Comparative cost-effectiveness analysis of dialysis access maintenance interventions by provider specialty

Purpose: To assess cost-effectiveness of dialysis access maintenance interventions by proceduralist specialty. Materials: Using Medicare 5% Limited Data Set, beneficiaries undergoing their first arteriovenous (AV) access placement in 2009 were identified using relevant CPT codes. All billed claims for this patient cohort were tracked longitudinally up to 5 years (2009-2014), from which post-intervention primary patency and total Medicare payment per visit were calculated. Cost-effectiveness was compared by specialty using dollar payment amount per patency-year gained. Generalized estimating equations regression was performed to adjust for covariates of: age, race, provider specialty (radiology, nephrology, surgery), census region, comorbid disease burden, number of prior interventions, patient clinical location (inpatient and outpatient hospital, emergency department, office), and type of intervention. Results: 2,693 index access conduit recipients in 2009 underwent a total of 10,045 maintenance interventions over 5 years of follow up. Radiologists performed 38% of interventions (32% nephrology, 27% surgery, 3% others). Nephrologists performed most office-based procedures (56%), while radiologists performed most cases in the inpatient (60%) and emergency department (90%) settings. Utilization frequency of angioplasty was highest with nephrology (80% nephrology, 76% radiology, 68% surgery), stenting with surgery (13% surgery, 11% radiology, 9% nephrology) and thrombolysis/thrombectomy with radiology (26% radiology, 23% nephrology, 18% surgery). Unadjusted payment per patency-year differed significantly by provider specialty: $47k for radiology vs 60k for nephrology and 122k for surgery (p<0.001). Radiology was predictive of lower cost per patency-year independent of all covariates in the regression model (Coeff: -0.23 p<0.05). Conclusions: Cost-effectiveness of dialysis access maintenance interventions varies by provider specialty and is highest for radiologists. With increasing focus on value-based payments in healthcare, provider specialty involvement in dialysis access maintenance warrants further investigation.