Value-Based Model for Vascular Access Management in the End-Stage Kidney Disease Population

Area of Science:

• Nephrology
• Vascular Surgery
• Health Economics

Background:

• Value-based medicine (VBM) aims to improve patient outcomes relative to cost.
• Vascular access (VA) is a critical, modifiable factor influencing morbidity, mortality, and healthcare expenditure in end-stage kidney disease (ESKD).

Purpose of the Study:

• To review and synthesize current evidence on vascular access (VA) creation, maintenance, and salvage in ESKD.
• To evaluate clinical outcomes, patient experience, and economic impact of different VA types within a VBM framework.

Main Methods:

• Narrative review of published studies and gray literature.
• Synthesis of findings using a value-based medicine framework.
• Analysis focused on clinical outcomes, patient experience, and economic impact.

Main Results:

• Tunneled dialysis catheters (TDCs) are linked to infections, complications, and higher costs compared to autogenous arteriovenous fistulas (AVFs).
• Arteriovenous grafts (AVGs) offer value in specific patient groups by reducing catheter time but incur higher maintenance costs.
• Optimizing VA strategy includes selective imaging, ultrasound guidance, considering peritoneal dialysis (PD), and site-of-service adjustments.

Conclusions:

• A value-based VA strategy for ESKD necessitates minimizing catheter exposure and judiciously selecting between AVF and AVG based on patient risk.
• Integrating peritoneal dialysis (PD) and optimizing the site of service are crucial for cost-effectiveness.
• Multidisciplinary access teams and selective monitoring enhance quality and reduce costs.