Value-based approach to AVF maintenance: institutional micro-costing of drug-coated versus plain balloon angioplasty in a fixed-reimbursement system

PURPOSE: To evaluate the institutional cost-efficiency of paclitaxel drug-coated balloon (DCB; IN.PACT Admiral, Medtronic) versus plain balloon (PB) angioplasty for dysfunctional hemodialysis arteriovenous fistulas (AVFs) over 24 months, in order to inform resource allocation policy in a fixed-reimbursement system. MATERIALS AND METHODS: This analysis uses clinical outcomes from a previously published single-center cohort of 62 patients (31 DCB, 31 PB) treated for dysfunctional AVFs. The paclitaxel DCB used in the cohort was IN.PACT Admiral (Medtronic). A detailed institutional micro-costing approach based on cost-recovery self-pay tariffs was applied to quantify direct procedural costs. Total mean cost per patient and cost per year of primary patency (CPYPP) were calculated, and a sensitivity analysis was performed to explore the impact of varying the DCB device price. RESULTS: The DCB group demonstrated higher mean target-lesion primary patency (1.46 ± 0.56 vs 0.86 ± 0.59 years) and required fewer AVF-related endovascular interventions per patient over 24 months (1.55 ± 0.81 vs 2.29 ± 0.94). Total mean cost per patient was lower with DCB (€8496.02 vs €11,324.55), resulting in a lower cost per year of primary patency (CPYPP €5819 vs €13,168). Sensitivity analysis suggested that this cost-saving profile remained robust across a wide range of DCB device prices. CONCLUSION: Despite the higher device cost, DCB angioplasty appeared to be a cost-saving and clinically more effective alternative to PB angioplasty in this cohort. Lower overall institutional expenditure and reduced reintervention frequency support its consideration for integration into AVF maintenance protocols and value-based care pathways in similar fixed-reimbursement settings.