Cost-effectiveness Analysis of Vascular Access Referral Policies in CKD
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...
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| Veröffentlicht in: | American journal of kidney diseases 2017-09, Vol.70 (3), p.368-376 |
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| creator | Shechter, Steven M., PhD Chandler, Talon, BASc Skandari, M. Reza, PhD Zalunardo, Nadia, MD, SM |
| description | 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. 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 |
| doi_str_mv | 10.1053/j.ajkd.2017.04.020 |
| format | Article |
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Reza, PhD ; Zalunardo, Nadia, MD, SM</creator><creatorcontrib>Shechter, Steven M., PhD ; Chandler, Talon, BASc ; Skandari, M. Reza, PhD ; Zalunardo, Nadia, MD, SM</creatorcontrib><description>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. 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/1.73 m2. 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.</description><identifier>ISSN: 0272-6386</identifier><identifier>EISSN: 1523-6838</identifier><identifier>DOI: 10.1053/j.ajkd.2017.04.020</identifier><identifier>PMID: 28599902</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>arteriovenous fistula (AVF) ; arteriovenous graft (AVG) ; Arteriovenous Shunt, Surgical - instrumentation ; Arteriovenous Shunt, Surgical - methods ; Arteriovenous Shunt, Surgical - psychology ; central venous catheter (CVC) ; chronic kidney disease (CKD) ; Cost-Benefit Analysis ; cost-effectiveness ; end-stage renal disease (ESRD) ; health care costs ; hemodialysis ; Humans ; Kidney Failure, Chronic - economics ; Kidney Failure, Chronic - psychology ; Kidney Failure, Chronic - therapy ; Monte Carlo Method ; Nephrology ; predialysis care ; Quality-Adjusted Life Years ; Referral and Consultation - economics ; Referral and Consultation - organization & administration ; Renal Dialysis - economics ; Renal Dialysis - instrumentation ; Renal Dialysis - methods ; United States ; Vascular access ; Vascular Access Devices - economics ; vascular access referral</subject><ispartof>American journal of kidney diseases, 2017-09, Vol.70 (3), p.368-376</ispartof><rights>National Kidney Foundation, Inc.</rights><rights>2017 National Kidney Foundation, Inc.</rights><rights>Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c411t-51799c9de149d6de6242c0919a3870a6a3fb5c8439b058dc894692ed49acb69d3</citedby><cites>FETCH-LOGICAL-c411t-51799c9de149d6de6242c0919a3870a6a3fb5c8439b058dc894692ed49acb69d3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://dx.doi.org/10.1053/j.ajkd.2017.04.020$$EHTML$$P50$$Gelsevier$$H</linktohtml><link.rule.ids>314,780,784,3550,27924,27925,45995</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/28599902$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Shechter, Steven M., PhD</creatorcontrib><creatorcontrib>Chandler, Talon, BASc</creatorcontrib><creatorcontrib>Skandari, M. Reza, PhD</creatorcontrib><creatorcontrib>Zalunardo, Nadia, MD, SM</creatorcontrib><title>Cost-effectiveness Analysis of Vascular Access Referral Policies in CKD</title><title>American journal of kidney diseases</title><addtitle>Am J Kidney Dis</addtitle><description>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. 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/1.73 m2. 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.</description><subject>arteriovenous fistula (AVF)</subject><subject>arteriovenous graft (AVG)</subject><subject>Arteriovenous Shunt, Surgical - instrumentation</subject><subject>Arteriovenous Shunt, Surgical - methods</subject><subject>Arteriovenous Shunt, Surgical - psychology</subject><subject>central venous catheter (CVC)</subject><subject>chronic kidney disease (CKD)</subject><subject>Cost-Benefit Analysis</subject><subject>cost-effectiveness</subject><subject>end-stage renal disease (ESRD)</subject><subject>health care costs</subject><subject>hemodialysis</subject><subject>Humans</subject><subject>Kidney Failure, Chronic - economics</subject><subject>Kidney Failure, Chronic - psychology</subject><subject>Kidney Failure, Chronic - therapy</subject><subject>Monte Carlo Method</subject><subject>Nephrology</subject><subject>predialysis care</subject><subject>Quality-Adjusted Life Years</subject><subject>Referral and Consultation - economics</subject><subject>Referral and Consultation - organization & administration</subject><subject>Renal Dialysis - economics</subject><subject>Renal Dialysis - instrumentation</subject><subject>Renal Dialysis - methods</subject><subject>United States</subject><subject>Vascular access</subject><subject>Vascular Access Devices - economics</subject><subject>vascular access referral</subject><issn>0272-6386</issn><issn>1523-6838</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2017</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kUuP1DAQhC0EYoeFP8AB5cglof2IE0sIaTTAglgJxOtqeeyO5KwnWdyTlebf42gWDhw49aGrqtVfMfacQ8Ohla_Gxo03oRHAuwZUAwIesA1vhax1L_uHbAOiE7WWvb5gT4hGADBS68fsQvStMQbEhl3tZjrWOAzoj_EOJySqtpNLJ4pUzUP105FfksvV1vt19xUHzNml6sucoo9IVZyq3ae3T9mjwSXCZ_fzkv14_-777kN9_fnq4257XXvF-bFueWeMNwG5MkEH1EIJD4YbJ_sOnHZy2Le-V9Lsoe2D743SRmBQxvm9NkFespfn3Ns8_1qQjvYQyWNKbsJ5IcsNFDcIrYpUnKU-z0QZB3ub48Hlk-VgV4B2tCtAuwK0oGwBWEwv7vOX_QHDX8sfYkXw-izA8uVdxGypYJg8hpgLQxvm-P_8N__YfYpT9C7d4AlpnJdc6Jc_LAkL9tta4dog7yR05bz8DWaSlOo</recordid><startdate>20170901</startdate><enddate>20170901</enddate><creator>Shechter, Steven M., PhD</creator><creator>Chandler, Talon, BASc</creator><creator>Skandari, M. Reza, PhD</creator><creator>Zalunardo, Nadia, MD, SM</creator><general>Elsevier Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>20170901</creationdate><title>Cost-effectiveness Analysis of Vascular Access Referral Policies in CKD</title><author>Shechter, Steven M., PhD ; Chandler, Talon, BASc ; Skandari, M. Reza, PhD ; Zalunardo, Nadia, MD, SM</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c411t-51799c9de149d6de6242c0919a3870a6a3fb5c8439b058dc894692ed49acb69d3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2017</creationdate><topic>arteriovenous fistula (AVF)</topic><topic>arteriovenous graft (AVG)</topic><topic>Arteriovenous Shunt, Surgical - instrumentation</topic><topic>Arteriovenous Shunt, Surgical - methods</topic><topic>Arteriovenous Shunt, Surgical - psychology</topic><topic>central venous catheter (CVC)</topic><topic>chronic kidney disease (CKD)</topic><topic>Cost-Benefit Analysis</topic><topic>cost-effectiveness</topic><topic>end-stage renal disease (ESRD)</topic><topic>health care costs</topic><topic>hemodialysis</topic><topic>Humans</topic><topic>Kidney Failure, Chronic - economics</topic><topic>Kidney Failure, Chronic - psychology</topic><topic>Kidney Failure, Chronic - therapy</topic><topic>Monte Carlo Method</topic><topic>Nephrology</topic><topic>predialysis care</topic><topic>Quality-Adjusted Life Years</topic><topic>Referral and Consultation - economics</topic><topic>Referral and Consultation - organization & administration</topic><topic>Renal Dialysis - economics</topic><topic>Renal Dialysis - instrumentation</topic><topic>Renal Dialysis - methods</topic><topic>United States</topic><topic>Vascular access</topic><topic>Vascular Access Devices - economics</topic><topic>vascular access referral</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Shechter, Steven M., PhD</creatorcontrib><creatorcontrib>Chandler, Talon, BASc</creatorcontrib><creatorcontrib>Skandari, M. Reza, PhD</creatorcontrib><creatorcontrib>Zalunardo, Nadia, MD, SM</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>American journal of kidney diseases</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Shechter, Steven M., PhD</au><au>Chandler, Talon, BASc</au><au>Skandari, M. Reza, PhD</au><au>Zalunardo, Nadia, MD, SM</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Cost-effectiveness Analysis of Vascular Access Referral Policies in CKD</atitle><jtitle>American journal of kidney diseases</jtitle><addtitle>Am J Kidney Dis</addtitle><date>2017-09-01</date><risdate>2017</risdate><volume>70</volume><issue>3</issue><spage>368</spage><epage>376</epage><pages>368-376</pages><issn>0272-6386</issn><eissn>1523-6838</eissn><abstract>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. 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/1.73 m2. 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.</abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>28599902</pmid><doi>10.1053/j.ajkd.2017.04.020</doi><tpages>9</tpages></addata></record> |
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| subjects | arteriovenous fistula (AVF) arteriovenous graft (AVG) Arteriovenous Shunt, Surgical - instrumentation Arteriovenous Shunt, Surgical - methods Arteriovenous Shunt, Surgical - psychology central venous catheter (CVC) chronic kidney disease (CKD) Cost-Benefit Analysis cost-effectiveness end-stage renal disease (ESRD) health care costs hemodialysis Humans Kidney Failure, Chronic - economics Kidney Failure, Chronic - psychology Kidney Failure, Chronic - therapy Monte Carlo Method Nephrology predialysis care Quality-Adjusted Life Years Referral and Consultation - economics Referral and Consultation - organization & administration Renal Dialysis - economics Renal Dialysis - instrumentation Renal Dialysis - methods United States Vascular access Vascular Access Devices - economics vascular access referral |
| title | Cost-effectiveness Analysis of Vascular Access Referral Policies in CKD |
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