Increasing the use of arteriovenous fistula in hemodialysis: Economic benefits and economic barriers

The Fistula First Initiative set a goal of 66% arteriovenous (AV) fistula-based access among US hemodialysis patients. This study modeled the impact of achieving the target AV fistula placement rate on Medicare expenditures and on dialysis patient survival and also reviewed economic disincentives for providers that will inhibit achieving this target. The model projects lifetime costs and survival in the US 2003 incident hemodialysis population. Annual treatment costs were estimated from previous analyses of Medicare expenditures by access modality. Patient survival by mode of access was derived from the Dialysis Morbidity and Mortality Study (DMMS). These parameters were applied to a cohort of patients who meet the 66% AV fistula target and an identical cohort with the current vascular access case mix. Comparison of outcomes yields estimates of differential total expenditures and total patient life-years. If prevalence AV fistula-based access in the 2003 incident hemodialysis cohort were 66% rather than the observed 35%, then the Center for Medicare and Medicaid Services would save $840 million in access-attributed expenditures over the expected lifetime of these patients. However, population survival would increase by 35,000 additional life-years, increasing total lifetime expenditures by a net of $1.4 billion. Relative to the current mix of access modality, the shift to 66% AV fistula would be achieved at a net incremental cost of $40,000 per year of life gained. Economic barriers to reaching this goal include financial disincentives to providing adequate predialysis care, performing AV fistula surgical procedures, and monitoring vascular access flow. Achievement of the 66% AV fistula target is cost-effective. Financial incentives in the form of higher reimbursement to encourage wider use of AV fistula placement also could be cost-effective.