Cost-effectiveness Of Endovascular Versus Open Arteriovenous Fistula Creation In The United States
Bianca Mulaney, MSc MPH, Vy T. Ho, MD MS, Michael D. Sgroi, MD, Manuel Garcia-Toca, MD MS, Elizabeth L. George, MD MS.
Stanford University, Stanford, CA, USA.
OBJECTIVES: In the US, an estimated $1 billion annually is spent on vascular access and its complications. Endovascular arteriovenous fistula (endoAVF) creation is a novel, minimally invasive alternative to traditional surgical AV fistula (sAVF) creation in up to 60% of patients. Although cost-effective in single-payer systems, the clinical and financial impact of endoAVF in the US remains uncertain.
METHODS: We constructed a decision tree followed by a probabilistic cohort state-transition model to study the cost-effectiveness of endoAVF versus sAVF creation. We conducted a systematic review to obtain input parameters including technical success, maturation, patency, and utility values. We derived costs from the Medicare 2022 fee schedule and from the literature. We used a 5-year time horizon, an annual discount rate of 3% for costs and utilities (measured in quality adjusted life years, QALYs), and the common willingness-to-pay (WTP) threshold of $50,000. One-way sensitivity analyses varied technical success, patency, reintervention, cost, and utility parameters.
RESULTS: In the base-case scenario, endoAVF ($24.9 million costs, 1177 QALYs, 74% patent at 5 years) was not cost-effective compared to sAVF ($9.5 million costs, 1142 QALYs, 68% patent at 5 years), generating an incremental cost-effectiveness ratio (ICER) of $441,641 per QALY gained. EndoAVF only becomes cost-effective when the initial cost of sAVF creation exceeds endoAVF by at least $950 (e.g., if endoAVF creation costs $2,650 or less relative to the base-case sAVF cost of $3,600), the additional QALYs gained from endoAVF exceeds 0.2 QALYs/year (e.g., 0.89 QALYs gained/year from endoAVF compared to base-case sAVF 0.69 QALYs/year), the sAVF primary assisted patency rate is less than 35% (base case 73%), or the sAVF maturation rate is less than 55% (base case 78%).
CONCLUSIONS: EndoAVF is not cost-effective compared to sAVF when modeling 5-year outcomes. The main drivers of sAVF remaining cost-effective are the 4x higher up-front cost for endoAVF creation as well as a relatively low initial maturation rate and low primary unassisted patency rate for endoAVF. It will be important to establish how the endoAVF learning curve contributes to upfront cost and given the annual cost attributed to vascular access, a randomized controlled trial is warranted. 
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