Economic and opportunity cost associated with the overutilization of vascular ultrasound to diagnose arteriovenous access thrombosis

OBJECTIVES: The maintenance of a functioning hemodialysis access (HA) is central to achieve optimal outcomes for the end stage kidney-disease population. Access thrombosis (AT) is the leading cause of permanent HA loss. Clinical examination (CE) provides 100% sensitivity and specificity for the diagnosis of AT. However, vascular ultrasound (VUS) is routinely used to confirm the diagnosis, despite rarely impacting clinical management decisions. In this study, we explore the trends of VUS usage to diagnose AT and the associated direct economic and indirect opportunity costs. METHODS: This single-center, retrospective study includes all patients who underwent VUS for AT between January 2014 and December 2024. A chart review was performed to determine the type of access, study setting, ordering physician, HA salvage attempts, and reasons for avoiding interventions. We used the average reported cost of VUS ($2520) and a 60-min meantime to perform the study. RESULTS: A total of 690 patients were included, with 47.8% arteriovenous grafts (AVG) and 52.2% arteriovenous fistulas (AVF) thrombosed. The annual number of VUS increased starting in 2019. The VUS was most frequently ordered in outpatient settings (72.1%) and by vascular surgeons (71.9%). After VUS, 71.5% underwent interventions to salvage or create new HA, with 40.4% receiving percutaneous thrombectomy (PCT). PCT was more common in AVG patients than AVF (54.4% vs 26.1%). The economic burden of VUS for the included patients was estimated to be 1,738,800 USD. CONCLUSIONS: The overutilization of VUS is associated with significant economic costs and lost opportunities for other patients, with minimal impact on clinical decision making. VUS devices and technician's time could be better utilized. Our study highlights the need to reassess the routine VUS use for diagnosing AT, and to socialize best practice for the diagnosis of this common condition across the multiple specialties involved in the care of this growing population.