Economic repercussions of implementing a protocol for urgent surgical repair of thrombosed arteriovenous fistulae.

Introduction: When a patient undergoing haemodialysis suffers from arteriovenous fistula (AVF) thrombosis, (s)he needs an urgent procedure before the next dialysis session. Two different treatment options are available: placing a central venous catheter (CVC) or repairing the AVF. The objective of this study is to assess the possibility of urgent repair of thrombosed AVFs within the emergency care activity of a general surgery department and to determine the possible economic repercussions of implementing this working protocol in an area of healthcare.

Method: We completed the prospective collection of all the urgent surgical interventions made to repair thrombosed AVFs for the period 2000-2011 at our centre. The clinical results were analysed using two variables: rate of thrombosis (episodes/patient/year) and percentage of recovery. Recovery was deemed effective if after the surgery the patient was able to undergo dialysis of his/her AVF without the need to place a CVC. The "thrombosed AVF" clinical process was defined and implemented, and its economic cost was analysed via a detailed analysis conducted by our centre's Financial Department. This analysis was also conducted for the alternative clinical process (new AVF), using the data published by the Ministry of Health (weight of the Diagnosis-Related Group: vascular accesses for haemodialysis, hospital complexity unit, public cost of outpatient procedures and percentage of economic repercussions of the implementation of this process, comparing the costs of both procedures).

Results: During the study period 268 episodes of thrombosis occurred, a rate of 0.1 episodes/patient/year (0.05 on autologous AVFs and 0.43 on grafts). 203 (75%) were treated urgently by the surgery department, of which 168 AVFs (82%) were recovered. The cost of urgently repairing an AVF was estimated at €999. The average cost of a scheduled AVF intervention, plus the cost of placing and maintaining a CVC, was estimated at €6,397. The saving made by urgent repair of AVFs in our area of healthcare is €107,940/year. Extrapolating this to the entire country for a population of 23,000 patients on haemodialysis, the total would be €9,930,480/year.

Conclusions: It is possible to perform urgent surgical recovery on the majority of AVFs for haemodialysis. Implementing multidisciplinary protocol avoids fitting these patients with catheters, reducing the cost this entails.