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 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 m(2). 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 similar to$105k/QALY($101k/QALY) ata population level (HDcosts included). Pre-HDAVF 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 HDcosts, and patients' utilities for HD. When ongoing HDcosts 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. (C) 2017 by the National Kidney Foundation, Inc.