Economic analysis of angiography and preemptive angioplasty to prevent hemodialysis-access thrombosis.
OBJECTIVE
We sought to determine the economic value of early angiography and prophylactic angioplasty to prevent hemodialysis-access thrombosis.


BACKGROUND
End stage renal disease consumes more than 6% of the Medicare budget. There is a need to understand the financial impact of each component of care.


METHODS
We conducted an observational economic analysis of a closed cohort of 818 hemodialysis patients, of whom 560 were referred for 1437 consecutive radiographic procedures during an 8-year period. Patient-level, bottom-up microcosting methods provided supply and personnel costs before and after expansion of an angiographic referral program.


RESULTS
The rate of referral for malfunctioning but nonthrombosed hemodialysis accesses increased from 18.8 +/- 8.8 to 48.3 +/- 11.9 angiographic procedures per 100 patient-years (P < 0.001), which was associated with a decline in access thrombosis from 27.6 to 22.0 events per 100 patient-years (P = 0.029) and a net cost of $34,586 per 100 patient-years. The incremental cost-effectiveness ratio for invasive surveillance was $6,177 per thrombosis event avoided. The angiographic program expanded at the same time that the proportion of autogenous fistulas increased from 28.3% +/- 11.3% to 59.7% +/- 10.7% of total referrals (P = 0.0001). On multivariable logistic regression analysis, the expanded angiography program (P = 0.001) and the proportion of autogenous fistulas (P = 0.0001) were both independently associated with the reduction in access thrombosis.


CONCLUSIONS
Given the incremental costs and the relatively modest benefits in preventing access thrombosis, preemptive angiographic management may represent a less efficient use of healthcare resources than increasing the number of patients with autogenous fistulas. (c) 2009 Wiley-Liss, Inc.
Bittl
John A
JA
Ocala Heart Institute, Munroe Regional Medical Center, Ocala, FL 34474, USA. jabittl@mac.com
Cohen
David J
DJ
Seek
Melvin M
MM
Feldman
Robert L
RL
D000792:Angiography / Q000191:economics*; D000800:Angioplasty, Balloon / Q000191:economics*; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000191:economics*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000191:economics*; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging / Q000191:economics / Q000209:etiology / Q000517:prevention & control*; D017048:Health Care Costs; D015276:Health Care Rationing / Q000191:economics; D006801:Humans; D007676:Kidney Failure, Chronic / Q000191:economics / Q000628:therapy*; D016015:Logistic Models; D018803:Models, Economic; D017410:Practice Guidelines as Topic; D015397:Program Evaluation; D012017:Referral and Consultation / Q000191:economics; D006435:Renal Dialysis / Q000191:economics*; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000191:economics / Q000209:etiology / Q000517:prevention & control*; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency