Related Experiment Video
Updated: Feb 28, 2026
Assessment of Vascular Function in Patients With Chronic Kidney Disease
Published on: June 16, 2014
Cost-effectiveness Analysis of Vascular Access Referral Policies in CKD
Steven M Shechter1, Talon Chandler2, M Reza Skandari3
1Sauder School of Business, University of British Columbia, Vancouver, BC, Canada.
Insights
Optimal vascular access referral for hemodialysis (HD) patients is crucial. Pre-hemodialysis referral of arteriovenous fistulas (AVF) or grafts (AVG) is more cost-effective than delaying until HD initiation, especially for younger patients.
Area of Science:
- Nephrology
- Health Economics
- Medical Decision Making
Background:
- Optimal timing for vascular access referral in chronic kidney disease (CKD) patients needing hemodialysis (HD) remains unclear.
- Current referral policies lack rigorous cost-benefit analysis and patient-specific considerations like age.
Purpose of the Study:
- To evaluate the cost-effectiveness of different vascular access referral policies for CKD patients.
- To compare strategies including central venous catheter (CVC) only, and pre-hemodialysis referral for arteriovenous fistula (AVF) or graft (AVG).
Main Methods:
- A Monte Carlo simulation model was employed.
- Cost-effectiveness analysis from a payer perspective with a lifetime horizon.
- Compared policies: CVC only, AVF/AVG referral upon HD initiation, AVF/AVG referral 12 (3 for AVG) months pre-HD, and AVF/AVG referral at eGFR <15 (<10 for AVG) mL/min/1.73m².
Main Results:
- Pre-HD AVF/AVG referral dominates delaying referral until HD initiation.
- The incremental cost-effectiveness ratio (ICER) for AVF/AVG referral within 12 (3) months pre-HD versus CVC only is approximately $105k/$101k per QALY gained.
- ICER increases with patient age; results are sensitive to erythropoietin and HD costs, and patient utilities.
Conclusions:
- Vascular access referral cost-effectiveness is significantly influenced by HD and erythropoietin costs, and access-specific utilities.
- Limited literature exists on HD, AVF, and AVG utilities.
- Further research on dialysis-related quality of life is needed to refine referral decision-making.
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/1.73m2.
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 ∼$105k/QALY ($101k/QALY) at a population level (HD costs included). Pre-HD AVF 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 HD costs, and patients' utilities for HD. When ongoing HD costs 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.
Related Concept Videos
01:28Chronic Kidney Disease III: Interprofessional Care
01:30Acute Kidney Injury IV: Diagnostic Studies and Prevention
01:18Chronic Kidney Disease IV: Nursing Management
01:20Acute Kidney Injury V: Interprofessional Care
01:28Drug Dosing in Renal Diseases: Estimation of Glomerular Filtration Rate Based on Serum Creatinine Concentration
01:25Drug Dosing in Renal Diseases: Measurement of Glomerular Filtration Rate