Medicare Costs Associated With Arteriovenous Fistulas Among US Hemodialysis Patients

Thamer, Mae; Lee, Timmy C.; Wasse, Haimanot; Glickman, Marc H.; Qian, Joyce; Gottlieb, Daniel; Toner, Scott; Pflederer, Timothy A.

doi:10.1053/j.ajkd.2018.01.034

Cited by 127 publications

(100 citation statements)

References 28 publications

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“…The main finding of this study is that the costs of attaining and maintaining patency increased with increasing risk of fistula maturation failure at one, three, and five years. Those AV-accesses that were likely to be at high risk of failure also had the greatest need for interventions and consequent increased costs to achieve and maintain access patency, which is consistent with other studies (12,(32)(33)(34). However, AV-access type was not a significant predictor of cost when the interaction between access type and risk of fistula maturation failure was considered.…”

Section: Discussionsupporting

confidence: 86%

The Effect of Risk of Maturation Failure and Access Type on Arteriovenous Access-Related Costs among Hemodialysis Patients

2020

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Background: Several studies report lower costs associated with attaining and maintaining patency for arteriovenous (AV) fistulas as compared to AV-grafts among hemodialysis patients. However, these costs may vary according to the AV-access's risk of failure to mature (FTM). To analyze the impact of AV-access type and risk of FTM on the total costs of attaining and maintaining Av-access patency over one, three, and five years post creation, among incident accesses.Methods: All first AV-access creations (January 1, 2002 -January 1, 2018), revisions/resections, and interventions from a single academic institution were prospectively captured. The units costs (2011 CAD) were estimated primarily through the provincial patient Ontario Case Costing Initiative database. The present value of total vascular access related costs from a third party payer perspective was calculated by multiplying specific unit costs by the number of AV-access creations, revisions/resections and interventions from the date of creation to one-, three-, and five-post creation. The potential associations of AV-access type and FTM risk stratum with AV-access cost were examined using Loglinear models and generalized estimating equations.Results: A total of 906 patients were included in the study, 696 fistulas and 210 grafts. The median present value of total costs to attain and maintain AV-access over one, three, and five years was positively associated with the highest FTM risk stratum in all models. It was not associated with AV-access type when the interaction between AV-access type and FTM risk stratum was considered. Conclusions:The costs of attaining and maintaining AV-access were increased among patients with high/very high FTM risk. Risk of FTM, related interventions and costs should be considered when choosing vascular access type for an individual patient. BackgroundFor adequate hemodialysis, a reliable vascular access is essential and remains the "Achille's Heel" of hemodialysis. The United States' national quality initiative to improve vascular access outcomes, originally called "Fistula First", was based on the perception that arteriovenous (AV) fistulas have superior patency, the fewest complications and are less costly compared with other vascular access types (1, 2). Indeed, catheters have been established as associated with the highest rates of complications, particularly infection (3-10), although they are often needed as a temporary measure, such as until an AV-access (fistula or graft) can be created and used, or as a valid long-term option in select circumstances (11,12). The validity of Fistula First has been recently been challenged in comparisons of outcomes of fistulas and grafts (12)(13)(14)(15)(16).A systematic review of observational studies comparing clinical outcomes between fistulas and grafts found that the former is associated with high rates of maturation failure but longer-term patency, while the latter is more likely to mature and mature quickly, but with shorter patency (17). The review noted that the included st...

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Section: Discussionsupporting

confidence: 86%

The Effect of Risk of Maturation Failure and Access Type on Arteriovenous Access-Related Costs among Hemodialysis Patients

2020

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“…As a result, the cohort studied is somewhat older than the incident population overall as reported in the ADR. A similar approach was undertaken in a recent analysis of USRDS data evaluating the costs of AVF among Medicare patients [24].…”

Section: Doi: 101159/000495355mentioning

confidence: 99%

Clinical Outcomes of Arteriovenous Access in Incident Hemodialysis Patients with Medicare Coverage, 2012–2014

et al. 2019

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Background: Chronic hemodialysis requires a mode of vascular access through an arteriovenous fistula (AVF), a prosthetic arteriovenous graft (AVG), or a central venous catheter (CVC). AVF is recommended over AVG or CVC due to increased patency and decreased intervention rates for those that mature. AVG are preferred over CVC due to decreased infection and mortality risk. The aims of this study were to evaluate the lifespan of AVF and AVG in maturation, sustained access use, and abandonment. Methods: The United States Renal Data System (USRDS), Medicare claims, and CROWNWeb were used to identify access placements. Patients with a first end-stage renal disease (ESRD) service from January 1, 2012 to June 30, 2014 with continuous coverage with Medicare as primary payer and ≥1 AVF or AVG placed after ESRD onset were included. Maturation was defined as the first use of the access for hemodialysis recorded in CROWNWeb. Sustained access use was defined as 3 consecutive months of use without catheter placement or replacement. Accesses that were never used at any time post-placement were considered abandoned. Results: The cohort included 38,035 AVF placements and 12,789 AVG placements. Sixty-nine percent of AVF and 72% of AVG matured. Fifty-two percent of AVF and 51% of AVG achieved sustained access use. One quarter of AVF and 14% of AVG were abandoned without use as recorded in CROWNWeb. Conclusion: Although considered the gold standard for vascular access, only half of AVF and AVG placements achieved sustained access use. The USRDS database has inherent limitations but provides useful clinical insight into maturation, sustained use, and abandonment.

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“…In Singapore, vascular access problems account for 40% of all renal admissions and 68% of all recurrent admission. Vascular access problems often results in significant morbidity in patients on maintenance haemodialysis, leading to loss of dialysis time, hospital admissions, an increase in catheter use and overall health‐care costs. Percutaneous transluminal angioplasty (PTA) with plain balloon angioplasty is the current standard of care for the treatment of dysfunctional AV accesses.…”

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confidence: 99%

Paclitaxel‐coated balloon in the treatment of recurrent dysfunctional arteriovenous access, real‐world experience and longitudinal follow up

et al. 2019

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Aim Dysfunctional arteriovenous (AV) access remains a significant cause of morbidity and hospital admission for patients with end stage renal failure on haemodialysis. This study was performed to evaluate the impact of paclitaxel‐coated Balloon (PCB) on the patency of AV access with recurrent stenoses. Methods We retrospectively studied haemodialysis patients who presented to our centre with recurrent AV access dysfunction and compared intervention‐free patency using plain balloon versus PCB. Results A total of 147 patients were followed up longitudinally. Intervention‐free patency was better following PCB compared to previous intervention using plain balloons (6.4 ± 5.8 versus 4.0 ± 3.7, P < 0.01). The 3‐ and 6‐month patency rates after PCB were significantly better compared to standard plain angioplasty balloon: 69.4% versus 52.4%, P < 0.01 and 42.9% versus 15.6%, P < 0.01 respectively. Kaplan–Meier survival analysis of circuit patency demonstrated the superiority of PCB over plain balloon angioplasty in both arteriovenous fistula and arteriovenous graft (P < 0.01 and P = 0.01 respectively) although the patency of arteriovenous fistula remained significantly better than arteriovenous graft following interventions with PCB (P < 0.01). Age of AV access and the number of previous interventions were found to be significant predictors of patency following PCB intervention. Conclusion Arteriovenous access intervention with PCB was shown to be superior compared to plain balloon in the treatment of both non‐thrombosed and thrombosed AV accesses in our multi‐ethnic population.

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Medicare Costs Associated With Arteriovenous Fistulas Among US Hemodialysis Patients

Cited by 127 publications

References 28 publications

The Effect of Risk of Maturation Failure and Access Type on Arteriovenous Access-Related Costs among Hemodialysis Patients

The Effect of Risk of Maturation Failure and Access Type on Arteriovenous Access-Related Costs among Hemodialysis Patients

Clinical Outcomes of Arteriovenous Access in Incident Hemodialysis Patients with Medicare Coverage, 2012–2014

Paclitaxel‐coated balloon in the treatment of recurrent dysfunctional arteriovenous access, real‐world experience and longitudinal follow up

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