Cost-effectiveness of Endovascular Versus Open Arteriovenous Fistula Creation in the United States

In the United States, an estimated $1 billion annually is spent on vascular access and its complications. Endovascular arteriovenous fistula (endoAVF) creation a novel, minimally invasive alternative to traditional surgical AVF (sAVF) in up 60% of patients. Although cost effective single-payer systems, clinical financial impact endoAVF States remains uncertain. We constructed decision tree followed by probabilistic cohort state-transition model study effectiveness versus sAVF creation. conducted systematic review obtain input parameters including technical success, maturation, patency, utility values. derived costs from Medicare 2022 fee schedule literature. used 5-year time horizon, annual discount rate 3% for utilities (measured quality-adjusted life-years, QALYs), common willingness-to-pay threshold $50,000. One-way sensitivity analyses varied reintervention, cost, parameters. base-case scenario, ($24.9 million costs; 1177 QALYs; 74% patent at 5 years) was not compared with ($9.5 1142 68% years), generating incremental cost-effectiveness ratio (ICER) $441,641 per QALY gained. EndoAVF only becomes when initial exceeds least $950 (eg, if ≤$2650 relative $3600), additional QALYs gained 0.2 QALYs/year 0.89 gained/year 0.69 QALYs/year), primary-assisted patency less than 35% (base case 73%), or maturation 55% 78%) (Fig). modeling outcomes. The main drivers remaining are four times higher up-front creation, as well relatively low primary unassisted endoAVF. It will be important establish how learning curve contributes given attributed access, randomized controlled trial warranted.