title: Cost-benefit comparison of hemodialysis access creation in a developing country and North American centres.
abstract: OBJECTIVE
  It has been suggested that vascular access operations should only be performed in high-volume centres to ensure good outcomes. Vascular access operations have been routinely performed in the Cayman Islands since 2005. However, with an estimated population of 45,000 persons, only a small number of patients require vascular access in any given interval. A cost-benefit analysis of this practice was performed.
  
  
  METHODS
  All patients who had vascular access operations over four years were retrospectively identified. Two groups were defined - the local group, who had operations performed by surgeons in the Cayman Islands, and the offshore group, who were transferred off the island and had operations overseas. Cumulative cost, morbidity, patency and failure rates were compared. Significance was considered present with a two-tailed P≤0.05.
  
  
  RESULTS
  There were 14 patients in the local group and 22 in the offshore group. The mean cost of access creation was 6.9 times greater in the offshore group (US$26,883.36 versus US$3,913.33; P<0.001). The likelihood of the use of arteriovenous grafts was significantly greater in the offshore group (P=0.04). When therapeutic outcomes were compared, there were no differences in primary or secondary failure, primary or secondary patency, or overall access-specific morbidity.
  
  
  CONCLUSIONS
  In the present setting, vascular access creation exceeded all the goals set by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative and the Fistula First Breakthrough Initiative. Compared with overseas centres, this is being achieved at a significantly lower cost, with a greater likelihood of native fistula use and similar therapeutic outcomes.
authors.affiliation: Department of Surgery, Radiology, Anaesthesia and Intensive Care, Faculty of Medical Sciences, University of the West Indies, Kingston, Jamaica;
authors.forename: Shamir O
authors.initials: SO
authors.lastname: Cawich
authors.forename: Delroy
authors.initials: D
authors.lastname: Jefferson
authors.forename: Gerald
authors.initials: G
authors.lastname: Smith
authors.forename: Greg
authors.initials: G
authors.lastname: Hoeksema
authors.forename: Nelson
authors.initials: N
authors.lastname: Iheonunekwu
authors.forename: Frits
authors.initials: F
authors.lastname: Hendriks
authors.forename: Laurence
authors.initials: L
authors.lastname: Van Hanswijck de Jonge
authors.forename: Hyacinth E
authors.initials: HE
authors.lastname: Harding
authors.forename: Georgiana
authors.initials: G
authors.lastname: Gordon-Strachan