Cost-Effectiveness Analysis of Immediate Access Arteriovenous Grafts Versus Standard Grafts for Hemodialysis.

Abstract Objectives Immediate access arteriovenous grafts (IAAVGs), or early cannulation arteriovenous grafts, are more expensive than standard grafts (sAVGs) but can be used immediately after placement, reducing the need for a tunneled dialysis catheter (TDC). We hypothesized that a decrease in TDC-related complications would make IAAVGs a cost-effective alternative to sAVGs. Methods We constructed a Markov state transition model in which patients initially received either (1) an IAAVG or (2) a sAVG, and a TDC until graft usability; patients were followed through multiple subsequent access procedures for a 60-month time horizon. The model simulated mortality and typical graft- and TDC-related complications, with parameter estimates including probabilities, costs, and utilities derived from previous literature. A key parameter was median time to TDC removal after graft placement, which was studied under both real-world (7 days for IAAVG and 70 days for sAVG) and ideal conditions (no TDC placed with IAAVG and 1 month for sAVG). Costs were based on current Medicare reimbursement rates and reflect a payer perspective. Both microsimulation (10,000 trials) and probabilistic sensitivity analysis (10,000 samples) were performed. The willingness-to-pay threshold was set at $100,000 per quality-adjusted life-year (QALY). Results IAAVG placement is a dominant strategy, both under real-world ($1,201.16 less expensive and 0.03 QALYs more effective) and ideal conditions ($1,457.97 less expensive and 0.03 QALYs more effective). Under real-world parameters, the result was most sensitive to the time to TDC removal: IAAVGs are cost-effective if a TDC is maintained for ≥23 days after sAVG placement. The mean catheter time was lower with IAAVG (3.9 vs. 8.7 months, P Conclusions The Markov decision-analysis model supported our hypothesis that IAAVGs come with added initial cost but are ultimately cost-saving and more effective. This apparent benefit is due to our prediction that a decreased number of catheter-days per patient would lead to a decreased number of access-related infections.