Medicare Costs Associated With Arteriovenous Fistulas Among US Hemodialysis Patients

BackgroundAn arteriovenous fistula (AVF) is the recommended vascular access for hemodialysis (HD). Previous studies have not examined the resources and costs associated with creating and maintaining AVFs. Study DesignRetrospective observational study. Setting & ParticipantsElderly US Medicare patients initiating hemodialysis therapy during 2010 to 2011. PredictorAVF primary and secondary patency and nonuse in the first year following AVF creation. OutcomesAnnualized vascular access costs per patient per year. ResultsAmong patients with only a catheter at HD therapy initiation, only 54% of AVFs were successfully used for HD, 10% were used but experienced secondary patency loss within 1 year of creation, and 83% experienced primary patency loss within 1 year of creation. Mean vascular access costs per patient per year in the 2. 5 years after AVF creation were 7, 871 for AVFs that maintained primary patency in year 1, 13, 282 for AVFs that experienced primary patency loss in year 1, 17, 808 for AVFs that experienced secondary patency loss in year 1, and 31, 630 for AVFs that were not used. Similar patterns were seen among patients with a mature AVF at HD therapy initiation and patients with a catheter and maturing AVF at HD therapy initiation. Overall, in 2013, fee-for-service Medicare paid 2. 8 billion for dialysis vascular access–related services, ∼12% of all end-stage renal disease payments. LimitationsLack of granularity with certain billing codes. ConclusionsAVF failure in the first year after creation is common and results in substantially higher health care costs. Compared with patients whose AVFs maintained primary patency, vascular access costs were 2 to 3 times higher for patients whose AVFs experienced primary or secondary patency loss and 4 times higher for patients who never used their AVFs. There is a need to improve AVF outcomes and reduce costs after AVF creation. An arteriovenous fistula (AVF) is the recommended vascular access for hemodialysis (HD). Previous studies have not examined the resources and costs associated with creating and maintaining AVFs. Retrospective observational study. Elderly US Medicare patients initiating hemodialysis therapy during 2010 to 2011. AVF primary and secondary patency and nonuse in the first year following AVF creation. Annualized vascular access costs per patient per year. Among patients with only a catheter at HD therapy initiation, only 54% of AVFs were successfully used for HD, 10% were used but experienced secondary patency loss within 1 year of creation, and 83% experienced primary patency loss within 1 year of creation. Mean vascular access costs per patient per year in the 2. 5 years after AVF creation were 7, 871 for AVFs that maintained primary patency in year 1, 13, 282 for AVFs that experienced primary patency loss in year 1, 17, 808 for AVFs that experienced secondary patency loss in year 1, and 31, 630 for AVFs that were not used. Similar patterns were seen among patients with a mature AVF at HD therapy initiation and patients with a catheter and maturing AVF at HD therapy initiation. Overall, in 2013, fee-for-service Medicare paid 2. 8 billion for dialysis vascular access–related services, ∼12% of all end-stage renal disease payments. Lack of granularity with certain billing codes. AVF failure in the first year after creation is common and results in substantially higher health care costs. Compared with patients whose AVFs maintained primary patency, vascular access costs were 2 to 3 times higher for patients whose AVFs experienced primary or secondary patency loss and 4 times higher for patients who never used their AVFs. There is a need to improve AVF outcomes and reduce costs after AVF creation.