Establishment and Maintenance of Vascular Access in Incident Hemodialysis Patients

Abstract

Despite the importance of hemodialysis vascular access, the cost of vascular access care has not been studied in detail. A prospective cost analysis was performed among incident hemodialysis patients to determine the cost of vascular access care overall and on the basis of access type. Detailed clinical and demographic information, as well as data on access type, was collected for all local incident hemodialysis patients between July 1, 1999, and November 1, 2001. A comprehensive measure of total vascular access costs, including surgery, radiology, hospitalization for access complications, physician costs, costs for management of outpatient bacteremia, and vascular access monitoring costs, was obtained. Costs are reported in 2002 Canadian dollars (1 CAN dollar = 0.69 US dollar). A total of 239 consecutive incident hemodialysis patients were identified, 49, 157, and 33 of whom were dialyzed exclusively with a catheter or had a native arteriovenous fistula or synthetic graft attempted, respectively. In year 1, 18.4% of all hospital admissions were for vascular access-related complications. The mean cost of all vascular access care in year 1 was 6890 CAN dollars(median 4020 dollars; interquartile range [IQR] 2440 dollars to 7540 dollars). The mean cost of access care per patient-year at risk for maintaining a catheter exclusively, attempting an arteriovenous fistula, or attempting a graft was 9180 dollars (median 3812 dollars; IQR 2250 dollars to 7762 dollars), 7989 dollars (median 4641 dollars ; IQR 3035 dollars to 8832 dollars), and 11,685 dollars (median 8152 dollars; IQR 3395 dollars to 12,908 dollars), respectively (P = 0.01). Vascular access care is responsible for a significant proportion of health care costs in the first year of hemodialysis. These results support clinical practice guidelines that recommend preferential placement of a native fistula.

Relationship between Blood Flow in Central Venous Catheters and Hemodialysis Adequacy

“…The costs that are attributed to the use of t-PA and line exchange are not known. A recent cost analysis of vascular access calculated CVC at $9180 Can (median $3812; interquartile range $2250 to $7762) per patient-year (16). In this study, catheter dysfunction was defined as blood flow of Ͻ200 ml/min, and the cost of t-PA was $199 per patient-year at risk.…”

“…The reported incidence of catheter dysfunction ranges from 5 to 80%, depending on the definition, population, and catheter characteristics (7)(8)(9)(10)(11)(12)(13)(14)(15)(16). The interpretation of studies that use blood flow as a measure of catheter dysfunction are challenging without knowledge of blood pump setting, use of average versus episodic measures of blood flow, percentage of recirculation, and other dialysis variables.…”

“…The definition of CVC dysfunction varies across the literature and includes variable rates of blood flow ranging from Ͻ100 to 350 ml/min (7)(8)(9)(10)(11)(12)(13)(14)(15)(16). The NKF-DOQI vascular access guideline defines CVC dysfunction as failure to attain and maintain extracorporeal blood flow that is sufficient to perform HD without significantly lengthening the HD treatment and considered insufficient extracorporeal blood flow to be Ͻ300 ml/min (6).…”

Fistula First Initiative

“…The majority (70%) of the cost of maintaining an AVF is in the initial surgery and diagnostic radiology procedures required to support AVF function (62). In Canada, this cost to facilitate AVF maturation is not different from that of a successful graft (AVF CAN$7740 in the first year versus graft CAN$8130 in the first year) (62). In the United States, the cost of AVF creation and managing its complications is $11,609/yr (40).…”

“…Annually, approximately 30% of patients who use a CVC have a septic or bacteremic episode (45). Studies that compare the financial costs of creating and maintaining access types (62,66) underestimate the cost of CVC, because CVC-attributable costs are excluded once patients have died (62) (mortality rate was 51% in the first year in patients who exclusively used CVC). It is further underestimated as a result of the inability to capture data on access procedures, infection-related hospitalizations, or deaths in non-Medicareinsured patients.…”