Al-Balas Alian, Lee Timmy, Young Carlton J, Allon Michael
Division of Nephrology, University of Alabama at Birmingham, Birmingham, Ala.
Division of Nephrology, University of Alabama at Birmingham, Birmingham, Ala; Veterans Affairs Medical Center, Birmingham, Ala.
J Vasc Surg. 2018 Dec;68(6):1858-1864.e1. doi: 10.1016/j.jvs.2018.03.419. Epub 2018 Jun 21.
We have previously shown that arteriovenous fistulas (AVFs) are more expensive to create and to maintain than arteriovenous grafts (AVGs) in patients undergoing their first access. Because those for whom this first access fails may be a more disadvantaged group, we hypothesized that the cost of a second access may be different from that in the primary access group. With this in mind, we compared access costs in patients receiving a secondary AVF or AVG after their initial AVF failed to mature.
This was a retrospective cohort study of 92 patients who received a second vascular access (44 AVFs and 48 AVGs) after their first AVF failed to mature. We quantified the yearly frequency of percutaneous or surgical access interventions and catheter-related bacteremias (CRBs) using a computerized vascular access database. The costs associated with access procedures were quantified using the outpatient prospective payment schedule, and those related to hospitalization for CRB were determined from the diagnosis-related groups fee schedule.
Patients receiving an AVF had fewer percutaneous procedures than those receiving an AVG (2.09 [95% confidence interval, 1.86-2.34] vs 2.61 [2.35-2.88]; P = .004), tended to undergo surgical interventions more frequently (1.21 [1.04-1.40] vs 1.00 [0.84-1.17]; P = .08), and experienced a similar yearly frequency of CRB hospitalizations (0.40 [0.31-0.52 vs 0.28 [0.20-0.38]; P = .07). Patients with a secondary AVF vs an AVG had a similar median yearly cost of percutaneous access interventions ($3567 [interquartile range, $1219-$4680] vs $4989 [$1570-$9752]; P = .14) and surgical access procedures ($6403 [$3494-$13,127] vs $4728 [$2563-$12,254]; P = .38) but a higher annual cost for CRBs ($3405 [$0-$12,825] vs $0 [$0-$5477]; P = .04). The total yearly access-related cost was similar in both groups ($19,477 [$9162-$36,916] vs $18,285 [$6850-$31,768]; P = .56).
Patients undergoing a secondary AVF required more surgical procedures and sustained more bacteremia complications than patients undergoing a secondary AVG implantation. There was no significant difference in the total cost of access care for hemodialysis patients receiving a secondary AVF vs AVG.
我们之前已经表明，对于首次建立血管通路的患者，动静脉内瘘（AVF）的建立和维护成本高于动静脉移植物（AVG）。由于首次血管通路失败的患者可能是更弱势的群体，我们推测二次血管通路的成本可能与初次血管通路组不同。考虑到这一点，我们比较了初次AVF未成熟后接受二次AVF或AVG的患者的血管通路成本。
这是一项回顾性队列研究，研究对象为92例初次AVF未成熟后接受二次血管通路的患者（44例AVF和48例AVG）。我们使用计算机化血管通路数据库对经皮或手术血管通路干预及导管相关菌血症（CRB）的年度发生频率进行量化。使用门诊前瞻性支付计划对血管通路程序相关成本进行量化，与CRB住院相关的成本则根据诊断相关分组费用表确定。
接受AVF的患者经皮操作次数少于接受AVG的患者（2.09[95%置信区间，1.86 - 2.34]对2.61[2.35 - 2.88]；P = 0.004），手术干预频率更高（1.21[1.04 - 1.40]对1.00[0.84 - 1.17]；P = 0.08），CRB住院的年度发生频率相似（0.40[0.31 - 0.52]对0.28[0.20 - 0.38]；P = 0.07）。二次AVF与AVG患者经皮血管通路干预的年度中位数成本相似（3567美元[四分位间距，1219 - 4680美元]对4989美元[1570 - 9752美元]；P = 0.14），手术血管通路程序成本也相似（6403美元[3494 - 13127美元]对4728美元[2563 - 12254美元]；P = 0.38），但CRB的年度成本更高（3405美元[0 - 12825美元]对0美元[0 - 5477美元]；P = 0.）。两组的年度血管通路相关总成本相似（19477美元[91,62 - 36916美元]对18285美元[6850 - 31768美元]；P = 0.56）。
接受二次AVF的患者比接受二次AVG植入的患者需要更多的手术操作，且菌血症并发症更多。接受二次AVF与AVG的血液透析患者的血管通路护理总成本无显著差异。
