title: Synthetic vascular hemodialysis access versus native arteriovenous fistula: a cost-utility analysis.
abstract: OBJECTIVE
  To determine the cost-effectiveness of 2 different vascular access strategies among incident dialysis patients.
  
  
  BACKGROUND
  Vascular access is a principal cause of morbidity and cost in hemodialysis patients. Recent guidelines and initiatives are intended to increase the proportion of patients with a fistula. However, there is growing awareness of the high prevalence of fistula failures and attendant complications.
  
  
  METHODS
  A decision analysis using a Markov model was implemented to compare 2 different vascular access strategies among incident dialysis patients: (1) placing an arteriovenous fistula (AVF1st) as the initial access followed by a synthetic vascular access if the AVF did not mature compared to (2) placing a synthetic vascular access (SVA1st) as the initial access device. The cost-utility was evaluated across a range of the risk of complications from temporary catheters and SVA.
  
  
  RESULTS
  Under base case assumptions, the AVF1st strategy yielded 2.19 quality-adjusted life years (QALYs) compared with 2.06 QALYs from the SVA1st strategy. The incremental cost-effectiveness was $9389 per QALY for AVF1st compared to SVA1st and was less than $50,000 per QALY as long as the probability of maturation is 36% or greater. AVF1st was the dominant strategy when the AVF maturation rate was 69% or greater.
  
  
  CONCLUSIONS
  The high risk of complications of temporary catheters and the overall low AVF maturation rate explain why a universal policy of AVF1st for all incident dialysis patients may not optimize clinical outcomes. Strong consideration should be given to a more patient-centered approach taking into account the likelihood of AVF maturation.
authors.affiliation: Renal, Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Sylvia.rosas@uphs.upenn.edu
authors.forename: Sylvia E
authors.initials: SE
authors.lastname: Rosas
authors.forename: Harold I
authors.initials: HI
authors.lastname: Feldman
mesh_terms: D001166:Arteriovenous Shunt, Surgical / Q000191:economics* / Q000401:mortality; D002408:Catheters, Indwelling / Q000191:economics*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D006083:Graft Occlusion, Vascular / Q000191:economics / Q000401:mortality / Q000601:surgery; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D007676:Kidney Failure, Chronic / Q000191:economics* / Q000401:mortality / Q000628:therapy*; D008297:Male; D008390:Markov Chains; D008484:Medicaid / Q000191:economics; D006278:Medicare / Q000191:economics; D008875:Middle Aged; D011138:Polytetrafluoroethylene; D019057:Quality-Adjusted Life Years; D006435:Renal Dialysis / Q000191:economics* / Q000401:mortality; D012086:Reoperation / Q000191:economics; D015996:Survival Rate; D014481:United States
chemical_list: D011138:Polytetrafluoroethylene