The optimal timing of vascular access referral for patients with chronic kidney disease who may need hemodialysis (HD) is a pressing question in nephrology. Current referral policies have not been rigorously compared with respect to costs and benefits and do not consider patient-specific factors such as age” Shechter et al (2017).
BACKGROUND: The optimal timing of vascular access referral for patients with chronic kidney disease who may need hemodialysis (HD) is a pressing question in nephrology. Current referral policies have not been rigorously compared with respect to costs and benefits and do not consider patient-specific factors such as age.
STUDY DESIGN: Monte Carlo simulation model.
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SETTING & POPULATION: Patients with chronic kidney disease, referred to a multidisciplinary kidney clinic in a universal health care system.
MODEL, PERSPECTIVE, & TIMEFRAME: Cost-effectiveness analysis, payer perspective, lifetime horizon.
INTERVENTION: The following vascular access referral policies are considered: central venous catheter (CVC) only, arteriovenous fistula (AVF) or graft (AVG) referral upon HD initiation, AVF (or AVG) referral when HD is forecast to begin within 12 (or 3 for AVG) months, AVF (or AVG) referral when estimated glomerular filtration rate is <15 (or <10 for AVG) mL/min/1.73m2.
OUTCOMES: Incremental cost-effectiveness ratios (ICERs, in 2014 US dollars per quality-adjusted life-year [QALY] gained).
RESULTS: The ICER of AVF (AVG) referral within 12 (3) months of forecasted HD initiation, compared to using only a CVC, is ∼$105k/QALY ($101k/QALY) at a population level (HD costs included). Pre-HD AVF or AVG referral dominates delaying referral until HD initiation. The ICER of pre-HD referral increases with patient age. Results are most sensitive to erythropoietin costs, ongoing HD costs, and patients’ utilities for HD. When ongoing HD costs are excluded from the analysis, pre-HD AVF dominates both pre-HD AVG and CVC-only policies.
LIMITATIONS: Literature-based estimates for HD, AVF, and AVG utilities are limited.
CONCLUSIONS: The cost-effectiveness of vascular access referral is largely driven by the annual costs of HD, erythropoietin costs, and access-specific utilities. Further research is needed in the field of dialysis-related quality of life to inform decision making regarding vascular access referral.
Shechter, S.M., Chandler, T., Skandari, M.R. and Zalunardo, N. (2017) Cost-effectiveness Analysis of Vascular Access Referral Policies in CKD. American Journal of Kidney Diseases. June 7th. [Epub ahead of print].
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