Desai Sapan S
Director of Performance Improvement, Northwest Community Healthcare, Arlington Heights, IL.
Ann Vasc Surg. 2019 Aug;59:158-166. doi: 10.1016/j.avsg.2019.02.007. Epub 2019 Apr 19.
Almost 80% of patients with end-stage renal disease (ESRD) initiate dialysis via a central venous catheter (CVC). CVCs are associated with multiple complications and a high cost of care. The purpose of our project is to determine the impact of early cannulation arteriovenous grafts (ECAVGs) on quality of care and costs.
The dialysis access modality, complications, secondary interventions, hospital outcomes, and detailed costs were tracked for 397 sequential patients who underwent access creation between July 2014 and October 2018. Complications were grouped into deep vein thrombosis, line infections, sepsis, pneumothorax, and other. Secondary interventions included angioplasty, angioplasty and stent grafting, thrombectomy, surgical revision, and explantation. Hospital outcomes included length of stay, inpatient mortality, 30-day readmission, and discharge disposition. Costs included supplies, medications, laboratory tests, labor, and other direct costs. All variables were measured at the time of the index procedure, 30 days, 90 days, 180 days, 270 days, 1 year, 18 months, and 2 years.
There were 131 patients who underwent arteriovenous fistula (AVF) and 266 who received ECAVG for dialysis access. The total cost of care per patient was $17,523 for AVF and $5,894 for ECAVG at 1 year (P < 0.01). Primary-assisted patency for AVF was 49.3% versus 81.4% for ECAVG (P = 0.027), and secondary-assisted patency for AVF was 63.8% versus 85.4% for ECAVG at 1 year (P = 0.011). There was a survival advantage for ECAVGs at 1 year (78.6% for AVF vs 85.0% for ECAVG, P = 0.034). Patients who received ECAVG had fewer CVC days (2.3% vs 19.1% for AVF, P < 0.001), fewer complications (1.6% vs. 21.5% for AVF, P < 0.001), and fewer secondary interventions (17.0% vs 52.5% for AVF, P < 0.001).
This is the first study on patients with ESRD to report detailed outcomes and cost analysis as it relates to AVF versus ECAVG. ECAVGs have an advantage over AVFs due to lower overall cost and better clinical outcomes at 1 year. Implementation of an urgent start dialysis access program centered around ECAVGs may help achieve the national goal of better health care at a lower cost for patients with ESRD.
近80%的终末期肾病（ESRD）患者通过中心静脉导管（CVC）开始透析。CVC与多种并发症及高昂的护理成本相关。我们项目的目的是确定早期动静脉移植物插管（ECAVG）对护理质量和成本的影响。
对2014年7月至2018年10月期间连续接受通路建立的397例患者的透析通路方式、并发症、二次干预、住院结局及详细成本进行跟踪。并发症分为深静脉血栓形成、管路感染、脓毒症、气胸及其他。二次干预包括血管成形术、血管成形术及支架植入术、血栓切除术、手术修复及取出。住院结局包括住院时间、住院死亡率、30天再入院率及出院处置情况。成本包括耗材、药物、实验室检查、人工及其他直接成本。所有变量在首次手术时、30天、90天、180天、270天、1年、18个月及2年时进行测量。
131例患者接受了动静脉内瘘（AVF），266例接受了ECAVG用于透析通路。1年时，AVF组患者的人均护理总成本为17,523美元，ECAVG组为5,894美元（P < 0.01）。AVF的一期辅助通畅率为49.3%，而ECAVG为81.4%（P = 0.027）；1年时，AVF的二期辅助通畅率为63.8%，而ECAVG为85.4%（P = 0.011）。1年时ECAVG具有生存优势（AVF为78.6%，ECAVG为85.0%，P = 0.034）。接受ECAVG的患者CVC使用天数更少（AVF为19.1%，ECAVG为2.3%，P < 0.001），并发症更少（AVF为21.5%，ECAVG为1.6%，P < 0.001），二次干预更少（AVF为52.5%，ECAVG为17.0%，P < 0.001）。
这是第一项针对ESRD患者报告与AVF和ECAVG相关的详细结局及成本分析的研究。由于总体成本较低且1年时临床结局更好，ECAVG比AVF更具优势。实施以ECAVG为中心的紧急开始透析通路计划可能有助于实现以更低成本为ESRD患者提供更好医疗保健的国家目标。
