Synthetic vascular hemodialysis access versus native arteriovenous fistula: a cost-utility analysis.

Abstract

To determine the cost-effectiveness of 2 different vascular access strategies among incident dialysis patients. Vascular access is a principal cause of morbidity and cost in hemodialysis patients. Recent guidelines and initiatives are intended to increase the proportion of patients with a fistula. However, there is growing awareness of the high prevalence of fistula failures and attendant complications. A decision analysis using a Markov model was implemented to compare 2 different vascular access strategies among incident dialysis patients: (1) placing an arteriovenous fistula (AVF1st) as the initial access followed by a synthetic vascular access if the AVF did not mature compared to (2) placing a synthetic vascular access (SVA1st) as the initial access device. The cost-utility was evaluated across a range of the risk of complications from temporary catheters and SVA. Under base case assumptions, the AVF1st strategy yielded 2.19 quality-adjusted life years (QALYs) compared with 2.06 QALYs from the SVA1st strategy. The incremental cost-effectiveness was $9389 per QALY for AVF1st compared to SVA1st and was less than $50,000 per QALY as long as the probability of maturation is 36% or greater. AVF1st was the dominant strategy when the AVF maturation rate was 69% or greater. The high risk of complications of temporary catheters and the overall low AVF maturation rate explain why a universal policy of AVF1st for all incident dialysis patients may not optimize clinical outcomes. Strong consideration should be given to a more patient-centered approach taking into account the likelihood of AVF maturation.