Wagner Jason Kane, Fish Larry, Weisbord Steven D, Yuo Theodore H
Division of Vascular Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Division of Vascular Surgery, UPMC Presbyterian Hospital, UPMC Heart and Vascular Institute, Pittsburgh, PA, USA.
J Vasc Access. 2020 May;21(3):308-313. doi: 10.1177/1129729819874307. Epub 2019 Sep 9.
Arteriovenous fistula is the ideal hemodialysis access, but most patients start with tunneled dialysis catheter. Arteriovenous fistula and arteriovenous graft surgery may reduce tunneled dialysis catheter use and also increase procedural expenses. We compared Medicare costs associated with arteriovenous fistula, arteriovenous graft, and tunneled dialysis catheter.
Using the US Renal Data System, we identified incident hemodialysis patients in 2008 who started with tunneled dialysis catheter, survived at least 90 days, and had adequate Medicare records for analysis. We followed them until death or end of 2011; access modality was based on billing evidence of arteriovenous fistula or arteriovenous graft creation. We assumed patients without such records remained with tunneled dialysis catheter. We generated multivariate linear regression models predicting Medicare expenditures, censoring costs when patients died; we included all payments to physicians and institutions. We also created algorithms to identify access-related costs.
There were 113,505 patients in the US Renal Data System who started hemodialysis in 2008, of whom 51,002 Medicare patients met inclusion criteria. Of that group, 41,532 (81%) began with tunneled dialysis catheter; 27,064 patients were in the final analysis file. In the first 90 days after hemodialysis initiation, 6100 (22.5%) received arteriovenous fistula, 1813 (6.7%) arteriovenous graft, and 19,151 (70.8%) stayed with tunneled dialysis catheter. Annualized access costs by modality were tunneled dialysis catheter US$13,625 (95% confidence interval: US$13,426-US$13,285); arteriovenous fistula US$16,864 (95% confidence interval: US$16,533-US$17,194); and arteriovenous graft US$20,961 (95% confidence interval: US$20,967-US$21,654; p < .001). Multivariate linear regression demonstrated that staying with tunneled dialysis catheter had lowest access-related costs, arteriovenous fistula was intermediate, and those who underwent arteriovenous graft surgery were highest (p < .021). Access type was not significantly associated with total costs. Additional arteriovenous fistula and arteriovenous graft creation (US$3525 and US$3804 per access per year, respectively) and open and endovascular access-related interventions (US$3102 and US$3569 per procedure per year, respectively; all p < .001) were important predictors of increased cost.
Among patients starting hemodialysis with tunneled dialysis catheter, continued tunneled dialysis catheter use is associated with lowest access-related cost. Both endovascular and open interventions are associated with significant additional costs. Further investigation is warranted to develop efficient patient-centered strategies for hemodialysis access.
动静脉内瘘是理想的血液透析通路，但大多数患者起始采用带隧道的透析导管。动静脉内瘘和动静脉移植物手术可能会减少带隧道的透析导管的使用，同时也会增加手术费用。我们比较了与动静脉内瘘、动静脉移植物和带隧道的透析导管相关的医疗保险费用。
利用美国肾脏数据系统，我们确定了2008年起始采用带隧道的透析导管、存活至少90天且有足够医疗保险记录用于分析的新接受血液透析的患者。我们对他们进行随访直至死亡或2011年底；通路方式基于动静脉内瘘或动静脉移植物创建的计费证据。我们假定没有此类记录的患者仍使用带隧道的透析导管。我们生成了预测医疗保险支出的多变量线性回归模型，在患者死亡时对费用进行截尾；我们纳入了向医生和机构的所有支付。我们还创建了算法来识别与通路相关的费用。
美国肾脏数据系统中有113,505例患者在2008年开始进行血液透析，其中51,002例医疗保险患者符合纳入标准。在该组中，41,532例（81%）起始采用带隧道的透析导管；27,064例患者纳入最终分析文件。在开始血液透析后的前90天内，6100例（22.5%）接受了动静脉内瘘手术，1813例（6.7%）接受了动静脉移植物手术，19,151例（70.8%）仍使用带隧道的透析导管。按通路方式计算的年化通路成本为：带隧道的透析导管13,625美元（95%置信区间：13,426美元 - 13,285美元）；动静脉内瘘16,864美元（95%置信区间：16,533美元 - 17,194美元）；动静脉移植物20,961美元（95%置信区间：20,967美元 - 21,654美元；p <.001）。多变量线性回归表明，继续使用带隧道的透析导管的通路相关成本最低，动静脉内瘘居中，接受动静脉移植物手术的患者成本最高（p <.021）。通路类型与总成本无显著关联。额外的动静脉内瘘和动静脉移植物创建（分别为每年每次通路3525美元和3804美元）以及开放和血管腔内与通路相关的干预（分别为每年每次手术3102美元和3569美元；所有p <.001）是成本增加的重要预测因素。
在起始采用带隧道的透析导管进行血液透析的患者中，继续使用带隧道的透析导管与最低的通路相关成本相关。血管腔内和开放干预均与显著的额外成本相关。有必要进行进一步研究以制定以患者为中心的高效血液透析通路策略。
