The Clinical and Economic Effect of Vascular Access Selection in Patients Initiating Hemodialysis with a Catheter

Abstract

Patients in the United States frequently initiate hemodialysis with a central venous catheter (CVC) and subsequently undergo placement of a new arteriovenous fistula (AVF) or arteriovenous graft (AVG). Little is known about the clinical and economic effects of initial vascular access choice. We identified 479 patients starting hemodialysis with a CVC at a large medical center (during 2004-2012) who subsequently had an AVF (n=295) or AVG (n=105) placed or no arteriovenous access (CVC group, n=71). Compared with patients receiving an AVG, those receiving an AVF had more frequent surgical access procedures per year (1.01 [95% confidence interval, 0.95 to 1.08] versus 0.62 [95% confidence interval, 0.55 to 0.70]; P<0.001) but a similar frequency of percutaneous access procedures per year. Patients receiving an AVF had a higher median annual cost (interquartile range) of surgical access procedures than those receiving an AVG ($4857 [$2523-$8835] versus $2819 [$1411-$4274]; P<0.001), whereas the annual cost of percutaneous access procedures was similar in both groups. The AVF group had a higher median overall annual access-related cost than the AVG group ($10,642 [$5406-$19,878] versus $6810 [$3718-$13,651]; P=0.001) after controlling for patient age, sex, race, and diabetes. The CVC group had the highest median annual overall access-related cost ($28,709 [$11,793-$66,917]; P<0.001), largely attributable to the high frequency of hospitalizations due to catheter-related bacteremia. In conclusion, among patients initiating hemodialysis with a CVC, the annual cost of access-related procedures and complications is higher in patients who initially receive an AVF versus an AVG.

Keywords: arteriovenous access; arteriovenous fistula; arteriovenous graft.

Figure 1.

Flowsheet of patients included in the analysis, including initial vascular access placed, patient events during follow-up, and vascular access in use at the end of patient follow-up. fxn, function; HD, hemodialysis; PD, peritoneal dialysis.

Figure 2.

Patients initiating hemodialysis with a CVC frequently require multiple AVF and AVG placements during follow-up.

Figure 3.

The annual cost is higher in patients who initially receive an AVF rather than an AVG in multiple patient sub-groups. *P<0.05; **P<0.01 for AVG versus AVF. CHF, congestive heart failure; DM, diabetes mellitus.