Schon Donald, Blume Steven W, Niebauer Kimberly, Hollenbeak Christopher S, de Lissovoy Gregory
Arizona Kidney Disease and Hypertension Center, Phoenix, Arizona, USA.
Clin J Am Soc Nephrol. 2007 Mar;2(2):268-76. doi: 10.2215/CJN.01880606. Epub 2007 Jan 24.
The Fistula First Initiative set a goal of 66% arteriovenous (AV) fistula-based access among US hemodialysis patients. This study modeled the impact of achieving the target AV fistula placement rate on Medicare expenditures and on dialysis patient survival and also reviewed economic disincentives for providers that will inhibit achieving this target. The model projects lifetime costs and survival in the US 2003 incident hemodialysis population. Annual treatment costs were estimated from previous analyses of Medicare expenditures by access modality. Patient survival by mode of access was derived from the Dialysis Morbidity and Mortality Study (DMMS). These parameters were applied to a cohort of patients who meet the 66% AV fistula target and an identical cohort with the current vascular access case mix. Comparison of outcomes yields estimates of differential total expenditures and total patient life-years. If prevalence AV fistula-based access in the 2003 incident hemodialysis cohort were 66% rather than the observed 35%, then the Center for Medicare and Medicaid Services would save $840 million in access-attributed expenditures over the expected lifetime of these patients. However, population survival would increase by 35,000 additional life-years, increasing total lifetime expenditures by a net of $1.4 billion. Relative to the current mix of access modality, the shift to 66% AV fistula would be achieved at a net incremental cost of $40,000 per year of life gained. Economic barriers to reaching this goal include financial disincentives to providing adequate predialysis care, performing AV fistula surgical procedures, and monitoring vascular access flow. Achievement of the 66% AV fistula target is cost-effective. Financial incentives in the form of higher reimbursement to encourage wider use of AV fistula placement also could be cost-effective.
“动静脉内瘘优先计划”设定了一个目标，即让美国血液透析患者中66%的患者使用基于动静脉（AV）内瘘的血管通路。本研究模拟了实现目标动静脉内瘘置入率对医疗保险支出以及透析患者生存率的影响，还审视了会阻碍实现该目标的对医疗服务提供者的经济抑制因素。该模型预测了2003年美国首次接受血液透析人群的终身成本和生存率。年度治疗成本是根据先前按血管通路方式对医疗保险支出的分析估算得出的。不同血管通路方式下的患者生存率源自透析发病率和死亡率研究（DMMS）。这些参数应用于一组达到66%动静脉内瘘目标的患者以及一组血管通路病例组合与当前相同的患者。对结果进行比较可得出不同的总支出和患者总生命年数的估算值。如果2003年首次接受血液透析队列中基于动静脉内瘘的血管通路普及率为66%而非观察到的35%，那么医疗保险和医疗补助服务中心在这些患者的预期生存期内将在与血管通路相关的支出上节省8.4亿美元。然而，人群生存率将额外增加3.5万个生命年，使总终身支出净增加14亿美元。相对于当前血管通路方式的组合，向66%动静脉内瘘的转变将以每获得一年生命净增加4万美元的成本实现。实现这一目标的经济障碍包括提供充分的透析前护理、实施动静脉内瘘外科手术以及监测血管通路血流量方面的经济抑制因素。实现66%动静脉内瘘目标具有成本效益。以更高报销额度形式提供的经济激励措施以鼓励更广泛地使用动静脉内瘘置入也可能具有成本效益。
