Economic Impact of the Beneficial Effect of Changing Vascular Anastomotic Technique in Hemodialysis Access

Abstract

There is an urgent and compelling need to reduce the morbidity and expense of maintaining hemodialysis vascular access patency. We previously reported the beneficial effects of altering anastomotic technique on vascular access patency from a multicenter clinical trial. Interrupted anastomoses created with nonpenetrating clips showed significant improvement in primary, assisted primary, and secondary patencies of native vein fistulae (AVF) and synthetic arteriovenous grafts (AVG). In the current report, we provide an analysis of the economic impact of these procedures. The economic analysis is based on a subgroup of patients who underwent access procedures as outpatients during years 1998-1999 at a university-affiliated hospital that contributed 23% of procedures described in the multicenter clinical trial. Hospital charges and payments received were determined for fistula placement and for commonly performed surgical and endovascular procedures (thrombectomy and angioplasty) that maintain patency. Financial comparisons were based on the hospital's average accumulative charges and actual payments calculated on a daily basis. Cost curves were generated by using charge and payment data. Financial information was extrapolated to the entire study population to estimate the cost savings for the larger group. Both charge and payment calculations indicated financial benefit with the use of clips. When financial estimates were extrapolated to reflect the national volume, clip usage projected significant savings of $20 million for AVF and $30.8 million for AVG for every 1,000 days of access patency. Replacing conventional sutures with clips can reduce the morbidity and cost associated with maintaining permanent hemodialysis vascular accesses. This beneficial effect may be due to the biologic advantages of interrupted, nonpenetrating vascular anastomoses.

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

“…Furthermore, the breakout between incident and prevalent patients allowed for a more accurate comparison of the matched populations, given that almost one-half of the endoAVF patients in NEAT were incident at the time of fistula creation. Although we compared endoAVF costs with SAVF costs, there are limited studies within the SAVF literature comparing different AVF anastomotic techniques and associated cost of maintenance with SAVF (24). El-Gamil et al used USRDS to compare vascular access costs in freestanding office-based centers with the hospital outpatient department, but they combined SAVF and AVG outcomes, so the results can not be compared with the present study (25,26).…”

Comparison of Post-Creation Procedures and Costs between Surgical and an Endovascular Approach to Arteriovenous Fistula Creation

“…Due to the recent innovation of endoAVF, no prior endoAVF costing studies exist for comparison. Within the surgical AVF literature, there is also a paucity of economic studies evaluating different AVF anastomotic techniques that may have shown reduced costs associated with AVF creation and maintenance (16).…”

Pathogenesis and Prevention of Vascular Access Failure

“…There are multiple factors that contribute to the upstream events of vascular access dysfunction: (1) the proinflammatory uremic milieu that promotes endothelial dysfunction [16,60], (2) hemodynamic stressors at the anastomosis site due to a combination of small and non-compliant vessels, low shear stress and turbulence [16,61,62], (3) vascular injury at the time of fistula or graft formation due to vessel manipulation through surgical technique or angioplasty [16,61,62], (4) a localized inflammatory response involving cytokine release and macrophage migration caused by the synthetic graft material used in the formation of the AVG [16], (5) possible genetic predisposition to neointimal hyperplasia and vasoconstriction [11,16] 6and repeat cannulation injury [16,54].…”