal Data System to identify and follow access placements. AVF and AVG placements after ESRD onset for incident patients from 2012 to 2014 with continuous Medicare primary coverage were included. All-cause and access-related Medicare costs were averaged over the placement lifetime and expressed as per dialysis-month costs. RESULTS: The analysis included 38,035 AVF placements and 12,789 AVG placements. Total all-cause monthly costs for AVF averaged USD 8,508; mean monthly costs were USD 3,027 for inpatient (IP), USD 3,139 for outpatient (OP), USD 1,572 for physician services, and USD 770 for other care settings. Access-related monthly costs averaged USD 1,699 and represented 20% of all-cause charges for AVFs. Mean all-cause monthly costs for AVG were USD 9,605; by setting monthly costs were USD 3,811 for IP, USD 3,034 for OP, USD 1,881 for physician services and USD 879 for other care settings. Access-related monthly costs averaged USD 2,656 and represented 28% of all-cause charges for AVGs. DISCUSSION/CONCLUSIONS: This study indicates that costs due to VA are a significant burden on Medicare budgets and on patients. The factors driving access-related utilization and costs merit attention in future research. Both optimizing process of care and discovery innovation may significantly accelerate better stewardship of available healthcare resources.

Clinical and Economic Benefits of Stent Grafts in Dysfunctional and Thrombosed Hemodialysis Access Graft Circuits in the REVISE Randomized Trial.

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.

Impact of Early Cannulation Grafts on Quality and Cost of Care for Patients With End-Stage Renal Disease.

BACKGROUND: The annual cost of care associated with end-stage renal disease (ESRD) per patient on hemodialysis is approaching $100,000, with nearly $42 billion in national spend per year. Early cannulation arteriovenous grafts (ECAVGs) help decrease the use of central venous catheters (CVCs), thus potentially decreasing the cost of care. However, a formal financial analysis that also includes the cost of CVC-related complications and secondary interventions has not been completed. The purpose of this project is to evaluate the overall financial costs associated with ECAVGs on patients with ESRD during a one-year period. METHODS: Access modality, complications, secondary interventions, hospital outcomes, and cost of care were determined for 397 sequential patients who underwent access creation between July 2014 and October 2018. A detailed financial analysis was completed, including an evaluation of implant, supplies, medications, laboratories, labor, and other direct costs. All variables were measured at the time of the index procedure, 30 days, 90 days, 180 days, 270 days, and one year. RESULTS: There were 131 patients who underwent arteriovenous fistula (AVF) and 266 who underwent ECAVG for dialysis access. The average cost of care was $17,523 for AVF and $5,894 for ECAVG at one year (P < 0.01). Fewer CVC-related complications and secondary interventions associated with ECAVGs saved $11,630 per patient with ESRD, primarily in the form of supply costs. Fewer CVCs in the patients receiving ECAVGs led to an additional $1,083 decrease in cost associated with sepsis reduction at one year. A subsequent decrease in length of stay and ICU utilization led to an additional $2.0 million decrease in annual cost of care for patients with ESRD. CONCLUSIONS: The use of ECAVGs has significant cost savings over using an AVF and CVC for urgent-start dialysis in patients with ESRD. This cost savings is secondary to decreased CVC-related complications and fewer secondary interventions. Significant national savings are possible with appropriate use of ECAVGs in patients with ESRD.

Two-Year Outcomes of Early Cannulation Arteriovenous Grafts for End-Stage Renal Disease.

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.

Medicare Costs Associated With Arteriovenous Fistulas Among US Hemodialysis Patients.

BACKGROUND: An arteriovenous fistula (AVF) is the recommended vascular access for hemodialysis (HD). Previous studies have not examined the resources and costs associated with creating and maintaining AVFs. STUDY DESIGN: Retrospective observational study. SETTING & PARTICIPANTS: Elderly US Medicare patients initiating hemodialysis therapy during 2010 to 2011. PREDICTOR: AVF primary and secondary patency and nonuse in the first year following AVF creation. OUTCOMES: Annualized vascular access costs per patient per year. RESULTS: Among patients with only a catheter at HD therapy initiation, only 54% of AVFs were successfully used for HD, 10% were used but experienced secondary patency loss within 1 year of creation, and 83% experienced primary patency loss within 1 year of creation. Mean vascular access costs per patient per year in the 2.5 years after AVF creation were $7,871 for AVFs that maintained primary patency in year 1, $13,282 for AVFs that experienced primary patency loss in year 1, $17,808 for AVFs that experienced secondary patency loss in year 1, and $31,630 for AVFs that were not used. Similar patterns were seen among patients with a mature AVF at HD therapy initiation and patients with a catheter and maturing AVF at HD therapy initiation. Overall, in 2013, fee-for-service Medicare paid $2.8 billion for dialysis vascular access-related services, ∼12% of all end-stage renal disease payments. LIMITATIONS: Lack of granularity with certain billing codes. CONCLUSIONS: AVF failure in the first year after creation is common and results in substantially higher health care costs. Compared with patients whose AVFs maintained primary patency, vascular access costs were 2 to 3 times higher for patients whose AVFs experienced primary or secondary patency loss and 4 times higher for patients who never used their AVFs. There is a need to improve AVF outcomes and reduce costs after AVF creation.

Choice of a second vascular access in hemodialysis patients whose initial arteriovenous fistula failed to mature.

OBJECTIVE: We have previously shown that arteriovenous fistulas (AVFs) are more expensive to create and to maintain than arteriovenous grafts (AVGs) in patients undergoing their first access. Because those for whom this first access fails may be a more disadvantaged group, we hypothesized that the cost of a second access may be different from that in the primary access group. With this in mind, we compared access costs in patients receiving a secondary AVF or AVG after their initial AVF failed to mature. METHODS: This was a retrospective cohort study of 92 patients who received a second vascular access (44 AVFs and 48 AVGs) after their first AVF failed to mature. We quantified the yearly frequency of percutaneous or surgical access interventions and catheter-related bacteremias (CRBs) using a computerized vascular access database. The costs associated with access procedures were quantified using the outpatient prospective payment schedule, and those related to hospitalization for CRB were determined from the diagnosis-related groups fee schedule. RESULTS: Patients receiving an AVF had fewer percutaneous procedures than those receiving an AVG (2.09 [95% confidence interval, 1.86-2.34] vs 2.61 [2.35-2.88]; P = .004), tended to undergo surgical interventions more frequently (1.21 [1.04-1.40] vs 1.00 [0.84-1.17]; P = .08), and experienced a similar yearly frequency of CRB hospitalizations (0.40 [0.31-0.52 vs 0.28 [0.20-0.38]; P = .07). Patients with a secondary AVF vs an AVG had a similar median yearly cost of percutaneous access interventions ($3567 [interquartile range, $1219-$4680] vs $4989 [$1570-$9752]; P = .14) and surgical access procedures ($6403 [$3494-$13,127] vs $4728 [$2563-$12,254]; P = .38) but a higher annual cost for CRBs ($3405 [$0-$12,825] vs $0 [$0-$5477]; P = .04). The total yearly access-related cost was similar in both groups ($19,477 [$9162-$36,916] vs $18,285 [$6850-$31,768]; P = .56). CONCLUSIONS: Patients undergoing a secondary AVF required more surgical procedures and sustained more bacteremia complications than patients undergoing a secondary AVG implantation. There was no significant difference in the total cost of access care for hemodialysis patients receiving a secondary AVF vs AVG.

Comparative effectiveness of one-stage versus two-stage basilic vein transposition arteriovenous fistulas.

OBJECTIVE: Basilic vein transposition (BVT) fistulas may be performed as either a one-stage or two-stage operation, although there is debate as to which technique is superior. This study was designed to evaluate the comparative clinical efficacy and cost-effectiveness of one-stage vs two-stage BVT. METHODS: We identified all patients at a single large academic hospital who had undergone creation of either a one-stage or two-stage BVT between January 2007 and January 2015. Data evaluated included patient demographics, comorbidities, medication use, reasons for abandonment, and interventions performed to maintain patency. Costs were derived from the literature, and effectiveness was expressed in quality-adjusted life-years (QALYs). We analyzed primary and secondary functional patency outcomes as well as survival during follow-up between one-stage and two-stage BVT procedures using multivariate Cox proportional hazards models and Kaplan-Meier analysis with log-rank tests. The incremental cost-effectiveness ratio was used to determine cost savings. RESULTS: We identified 131 patients in whom 57 (44%) one-stage BVT and 74 (56%) two-stage BVT fistulas were created among 8 different vascular surgeons during the study period that each performed both procedures. There was no significant difference in the mean age, male gender, white race, diabetes, coronary disease, or medication profile among patients undergoing one- vs two-stage BVT. After fistula transposition, the median follow-up time was 8.3 months (interquartile range, 3-21 months). Primary patency rates of one-stage BVT were 56% at 12-month follow-up, whereas primary patency rates of two-stage BVT were 72% at 12-month follow-up. Patients undergoing two-stage BVT also had significantly higher rates of secondary functional patency at 12 months (57% for one-stage BVT vs 80% for two-stage BVT) and 24 months (44% for one-stage BVT vs 73% for two-stage BVT) of follow-up (P < .001 using log-rank test). However, there was no significant difference between groups in use of interventions (58% for one-stage BVT vs 51% for two-stage BVT; P = .5) to maintain patency. These findings were confirmed in multivariate analysis, in which two-stage BVTs were associated with a significantly lower rate of failure (hazard ratio, 0.39; 95% confidence interval, 0.2-0.8; P < .05) than one-stage BVTs after controlling for confounding variables. Finally, the two-stage BVT was more cost-effective (3.74 QALYs for two-stage BVT vs 3.32 QALYs for one-stage BVT) during 5 years, with an incremental cost-effectiveness ratio of $4681 per QALY. CONCLUSIONS: Our data show that two-stage BVTs are more durable and cost-effective than one-stage procedures, with significantly higher patency and lower rates of failure among comparable risk-stratified patients. These findings suggest that additional upfront costs and resources associated with creating two-stage BVTs are justified by their long-term outcomes.

Hemodialysis Access Maintenance in the Medicare Population: An Analysis Over a Decade of Trends by Provider Specialty and Site of Service.

PURPOSE: To evaluate annual national trends in hemodialysis access maintenance procedures in the Medicare population by specialty and setting. METHODS: Medicare Physician Supplier Procedure Summary Master Files between 2005 and 2015 were analyzed for procedure codes of hemodialysis access angiography and percutaneous thrombectomy. Using physician specialty codes, component procedure volume for endovascular services were queried for radiology, medicine, and surgery. Data entries were analyzed by provider specialty and place of service. Average submitted and allowed charges per intervention were extracted. Linear regression modeling was used to identify trends in number of and allowed charges by specialty and practice setting. RESULTS: Between 2005 and 2015, the frequency of dialysis access angiography for Medicare fee-for-service beneficiaries increased by a total of 74.71% (211,181 to 368,955). Specialty-specific analysis demonstrated volume increases of 220.21% (22,128 to 101,109) for surgery, 249.02% (32,690 to 114,094) for medicine, and 2.81% (135,564 to 139, 367) for radiology. By 2015, an increased trend from hospital-based to non-hospital-based procedures associated with significantly higher reimbursement rates to providers (+18,798 non-hospital-based cases/year, $46.95/year, P ≤ .001) was also observed, with medicine performing the highest volume of non-hospital-based procedures. In this period, there was also a modest total overall increase of percutaneous thrombectomy procedures by 7.75% (61,485 to 66,250). CONCLUSIONS: The frequency of endovascular hemodialysis access maintenance procedures in the Medicare fee-for-service program has increased from 2005 to 2015, with the majority market share transitioning from radiologists to non-radiologists. Similarly, most access maintenance in this time period changed from hospital-based to non-hospital-based interventions.

Comparison between Surgical and Endovascular Hemodialysis Arteriovenous Fistula Interventions and Associated Costs.

PURPOSE: To compare: (i) rate of arteriovenous fistula (AVF) interventions in both incident and prevalent end-stage kidney disease patients; (ii) their associated costs; and (iii) intervention-free survival between patients with surgical hemodialysis arteriovenous fistula (SAVF) versus those with an endovascularly created fistula (endoAVF). MATERIALS AND METHODS: Data from the United States Renal Data System (USRDS) were abstracted to determine the rate of AVF interventions performed in the first year and associated costs (based on Medicare payment rates) for SAVFs created from 2011 to 2013 in the incident and prevalent patient cohorts. Comparative data for endoAVF were obtained from the Novel Endovascular Access Trial (NEAT). Event rates, intervention-free survival, and costs were compared between endoAVF and SAVF cohorts after 1:1 propensity score (PS) matching. RESULTS: In the matched incident patients, the event rate was 0.74 per patient-year (PY) for endoAVF versus 7.22/PY for SAVF (P < .0001), with a difference in expenditures of $16,494. Similarly, in matched prevalent patients the event rate was 0.46/PY for endoAVF vs 4.10/PY for SAVF (P < .0001), resulting in a cost difference of $13,389. Time-to-event analysis showed that at 1 year, 70% of endoAVF patients experienced freedom from intervention versus only 18% of SAVF patients for incident patients; these numbers were 62% and 18% for endoAVF and SAVF prevalent patients, respectively (P < .0001 for both). CONCLUSIONS: Both incident and prevalent patients with endoAVF required fewer interventions and had lower costs within the first year compared with matched patients with SAVF.

Impact of pay for performance on access at first dialysis in Queensland.

AIM: Commencement of haemodialysis with an arteriovenous fistula (AVF) or arteriovenous graft (AVG) is associated with improved survival compared with commencement with a central venous catheter. In 2011-2012, Queensland Health made incentive payments to renal units for early referred patients who commenced peritoneal dialysis (PD), or haemodialysis with an AVF/AVG. The aim of this study was to determine if pay for performance improved clinical care. METHODS: All patients who commenced dialysis in Australia between 2009 and 2014 and were registered with the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) were included. A multivariable regression model was used to compare rates of commencing dialysis with a PD catheter or permanent AVF/AVG during the pay-for-performance period (2011-2012) with periods prior (2009-2010) and after (2013-2014). RESULTS: A total of 10 858 early referred patients commenced dialysis during the study period, including 2058 in Queensland. In Queensland, PD as first modality increased with time (P < 0.001) but there was no change in AVF/AVG rate at first haemodialysis (P = 0.5). In a multivariate model using the pay-for-performance period as reference, the odds ratio for commencement with PD or haemodialysis with an AVF/AVG in Queensland was 1.02 (95% CI 0.81-1.29) in 2009-2010 and 1.28 (95% CI 1.01-1.61) in 2013-2014. There was no change for the rest of Australia (0.97 95% CI 0.87-1.09 in 2009-2010 and 1.00 95% CI 0.90-1.11 in 2013-14). CONCLUSION: Pay for performance did not improve rates of commencement of dialysis with PD or an AVF/AVG during the payment period. A lag effect on clinical care may explain the improvement in later years.