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AVFs have high maintenance costs despite optimal access
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Arteriovenous fistula is considered the optimal access for patients on dialysis; however, a new study indicated that frequent and costly interventions are often required to make them useable among hemodialysis patients.
“Permanent AVF failure within the first year after surgical creation is reported to occur in up to 40% of patients and can result in prolonged [central venous catheter] dependence and subsequent morbidity, as well as the need for additional access surgery,” Mae Thamer, PhD, of the Medical Technology and Practice Patterns Institute in Bethesda, Md., and colleagues wrote.
The researchers used the U.S. Renal Data System (2010 to 2011) to analyze outcomes on access patency and nonuse of arteriovenous fistulas (AVFs) among patients aged 66 years and older.
They assigned patients (n = 10,135) to one of three cohorts: those who initiated hemodialysis (HD) therapy with a mature AVF; patients who initiated HD therapy with a central venous catheter (CVC) and a maturing AVF; and patients on HD therapy with a CVC only and an AVF created within 9 months after dialysis therapy initiation.
Investigators then tracked the procedures needed and costs associated with maintaining the access in the three groups, including the use of noninvasive diagnostic imaging, open surgical procedures, invasive imaging and endovascular interventions, inpatient admissions, and anesthesiology associated with access procedures. Patients may have had other accesses, such as a CVC, placed temporarily for dialysis with plans to use the AVF for long term use.
They found that among patients in cohorts 2 and 3, only 54% of the AVFs were successfully used for hemodialysis. Among that group, “10% were used but experienced secondary patency loss within 1 year of creation, and 83% experienced primary patency loss within 1 year of creation,” the researchers wrote. “Of AVFs that were used for HD, 40% to 63% required 1 or more interventional or surgical procedures before the first AVF use and 70% to 86% required 1 or more interventional or surgical procedure within 1 year of surgical creation,” they wrote.
As a result, costs for the AVF placement increased substantially as creating a usable fistula became more difficult. The vascular access–related per-patient per-year cost for a patient who initiated dialysis therapy with a mature fistula and had no procedures in the first year was $6,442. But as access interventions became necessary, costs to maintain the AVF climbed to $16,428 “for a patient who started dialysis therapy with a catheter, had an AVF created after initiation of dialysis therapy, and requires at least 1 additional procedure to maintain patency during the first year,” the researchers wrote. That rose to $17,808 for patients with AVFs who experienced secondary patency loss in year 1, and $31,630 for AVFs that were not used.
“AVF failure in the first year after creation is common and results in substantially higher health care costs,” the investigators concluded. “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.”
In a separate editorial, Jonathan H. Segal, MD and Richard A. Hirth, PhD of the Division of Nephrology and Department of Health Management and Policy at the University of Michigan, suggested that the push to use AVFs in patients who are best suited for other access options, such as arteriovenous grafts (AVGs), has led to a high failure rate. “Thus, after the initial gains brought about by the Fistula First program to increase the prevalence of AVFs, we have seen fistula rates reach a plateau in recent years, and many providers are adopting a more patient-centric approach that reconsiders the role of AVGs and even tunneled catheters.” And, while the assumption is that a fistula long-term is perhaps the best option for dialysis, “when we begin to account for additional procedures that are used to promote AVF maturation that were often missing in earlier literature, it becomes apparent that the median annual cost for vascular access care is nearly $4,000 greater in patients whose initial access is an AVF compared to an AVG despite a similar number of procedures for the 2 types of vascular access,” the investigators wrote. “This difference is largely driven by the surgical interventions used to salvage AVFs, which come at a higher cost than the percutaneous interventions more typically used with AVGs.” – by Mark Neumann
Disclosures: This study was funded by Proteon Therapeutics Inc, which is developing an investigational therapy for HD vascular access. Four authors are consultants for Proteon; one is an employee. Please see the full study for a complete list of financial disclosures.
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