Economic Analysis of Angiography and Preemptive Angioplasty to Prevent Hemodialysis-Access Thrombosis

Objectives: We sought to determine the economic value of early angiography and prophylactic angioplasty to prevent hemodialysis-access thrombosis. Background: End stage renal disease consumes more than 6% of the Medicare budget. There is a need to understand the financial impact of each component of care. Methods: We conducted an observational economic analysis of a closed cohort of 818 hemodialysis patients, of whom 560 were referred for 1437 consecutive radiographic procedures during an 8-year period. Patient-level, bottom-up microcosting methods provided supply and personnel costs before and after expansion of an angiographic referral program. Results: The rate of referral for malfunctioning but nonthrombosed hemodialysis accesses increased from 18.8 +/- 8.8 to 48.3 +/- 11.9 angiographic procedures per 100 patient-years (P < 0.001), which was associated with a decline in access thrombosis from 27.6 to 22.0 events per 100 patient-years (P = 0.029) and a net cost of $34,586 per 100 patient-years. The incremental cost-effectiveness ratio for invasive surveillance was $6,177 per thrombosis event avoided. The angiographic program expanded at the same time that the proportion of autogenous fistulas increased from 28.3% +/- 11.3% to 59.7% +/- 10.7% of total referrals (P = 0.0001). On multivariable logistic regression analysis, the expanded angiography program (P = 0.001) and the proportion of autogenous fistulas (P = 0.0001) were both independently associated with the reduction in access thrombosis. Conclusions: Given the incremental costs and the relatively modest benefits in preventing access thrombosis, preemptive angiographic management may represent a less efficient use of healthcare resources than increasing the number of patients with autogenous fistulas. (C) 2009 Wiley-Liss, Inc.