Choice of Hemodialysis Access in Older Adults: A Cost-Effectiveness Analysis

Abstract

Background and objectives: Although arteriovenous fistulas have been found to be the most cost-effective form of hemodialysis access, the relative benefits of placing an arteriovenous fistula versus an arteriovenous graft seem to be least certain for older adults and when placed preemptively. However, older adults' life expectancy is heterogeneous, and most patients do not undergo permanent access creation until after dialysis initiation. We evaluated cost-effectiveness of arteriovenous fistula placement after dialysis initiation in older adults as a function of age and life expectancy.

Design, setting, participants, & measurements: Using a hypothetical cohort of patients on incident hemodialysis with central venous catheters, we constructed Markov models of three treatment options: (1) arteriovenous fistula placement, (2) arteriovenous graft placement, or (3) continued catheter use. Costs, utilities, and transitional probabilities were derived from existing literature. Probabilistic sensitivity analyses were performed by age group (65-69, 70-74, 75-79, 80-84, and 85-89 years old) and quartile of life expectancy. Costs, quality-adjusted life-months, and incremental cost-effectiveness ratios were evaluated for up to 5 years.

Results: The arteriovenous fistula option was cost effective compared with continued catheter use for all age and life expectancy groups, except for 85-89 year olds in the lowest life expectancy quartile. The arteriovenous fistula option was more cost effective than the arteriovenous graft option for all quartiles of life expectancy among the 65- to 69-year-old age group. For older age groups, differences in cost-effectiveness between the strategies were attenuated, and the arteriovenous fistula option tended to only be cost effective in patients with life expectancy >2 years. For groups for which the arteriovenous fistula option was not cost saving, the cost to gain one quality-adjusted life-month ranged from $2294 to $14,042.

Conclusions: Among older adults, the cost-effectiveness of an arteriovenous fistula placed within the first month of dialysis diminishes with increasing age and lower life expectancy and is not the most cost-effective option for those with the most limited life expectancy.

Keywords: Arteriovenous Shunt, Surgical; Central Venous Catheters; Cost-Benefit Analysis; Humans; Medicare; Probability; arteriovenous fistula; arteriovenous graft; dialysis; frail elderly, vascular access, health care costs, geriatric nephrology; life-expectancy; renal dialysis.

Copyright © 2017 by the American Society of Nephrology.

Figures

Figure 1.

Conceptual model demonstrates transitions among different health states. The decision is modeled as hemodialysis initiation with central venous catheter (CVC). Options included (A) continue hemodialysis with CVC as access or (B) undergo arteriovenous (AV) fistula or AV graft placement.

Figure 2.

Markov model health-state probabilities at three points in time over a 5-year horizon for all age and life expectancy groups: the probabilities of functional arteriovenous fistula (AVF) and functional arteriovenous graft (AVG) peaked at 8 and 3 months, respectively. Subsequently, probability of functional arteriovenous access decreased, whereas probability of central venous catheter (CVC) use or death increased. Health-state probabilities for functional arteriovenous access, CVC use, and death at three time points ([1] time at which there is the highest probability of functional AVG [3 months], [2] time at which there is the highest probability of functional AVF [8 months], and [3] the last month of the simulation) are depicted for (A) AVF and (B) AVG Markov models. Health-state probabilities for the (C) CVC Markov model show the probability of death or CVC use at the same three time points. The proportions shown are for the highest (75th percentile) quartile of the 65- to 69-year-old age group.

Figure 3.

Estimates of arteriovenous fistula (AVF) cost-effectiveness decrease as life-expectancy decreases. Estimated costs and quality-adjusted life-months (QALMs) for AVF placement, arteriovenous graft (AVG) placement, and continued central venous catheter (CVC) use for the 75- to 79-year-old age group are depicted by three life expectancy categories: (A) highest, (B) intermediate, and (C) lowest quartiles. The AVF option costs were higher with lower life expectancy.