The Implementation of Stent Graft for the Maintenance of Vascular Access: Preliminary Results From a Multi-Dimensional Impact Assessment

OBJECTIVES: To analyze the multi-dimensional impacts related to the implementation of stent graft (SG), in comparison with percutaneous transluminal angioplasty (PTA), for the management of patients with chronic kidney disease, requiring hemodialysis.

METHODS: An impact assessment analysis was conducted, focusing on the definition of SG economic, organizational, social, and environmental sustainability, assuming a 12-month time-horizon. A process mapping technique was implemented, considering both "PTA+SG" and "PTA alone" standard clinical pathways, derived from the experience of a teaching hospital in northern Italy. Hospitalization, clinical consultations, diagnostic procedures, theater room, equipment, medical devices/materials, and human resources involved were accordingly valorized, thus also collecting the specific timing to perform each activity. The analyses also comprised the management of re-interventions and procedure-related adverse events, whose occurrence rate derived from the most updated scientific evidence.

RESULTS: Over a 12-month time-horizon, preliminary results reported a total cost per patient of 7,665.42€ for PTA alone and 13,740.56€ for PTA+SG, given the higher medical device acquisition cost. However, the economic assessment revealed the cost-effectiveness nature of PTA+SG, with an overall probability equal to 66% to be able to optimize the overall patients’ pathway and guarantee a higher efficacy (measured as Target Lesion Primary Patency=30.2% versus 18.2%).

From an organizational perspective, SG would generate a reduction in the overall hospital accesses devoted to the management of adverse events and/or complications, in terms of inpatient days freed up (-20%) and outpatients’ procedures (-44%). The decrease in the number of re-interventions and complications would also result in a lower patients’ productivity loss (-31%), with a consequent environmental advantage given a reduction in CO2 emission (-38%).

CONCLUSIONS: To appreciate SG implementation advantages, final results would assess the patients’ clinical pathway over a long-term time horizon, collecting real-life data based on administrative flow derived from the management control of the Italian hospital involved.