1
|
Rognoni C, Tozzi M, Tarricone R. Endovascular versus surgical creation of arteriovenous fistula in hemodialysis patients: Cost-effectiveness and budget impact analyses. J Vasc Access 2020; 22:48-57. [PMID: 32425096 PMCID: PMC7897778 DOI: 10.1177/1129729820921021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objectives: The aim of the present study was to perform cost-effectiveness and budget impact analyses comparing endovascular arteriovenous fistula creation to surgical arteriovenous fistula creation in hemodialysis patients from the National Healthcare Service (NHS) perspective in Italy. Methods: A systematic literature review has been conducted to retrieve complications’ rates after arteriovenous fistula creation procedures. One study comparing endovascular arteriovenous fistula creation, performed with WavelinQ device, to the surgical approach through propensity score matching was preferred to single-arm investigations to execute the economic evaluations. This study was chosen to populate a Markov model to project, on a time horizon of 1 year, quality adjusted life years and costs associated with endovascular arteriovenous fistula (WavelinQ) and surgical arteriovenous fistula options for both cohorts of incident and prevalent hemodialysis patients. Results: For both incident and prevalent hemodialysis patients, endovascular arteriovenous fistula creation, performed with WavelinQ, was the dominant strategy over surgical arteriovenous fistula approach, showing less cost and better patients’ quality of life. Compared to the current scenario, progressively increasing utilization rates of WavelinQ over surgical arteriovenous fistula creation in the next 5 years in incident hemodialysis patients are expected to save globally 30–36 million euros to the NHS. Conclusion: Endovascular arteriovenous fistula creation performed with WavelinQ could be a cost-saving strategy in comparison with the surgical approach for patients in hemodialysis. Future studies comparing different devices for endovascular arteriovenous fistula creation versus the surgical option would be needed to confirm or reject the validity of this preliminary evaluation. In the meantime, decision-makers can use these results to take decisions on the diffusion of endovascular procedures in Italy.
Collapse
Affiliation(s)
- Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milan, Italy
| | - Matteo Tozzi
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milan, Italy.,Department of Policy Analysis and Public Management, Bocconi University, Milan, Italy
| |
Collapse
|
2
|
Fila B, Roca-Tey R, Malik J, Malovrh M, Pirozzi N, Kusztal M, Gallieni M, Jemcov T. Quality assessment of vascular access procedures for hemodialysis: A position paper of the Vascular Access Society based on the analysis of existing guidelines. J Vasc Access 2019; 21:148-153. [DOI: 10.1177/1129729819848624] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Quality assessment in vascular access procedures for hemodialysis is not clearly defined. The aim of this article is to compare various guidelines regarding recommendation on quality control in angioaccess surgery. The overall population of end-stage renal disease patients and patients in need for hemodialysis treatment is growing every year. Chronic intermittent hemodialysis is still the main therapy. The formation of a functional angioaccess is the cornerstone in the management of those patients. Native (autologous) arteriovenous fistula is the best vascular access available. A relatively high percentage of primary failure and fistula abandonment increases the need for quality control in this field of surgery. There are very few recommendations of quality assessment on creation of a vascular access for hemodialysis in the searched guidelines. Some guidelines recommend the proportion of native arteriovenous fistula in incident and prevalent patients as well as the maximum tolerable percentage of central venous catheters and complications. According to some guidelines, surgeon’s experience and expertise have a considerable influence on outcomes. There are no specific recommendations regarding surgeon’s specialty, grade, level of skills, and experience. In conclusion, there is a weak recommendation in the guidelines on quality control in vascular access surgery. Quality assessment criteria should be defined in this field of surgery. According to these criteria, patients and nephrologists could choose the best vascular access center or surgeon. Centers with best results should be referral centers, and centers with poorer results should implement quality improvement programs.
Collapse
Affiliation(s)
- Branko Fila
- Department of Vascular Surgery, University Hospital Dubrava, Zagreb, Croatia
| | - Ramon Roca-Tey
- Department of Nephrology, Hospital de Mollet, Fundació Sanitària Mollet, Barcelona, Spain
| | - Jan Malik
- 3rd Department of Internal Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marko Malovrh
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Nicola Pirozzi
- Department of Clinical Science, Division of Nephrology and Dialysis, University La Sapienza, Rome, Italy
| | - Mariusz Kusztal
- Department and Clinic of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, S. Paolo Hospital, Milan, Italy
- Department of Medicine, Surgery and Dentistry, University of Milan, Milan, Italy
| | - Tamara Jemcov
- Department of Nephrology, Clinical Hospital Centre Zemun, Belgrade, Serbia
| |
Collapse
|
3
|
Fumagalli G, Trovato F, Migliori M, Panichi V, De Pietro S. The forearm arteriovenous graft between the brachial artery and the brachial vein as a reliable dialysis vascular access for patients with inadequate superficial veins. J Vasc Surg 2019; 70:199-207.e4. [PMID: 30894304 DOI: 10.1016/j.jvs.2018.10.101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 10/26/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The arteriovenous fistula (AVF) is recommended as the preferred hemodialysis access. However, placing an AVF in all patients may result in poor access outcomes and increased central venous catheter (CVC) use because of increased comorbid conditions, age, and suboptimal vessels. In patients with inadequate superficial veins for AVFs, the use of the brachial veins for creation of forearm arteriovenous grafts (AVGs) has received limited attention. This retrospective study aimed to evaluate outcomes of forearm brachial-brachial AVGs (BB-AVGs) placed in patients with poor superficial veins. METHODS We identified 111 BB-AVGs created in 111 consecutive patients, using standard-walled polytetrafluoroethylene grafts, between January 2010 and December 2015. After excluding 6 patients (non-dialysis initiation, missing information, and death within 1 month), we included 105 patients from 21 dialysis centers. We analyzed primary failures, time to cannulation, patency, complications, and revisions. Patency rates were calculated by the Kaplan-Meier method. The incidence of complications and revisions was expressed as number of events per person-year. RESULTS A total of 105 patients (median age, 69 years) were followed up for a median time of 21.2 months (interquartile range, 9.2-36.5 months). Of the patients, 72.4% were on chronic hemodialysis and had previously undergone one or more access procedures. At the time of BB-AVG placement, prior accesses were 39 AVFs, 20 tunneled CVCs, and 17 AVGs. BB-AVG rates of primary failure and revision before cannulation were 7.6% and 5.7%, respectively. BB-AVGs were cannulated after a median time of 3.4 weeks (interquartile range, 2.8-4.1 weeks). Primary patency rates at 12, 24, and 36 months were 49.5%, 29.5%, and 19.5%. Secondary patency rates at 12, 24, and 36 months were 76.3%, 62.7%, and 54.6%. After cannulation, the incidence of complications and revisions was 1.054 and 0.649 per person-year, respectively. Most complications and interventions were due to thrombosis (0.527 per person-year) or stenosis (0.381 per person-year) and related interventions (0.490 per person-year). A minority of patients experienced AVG infections (0.052 per person-year), with only two requiring access removal. CONCLUSIONS In patients with poor superficial veins, the forearm BB-AVG is a reliable access because of low access-related morbidity and considerable long-term access survival. BB-AVG placement has the advantage of preserving proximal vessels. In these patients, such an approach can delay both rapid exhaustion of vascular sites and early recourse to CVC permanent use.
Collapse
Affiliation(s)
- Giordano Fumagalli
- Nephrology and Dialysis Unit, USL Toscana Nord Ovest-Versilia Hospital, Lido di Camaiore, Lucca, Italy.
| | - Fabio Trovato
- Nephrology and Dialysis Unit, USL Toscana Nord Ovest-Versilia Hospital, Lido di Camaiore, Lucca, Italy; Department of Mathematics and Computer Science, Freie Universität Berlin, Berlin, Germany
| | - Massimiliano Migliori
- Nephrology and Dialysis Unit, USL Toscana Nord Ovest-Versilia Hospital, Lido di Camaiore, Lucca, Italy
| | - Vincenzo Panichi
- Nephrology and Dialysis Unit, USL Toscana Nord Ovest-Versilia Hospital, Lido di Camaiore, Lucca, Italy
| | - Stefano De Pietro
- Nephrology and Dialysis Unit, USL Toscana Nord Ovest-Versilia Hospital, Lido di Camaiore, Lucca, Italy
| |
Collapse
|
4
|
Tessitore N, Poli A. Pro: Vascular access surveillance in mature fistulas: is it worthwhile? Nephrol Dial Transplant 2019; 34:1102-1106. [DOI: 10.1093/ndt/gfz003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Indexed: 11/12/2022] Open
Abstract
Abstract
Guidelines recommend regular screening of mature arteriovenous fistulas (AVFs) for preemptive repair of significant stenosis (≥50% lumen reduction) at high risk of thrombosis, identifiable from clinical signs of access dysfunction (monitoring) or by measuring access blood flow (Qa surveillance), which also enables stenosis detection in functional accesses. To compare the value of Qa surveillance versus monitoring, a meta-analysis was performed on the randomized controlled trials (RCTs) comparing the two screening strategies. It emerged that correcting stenosis identified by Qa surveillance significantly halved the risk of thrombosis [relative risk (RR) = 0.51, 95% confidence interval (CI) 0.35–0.73] and access loss (RR = 0.47, 95% CI 0.28–0.80) in comparison with intervention prompted by clinical signs of access dysfunction. One small RCT aiming to identify an optimal Qa threshold showed that stenosis repair at Qa >500 mL/min produced a significant 3-fold reduction in the risk of thrombosis (RR = 0.37, 95% CI 0.12–0.97) and access loss (RR = 0.36, 95% CI 0.09–0.99) in comparison with intervening when Qa dropped to <400 mL/min as per guidelines. To test the real-world benefits of Qa surveillance, the expected RCT-based thrombosis and access loss rates with Qa surveillance were compared with the rates with monitoring reported in observational studies: the expected thrombosis and access loss rates with surveillance were only lower than with monitoring when a Qa >500 mL/min was considered (2.4, 95% CI 1.0–4.6 and 2.2, 95% CI 0.7–5.0 versus 9.4, 95% CI 7.4–11.3 and 10.3, 95% CI 7.7–13.4 events per 100 AVFs-year, P ≤ 0.024), suggesting that in clinical practice adopting Qa surveillance may only be worthwhile at centres with high thrombosis and access loss rates associated with monitoring, and adopting Qa thresholds >500 mL/min for elective stenosis repair.
Collapse
Affiliation(s)
- Nicola Tessitore
- Department of Medicine, Renal Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Albino Poli
- Department of Public Health and Community Medicine, University of Verona, Verona, Italy
| |
Collapse
|
6
|
Ikeda M, Terawaki H, Kanda E, Furuya M, Tanno Y, Nakao M, Maruyama Y, Maeda M, Higuchi C, Sakurada T, Kaneko T, Io H, Hashimoto K, Ueda A, Hirano K, Washida N, Yoshida H, Yoshikawa K, Taniyama Y, Harada K, Matsuo N, Okido I, Yokoo T. Interventional nephrology: current status and clinical impact in Japan. Clin Exp Nephrol 2017; 22:437-447. [PMID: 28770395 PMCID: PMC5838145 DOI: 10.1007/s10157-017-1457-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 07/25/2017] [Indexed: 12/03/2022]
Abstract
Background Current status and clinical significance of interventional nephrology has not been reported from Japan. Methods Questionnaires were mailed twice to the directors of all 534 Japanese certificated nephrology training institutions in 2014. The main questions were current performance, categorized annual procedure volume and managers of peritoneal dialysis (PD) access, vascular access (VA) surgery, endovascular intervention, and kidney biopsy. Frequencies of nephrologist involvement between high volume center and low volume center and association between the level of nephrologists’ involvement to each procedure and annual procedure volume were examined. Results 332 (62.2%) institutions answered performance of all procedures and 328 (61.4%) institutions answered all procedure volume. Kidney biopsy, VA surgery, endovascular intervention and PD access surgery were performed by any doctors in 94.2, 96.3, 88.4, and 76.2% and each involvement of nephrologist was 93.9, 54.1, 53.1 and 47.6%, respectively. Cochran–Armitage analyses demonstrated significant increases in all 4 procedure volume with greater management by nephrologists (p < 0.01). Nephrologists involvement to VA surgery associated with procedure volume increase in not only VA surgery, but also PD catheter insertion (p < 0.01) and kidney biopsy (p < 0.05). And nephrologists involvement to PD catheter insertion also associated with surgical volume increase in both VA surgery (p < 0.01) and endovascular intervention (p < 0.05). Conclusions Main manager of all 4 procedures was nephrologist in Japan. Each procedure volume increased as nephrologists become more involved. Acquisition of one specific procedure by nephrologist associated with increase not only in this specific procedure volume, but also the other procedure volume.
Collapse
Affiliation(s)
- Masato Ikeda
- Division of Nephrology and Hypertension, The Jikei University School of Medicine Katsushika Medical Center, 6-41-2 Aoto, Katsushika-ku, Tokyo, 125-8506, Japan.
| | - Hiroyuki Terawaki
- Dialysis Center, Fukushima Medical University Hospital, 1 Hikariga-oka, Fukushima, 960-1295, Japan
| | - Eiichiro Kanda
- Department of Nephrology, Tokyo Kyosai Hospital, 2-3-8 Nakameguro, Meguro-ku, Tokyo, 153-8934, Japan
| | - Maiko Furuya
- Division of Nephrology and Hypertension, The Jikei University School of Medicine Katsushika Medical Center, 6-41-2 Aoto, Katsushika-ku, Tokyo, 125-8506, Japan
| | - Yudo Tanno
- Division of Nephrology and Hypertension, The Jikei University School of Medicine Katsushika Medical Center, 6-41-2 Aoto, Katsushika-ku, Tokyo, 125-8506, Japan
| | - Masatsugu Nakao
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yukio Maruyama
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masutaka Maeda
- Nephrology Division, Department of Internal Medicine, JA Toride Medical Center, 2-1-1 Hongo, Toride, Ibaraki, 302-0022, Japan
| | - Chieko Higuchi
- Division of Internal Medicine, Tokyo Women's Medical University Medical Center East, 1-10-2 Nishiogu, Arakawa-ku, Tokyo, 116-8567, Japan
| | - Tsutomu Sakurada
- Division of Nephrology and Hypertension, Integrated Care Center for Kidney Disease, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216- 8511, Japan
| | - Tomohiro Kaneko
- Division of Nephrology, Department of Internal Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Hiroaki Io
- Division of Nephrology, Department of Internal Medicine, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Koji Hashimoto
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Atsushi Ueda
- Tsukuba University Hospital Hitachi Medical Education and Research Center, Jonan-cho 2-1-1, Hitachi, Ibaraki, 317-0077, Japan
| | - Keita Hirano
- Division of Nephrology, Department of Internal Medicine, Ashikaga Red Cross Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, 326-0843, Japan
| | - Naoki Washida
- Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan
| | - Hiraku Yoshida
- Hiraku Clinic, 5-18-9 Kamisoshigaya, Setagaya-ku, Tokyo, 157-0065, Japan
| | - Kazuhiro Yoshikawa
- Department of Nephrology, Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka-shi, Iwate, 020-0066, Japan
| | - Yoshihiro Taniyama
- Department of Nephrology, Kinki University School of Medicine, 377-2 Ohno-higashi, Osakasayama-shi, Osaka, 589-8511, Japan
| | - Kenji Harada
- Division of Nephrology, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu-shi, Fukuoka, 802-8555, Japan
| | - Nanae Matsuo
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Ichiro Okido
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| |
Collapse
|