Economic analysis of angiography and preemptive angioplasty to prevent hemodialysis‐access thrombosis

Abstract

Objectives: We sought to determine the economic value of early angiography and prophylactic angioplasty to prevent hemodialysis‐access thrombosis. Background: End stage renal disease consumes more than 6% of the Medicare budget. There is a need to understand the financial impact of each component of care. Methods: We conducted an observational economic analysis of a closed cohort of 818 hemodialysis patients, of whom 560 were referred for 1437 consecutive radiographic procedures during an 8‐year period. Patient‐level, bottom‐up microcosting methods provided supply and personnel costs before and after expansion of an angiographic referral program. Results: The rate of referral for malfunctioning but nonthrombosed hemodialysis accesses increased from 18.8 ± 8.8 to 48.3 ± 11.9 angiographic procedures per 100 patient‐years (P < 0.001), which was associated with a decline in access thrombosis from 27.6 to 22.0 events per 100 patient‐years (P = 0.029) and a net cost of $34,586 per 100 patient‐years. The incremental cost‐effectiveness ratio for invasive surveillance was $6,177 per thrombosis event avoided. The angiographic program expanded at the same time that the proportion of autogenous fistulas increased from 28.3% ± 11.3% to 59.7% ± 10.7% of total referrals (P = 0.0001). On multivariable logistic regression analysis, the expanded angiography program (P = 0.001) and the proportion of autogenous fistulas (P = 0.0001) were both independently associated with the reduction in access thrombosis. Conclusions: Given the incremental costs and the relatively modest benefits in preventing access thrombosis, preemptive angiographic management may represent a less efficient use of healthcare resources than increasing the number of patients with autogenous fistulas. © 2009 Wiley‐Liss, Inc.

Catheter Interventions for Hemodialysis Fistulas and Grafts

“…Beathard (53) reported 6-month patency rates of 61% and 1-year patency rate of 38% after a variety of catheter interventions by interventional nephrologists. Several studies (39,54) have shown that autogenous arteriovenous fistulas tend to have longer median patencies than prosthetic grafts after catheter-based intervention (Fig. 12).…”

Outcomes of Endovascular Intervention for Salvage of Failing Hemodialysis Access

“…Abandonment of a primary access frequently necessitates the creation of secondary and even tertiary accesses. The need for additional interventions 7) in a group of patients already immunocompromised by renal disease results in increased hospital stays, increased economic costs, 8) and increased morbidity and mortality. 1) Thus, it is important for nephrologists and vascular surgeons to adopt strategies that will minimize morbidity and maximize quality of life when dealing with patients on hemodialysis.…”

Percutaneous Treatment of Thrombosed Arteriovenous Fistulas

“…Bittl et al (12) recently published an economic analysis concluding that preemptive angiographic management of AVF dysfunction may represent a less efficient use of healthcare resources than increasing the number of patients with AVF. In the study presented here, we have demonstrated that salvage of clotted AVF by percutaneous thrombectomy rather than waiting for a new mature AVF, was associated with a reduction in access-related costs (Table 2).…”

“…Therefore, maintenance of a previously thrombosed AVF could be a highly expensive policy. Published data regarding the economic value of vascular access surveillance and prophylactic angioplasty to prevent AVF thrombosis are controversial (12,13), and information about the cost-effectiveness of AVF salvage procedures has been limited.…”