Value-Based Model for Vascular Access Management in the End-Stage Kidney Disease Population.

backgroundValue-based medicine (VBM) seeks to maximize patient-relevant outcomes per unit cost. In end-stage kidney disease (ESKD), vascular access (VA) is a dominant, modifiable driver of morbidity, mortality, and expenditure.

methodsWe performed a narrative review of published studies and gray literature on VA creation, maintenance, and salvage in ESKD, focusing on clinical outcomes, patient experience, and economic impact. Findings were synthesized within a VBM framework relevant to clinicians, health-system leaders, and policymakers.

resultsContemporary data confirm that tunneled dialysis catheters (TDCs) are associated with high rates of bloodstream infection, central venous injury, and mortality, and substantially higher costs than autogenous access. Arteriovenous fistulas (AVFs) offer the best long-term value when creation is risk-based, maturation is supported, and the access is actually used; nonmaturation, nonuse, and prolonged catheter dependence erode this advantage. Endovascular AVF and external support devices improve technical success and early patency but have uncertain cost-effectiveness at current device prices. Arteriovenous grafts (AVGs) can provide greater net value than AVFs in selected patients (older, frail, or with poor veins) by shortening catheter exposure, at the expense of higher reintervention rates and maintenance costs. Across access types, circuit failure and recurrent interventions drive a substantial share of hemodialysis admissions and Medicare spending. Selective preoperative imaging, targeted duplex ultrasound in response to clinical findings, and ultrasound-guided cannulation can improve access selection, maturation, and salvage while avoiding low-value routine surveillance. Peritoneal dialysis remains underutilized despite comparable outcomes in many cohorts and lower average per-patient costs than in-center hemodialysis. Site-of-service optimization (office-based/ASC vs. hospital) and multidisciplinary, life-plan-based access programs further reduce admissions, catheter days, and per-patient costs.

conclusionsA value-based VA strategy for ESKD should prioritize minimizing catheter exposure, tailoring AVF versus AVG use to patient risk, integrating PD where feasible, using selective imaging and monitoring, matching site of service to case complexity, and organizing multidisciplinary access teams aligned with quality and cost metrics.