Multi-institutional Two-year Outcomes In Dialysis Graft Management: Real World Evidence
Sapan S. Desai, MD, PhD, MBA, FACS, Vascular Outcomes Collaborative.
Northwest Community Hospital, Chicago, IL, USA.
Objectives There remains substantial debate around the most appropriate management algorithm for dialysis access grafts. The role of angioplasty (PTA) and stent-grafts (SG) remains controversial, and downstream effects of various treatment modalities remains unclear. Further, there is an absence of a proper financial analysis to calculate the overall cost of care for these patients. The purpose of this study is to determine the optimal algorithm for the management of dialysis patients with an upper arm dialysis graft.
Methods This is a retrospective, case-control, multicenter, multidisciplinary analysis with propensity score matching to compare the clinical outcomes, quality of care, and financial costs of PTA vs SG for the maintenance of upper extremity hemodialysis grafts. All-comers were identified via a purpose-built registry and grafts followed for a two-year period after the index intervention. A subgroup analysis is also completed to evaluate the secondary impact of additional PTA and SG on the access circuit.
Results A total of 4,736 upper arm dialysis grafts were treated at seven sites over a seven-year period. After propensity score matching, there were more interventions needed to maintain a circuit when PTA was the initial treatment compared to SG (4.5 vs 2.3, P < 0.001). The time to second intervention was almost twice as long when using SG for access maintenance compared to PTA (159.5 vs 79.5 days, P < 0.001). Almost twice as many grafts remained operational at one year when maintained using SG instead of PTA (Kaplan-Meier analysis; P < 0.001). Use of SG instead of PTA can save $17,546 per patient per year (P < 0.001).
Conclusions SG is the preferred modality for the maintenance of upper extremity graft patency. Revisions in physician and site of service compensation and alignment with pay for performance measures is necessary to maximize the utility of this management algorithm.
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