Placing the “gold standard” of access types – the arteriovenous fistula – in patients can be costlier in terms of access-related procedures and complications compared to placing an arteriovenous graft if a central venous catheter is also used at some point during dialysis, according to results of a recently published study.
Researchers at the University of Alabama and the VA Medical Center in Birmingham examined the clinical and economic effects of vascular access choice in 479 patients starting hemodialysis from 2004 to 2012 with a central venous catheter (CVC) and who later had an arteriovenous fistula (AVF; n=295) or arteriovenous graft (AVG; n=105) placed, or who had no arteriovenous access (CVC only group, n=71).
Although the AVF is considered more reliable and trouble-free compared to the AVG, patients who received an AVF had more frequent surgical access procedures per year but had a similar frequency of percutaneous access procedures per year, the authors wrote.
“Patients receiving an AVF had a higher median annual cost (interquartile range) of surgical access procedures than those receiving an AVG ($4857 [$2523 to $8835] vs. $2819 [$1411 to $4274]; P=0.001), whereas the annual cost of percutaneous access procedures was similar in both groups,” they wrote. “The AVF group had a higher median overall annual access-related cost than the AVG group ($10,642 [$5406 to $19,878] vs. $6810 [$3718 to $13,651]; P=0.001) after controlling for patient age, sex, race and diabetes.”
Patients who stayed with a CVC and had no arteriovenous replacement had the highest median annual overall access-related cost ($28,709), “largely attributable to the high frequency of hospitalizations due to catheter-related bacteremia,” the authors wrote.
In comparing the costs of access care, the authors noted the importance of recognizing the impact of both the placement and the working status of an AVF.
“AVFs are considered superior to arteriovenous grafts (AVGs) because they have a longer cumulative patency for dialysis and require fewer interventions to maintain this patency,” the authors wrote. “However, this conclusion may be misleading because it focuses only on those vascular accesses that have been successfully cannulated for dialysis. It does not consider the frequency of procedures required to achieve AVF maturation, the relatively high rate of AVFs that fail to mature despite percutaneous or surgical interventions to promote their maturation, or the effect of prolonged catheter dependence arising from AVF failure.” – by Mark E. Neumann
Al-Balas A, et al. J Am Soc Nephrol.2017;doi.org/10.1681/ASN.2016060707.