title: Vascular access choice in incident hemodialysis patients: a decision analysis.
abstract: Hemodialysis vascular access recommendations promote arteriovenous (AV) fistulas first; however, it may not be the best approach for all hemodialysis patients, because likelihood of successful fistula placement, procedure-related and subsequent costs, and patient survival modify the optimal access choice. We performed a decision analysis evaluating AV fistula, AV graft, and central venous catheter (CVC) strategies for patients initiating hemodialysis with a CVC, a scenario occurring in over 70% of United States dialysis patients. A decision tree model was constructed to reflect progression from hemodialysis initiation. Patients were classified into one of three vascular access choices: maintain CVC, attempt fistula, or attempt graft. We explicitly modeled probabilities of primary and secondary patency for each access type, with success modified by age, sex, and diabetes. Access-specific mortality was incorporated using preexisting cohort data, including terms for age, sex, and diabetes. Costs were ascertained from the 2010 USRDS report and Medicare for procedure costs. An AV fistula attempt strategy was found to be superior to AV grafts and CVCs in regard to mortality and cost for the majority of patient characteristic combinations, especially younger men without diabetes. Women with diabetes and elderly men with diabetes had similar outcomes, regardless of access type. Overall, the advantages of an AV fistula attempt strategy lessened considerably among older patients, particularly women with diabetes, reflecting the effect of lower AV fistula success rates and lower life expectancy. These results suggest that vascular access-related outcomes may be optimized by considering individual patient characteristics.
authors: Department of Medicine, Division of Nephrology and.
authors: David A
authors: DA
authors: Drew
authors: Department of Medicine, Division of Nephrology, Toronto General Hospital, Toronto, Ontario, Canada;
authors: Charmaine E
authors: CE
authors: Lok
authors: Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts;
authors: Joshua T
authors: JT
authors: Cohen
authors: Institute of Clinical Epidemiology and Biometry and Department of Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany; and.
authors: Martin
authors: M
authors: Wagner
authors: Department of Medicine, Division of Nephrology, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada.
authors: Navdeep
authors: N
authors: Tangri
authors: Department of Medicine, Division of Nephrology and dweiner@tuftsmedicalcenter.org.
authors: Daniel E
authors: DE
authors: Weiner
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001166:Arteriovenous Shunt, Surgical; D002755:Choice Behavior; D015331:Cohort Studies; D003198:Computer Simulation; D003661:Decision Support Techniques; D048909:Diabetes Complications / Q000473:pathology; D005260:Female; D017048:Health Care Costs; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000628:therapy*; D008297:Male; D016016:Proportional Hazards Models; D006435:Renal Dialysis / Q000191:economics / Q000295:instrumentation* / Q000379:methods*; D016896:Treatment Outcome
keywords: dialysis access; hemodialysis; survival