Cost-effectiveness Analysis of Vascular Access Referral Policies in CKD.

The optimal timing of vascular access referral for patients with chronic kidney disease who may need hemodialysis (HD) is a pressing question in nephrology. Current referral policies have not been rigorously compared with respect to costs and benefits and do not consider patient-specific factors such as age. Monte Carlo simulation model. Patients with chronic kidney disease, referred to a multidisciplinary kidney clinic in a universal health care system. Cost-effectiveness analysis, payer perspective, lifetime horizon. The following vascular access referral policies are considered: central venous catheter (CVC) only, arteriovenous fistula (AVF) or graft (AVG) referral upon HD initiation, AVF (or AVG) referral when HD is forecast to begin within 12 (or 3 for AVG) months, AVF (or AVG) referral when estimated glomerular filtration rate is <15 (or <10 for AVG) mL/min/1.73m2. Incremental cost-effectiveness ratios (ICERs, in 2014 US dollars per quality-adjusted life-year [QALY] gained). The ICER of AVF (AVG) referral within 12 (3) months of forecasted HD initiation, compared to using only a CVC, is ∼$105k/QALY ($101k/QALY) at a population level (HD costs included). Pre-HD AVF or AVG referral dominates delaying referral until HD initiation. The ICER of pre-HD referral increases with patient age. Results are most sensitive to erythropoietin costs, ongoing HD costs, and patients' utilities for HD. When ongoing HD costs are excluded from the analysis, pre-HD AVF dominates both pre-HD AVG and CVC-only policies. Literature-based estimates for HD, AVF, and AVG utilities are limited. The cost-effectiveness of vascular access referral is largely driven by the annual costs of HD, erythropoietin costs, and access-specific utilities. Further research is needed in the field of dialysis-related quality of life to inform decision making regarding vascular access referral.

Shechter SM ，Chandler T ，Skandari MR ，Zalunardo N ... -  《-》

Timing of arteriovenous fistula creation in patients With CKD: a decision analysis.

The optimal time for arteriovenous fistula (AVF) referral is uncertain. Improving the timeliness of referral may reduce central venous catheter (CVC) use. Monte Carlo simulation model. Patients with chronic kidney disease (CKD) followed up in a multidisciplinary clinic, overall and stratified by age. Decision analysis, patient, patient's lifetime. AVF referral, using 1 of 2 strategies: refer when hemodialysis is anticipated to begin within a certain time frame or refer when estimated glomerular filtration rate (eGFR) drops below a certain threshold. A range of values for each strategy are compared to each other with respect to incident vascular access type (AVF or CVC), percentage of patients with an unnecessary AVF creation, and life expectancy after dialysis therapy initiation. A 15-month referral time frame gave 34% with incident CVCs, 14% with unnecessary AVFs, and a life expectancy of 1,751 days. Time frames of 12-18 months performed similarly. Referral at eGFR of 20 mL/min/1.73 m(2) gave 38% with incident CVCs, 20% with unnecessary AVFs, and life expectancy of 1,742 days. Using an eGFR threshold of 15 mL/min/1.73 m(2), 10% had an unnecessary AVF. Policy performance was affected by CKD progression rate and age. For fast progressors (ΔeGFR = -7mL/min/1.73 m(2) per year), referral at eGFR of 25 mL/min/1.73 m(2) achieved a similar incident CVC percentage (~40%) as referral at 15 mL/min/1.73 m(2) in slower progressors (ΔeGFR = -2.78 mL/min/1.73 m(2) per year). For patients aged 70-80 and 80-90 years, time frames of 15-18 months yielded 16%-22% with unnecessary AVFs (vs 9%-11% in 50- to 60-year-olds); an eGFR threshold strategy of 20 mL/min/1.73 m(2) yielded 24% unnecessary AVFs in 80- to 90-year-olds versus 16% in 50- to 60-year-olds. Our model does not consider patients with nonlinear CKD progression or acute kidney injury. We did not include arteriovenous grafts or consider cost or quality of life. In general, AVF referral within about 12 months of the estimated time to dialysis performed best among time frame strategies, and referral at eGFR < 15-20 mL/min/1.73 m(2) performed best among threshold strategies. The timing of referral should also be guided by the individual rate of CKD progression. Elderly patients with CKD could be referred later to reduce the risk of creating an AVF that is never used.

Shechter SM ，Skandari MR ，Zalunardo N 《-》

Cost-effectiveness analysis of autogenous arteriovenous fistula, arteriovenous graft, and tunneled-cuffed catheter for hemodialysis in patients with end-stage kidney disease in Southern China.

Wong TS ，Chen Q ，Zhong Q ，Hu B ，Feng G ，Huang F ，Lu J ，Yin L ，Yu Z ，Akinwunmi BO ，Huang J ，Zhang CJ ，Ming WK ... -  《-》

The effects of vascular access types on the survival and quality of life and depression in the incident hemodialysis patients.

Kim DH ，Park JI ，Lee JP ，Kim YL ，Kang SW ，Yang CW ，Kim NH ，Kim YS ，Lim CS ... -  《-》

Catheter Dependence After Arteriovenous Fistula or Graft Placement Among Elderly Patients on Hemodialysis.

Creation of an arteriovenous fistula (AVF), compared with an arteriovenous graft (AVG), is associated with longer initial catheter dependence after starting hemodialysis (HD) but longer access survival and lower long-term catheter dependence. The extent of these potential long-term benefits in elderly patients is unknown. We assessed catheter dependence after AVF or AVG placement among elderly patients who initiated HD without a permanent access in place. Retrospective cohort study. Patients≥67 years of age identified in the US Renal Data System who had a first AVF (n=14,532) or AVG (n=3,391) placed within 1 year after HD initiation between May 2012 and May 2017. AVF versus AVG placement in the first year of HD. Catheter dependence after AVF or AVG placement assessed using CROWNWeb data. Generalized estimating equations and negative binomial regression for catheter use over time and Cox proportional hazards models for mortality. Creation of an AVF versus AVG placement was associated with greater catheter dependence at 1 month (95.6% vs 92.5%) and 3 months (82.8% vs 41.2%), but lower catheter dependence at 12 months (14.2% vs 15.8%) and 36 months (8.2% vs 15.0%). Creation of an AVF, however, remained significantly associated with greater cumulative catheter-dependent days (80.1 vs 54.6 days per person-year) and a lower proportion of catheter-free survival time (78.1% vs 85.1%) after 3 years of follow-up. Potential for unmeasured confounding and analyses limited to elderly patients. Creation of an AVF was associated with significantly greater cumulative catheter dependence than placement of an AVG in an elderly population initiating HD without a permanent access. As the long-term benefits in terms of catheter dependence of an AVF are not realized in many elderly patients, specific patient characteristics should be considered when making decisions regarding vascular access.

Lyu B ，Chan MR ，Yevzlin AS ，Astor BC ... -  《-》