Medicare Costs Associated With Arteriovenous Fistulas Among US Hemodialysis Patients

Am J Kidney Dis. 2018 Jul;72(1):10-18. doi: 10.1053/j.ajkd.2018.01.034. Epub 2018 Mar 28.


Background: An arteriovenous fistula (AVF) is the recommended vascular access for hemodialysis (HD). Previous studies have not examined the resources and costs associated with creating and maintaining AVFs.

Study design: Retrospective observational study.

Setting & participants: Elderly US Medicare patients initiating hemodialysis therapy during 2010 to 2011.

Predictor: AVF primary and secondary patency and nonuse in the first year following AVF creation.

Outcomes: Annualized vascular access costs per patient per year.

Results: Among patients with only a catheter at HD therapy initiation, only 54% of AVFs were successfully used for HD, 10% were used but experienced secondary patency loss within 1 year of creation, and 83% experienced primary patency loss within 1 year of creation. Mean vascular access costs per patient per year in the 2.5 years after AVF creation were $7,871 for AVFs that maintained primary patency in year 1, $13,282 for AVFs that experienced primary patency loss in year 1, $17,808 for AVFs that experienced secondary patency loss in year 1, and $31,630 for AVFs that were not used. Similar patterns were seen among patients with a mature AVF at HD therapy initiation and patients with a catheter and maturing AVF at HD therapy initiation. Overall, in 2013, fee-for-service Medicare paid $2.8 billion for dialysis vascular access-related services, ∼12% of all end-stage renal disease payments.

Limitations: Lack of granularity with certain billing codes.

Conclusions: AVF failure in the first year after creation is common and results in substantially higher health care costs. Compared with patients whose AVFs maintained primary patency, vascular access costs were 2 to 3 times higher for patients whose AVFs experienced primary or secondary patency loss and 4 times higher for patients who never used their AVFs. There is a need to improve AVF outcomes and reduce costs after AVF creation.

Keywords: AVF non-use; AVF outcomes; AVF primary patency loss; AVF secondary patency loss; Arteriovenous fistula (AVF); end-stage renal disease (ESRD); hemodialysis (HD); national claims data; vascular access complications; vascular access costs; vascular access creation; vascular access maintenance.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Arteriovenous Shunt, Surgical / economics*
  • Arteriovenous Shunt, Surgical / trends
  • Cohort Studies
  • Female
  • Health Care Costs* / trends
  • Humans
  • Kidney Failure, Chronic / diagnosis
  • Kidney Failure, Chronic / economics*
  • Kidney Failure, Chronic / therapy*
  • Male
  • Medicare / economics*
  • Medicare / trends
  • Renal Dialysis / economics*
  • Renal Dialysis / trends
  • Retrospective Studies
  • United States / epidemiology