Choice of Vascular Access among Incident Hemodialysis Patients: A Decision and Cost-Utility Analysis

Arteriovenous fistulas (AVFs) are widely accepted as the preferred hemodialysis vascular access type. However, supporting data have failed to consider morbidity and mortality incurred during failed creation attempts and may therefore overstate potential advantages. This study compares survival, qual...

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Bibliographic Details
Published in:Clinical journal of the American Society of Nephrology 2010-12, Vol.5 (12), p.2289-2296
Main Authors: Hui Xue, Eduardo Lacson, Jr, Weiling Wang, Gary C. Curhan, Steven M. Brunelli
Format: Article
Language:English
Subjects:
Arteriovenous Shunt, Surgical - economics
Costs and Cost Analysis
Humans
Markov Chains
Original
Probability
Renal Dialysis - economics
Renal Dialysis - mortality
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Summary:Arteriovenous fistulas (AVFs) are widely accepted as the preferred hemodialysis vascular access type. However, supporting data have failed to consider morbidity and mortality incurred during failed creation attempts and may therefore overstate potential advantages. This study compares survival, quality-adjusted survival, and costs among incident hemodialysis patients after attempted placement of AVFs or arteriovenous grafts (AVGs). Analogous Markov models were created, one each for AVF and AVG. Patients entered consideration at the time of first access creation, contemporaneous with dialysis initiation. Subsequent outcomes were determined probabilistically; transition probabilities, utilities, and costs were gathered from published sources. To ensure comparability between AVFs and AVGs, the timing and likelihood of access maturation were measured in a contemporary cohort of incident hemodialysis patients. Mean (SD) overall survival was 39.2 (0.8) and 36.7 (1.0) months for AVFs and AVGs, respectively: difference (95% confidence interval [CI]) 2.6 (1.8, 3.3) months. Quality-adjusted survival was 36.1 (0.8) and 32.5 (0.9) quality-adjusted life months (QALMs) for AVFs and AVGs, respectively: difference (95% CI) 3.6 (2.8, 4.3) QALMs. The incremental cost-effectiveness ratio (95% CI) for AVFs relative to AVGs was $446 (-6023, 6994) per quality-adjusted life year saved. AVFs are associated with greater overall and quality-adjusted survival than AVGs. Observed differences were much less pronounced than might be expected from existing literature, suggesting that prospective identification of patients at high risk for AVF maturational failure might enable improvements in health outcomes via individualization of access planning.
ISSN:1555-9041
1555-905X
DOI:10.2215/CJN.03210410