BACKGROUND: Current clinical practice guidelines recommend a native arteriovenous fistula (AVF) as the vascular access of first choice. Despite this, most patients in western countries start hemodialysis therapy using a catheter. Little is known regarding specific physician and system characteristics that may be responsible for delays in permanent access creation. STUDY DESIGN: Multicenter cohort study using mixed methods; qualitative and quantitative analysis. SETTING & PARTICIPANTS: 9 nephrology centers in Australia and New Zealand, including 319 adult incident hemodialysis patients. PREDICTOR: Identification of barriers and enablers to AVF placement. OUTCOMES: Type of vascular access used at the start of hemodialysis therapy. MEASUREMENTS: Prospective data collection included data concerning predialysis education, interviews of center staff, referral times, and estimated glomerular filtration rate (eGFR) at AVF creation and dialysis therapy start. RESULTS: 319 patients started hemodialysis therapy during the 6-month period, 39% with an AVF and 59% with a catheter. Perceived barriers to access creation included lack of formal policies for patient referral, long wait times for surgical review and access placement, and lack of a patient database for management purposes. eGFR thresholds at referral for and creation of vascular accesses were considerably lower than appreciated (in both cases, median eGFR of 7 mL/min/1.73 m(2)), with median wait times for access creation of only 3.7 weeks. First assessment by a nephrologist less than 12 months before dialysis therapy start was an independent predictor of catheter use (OR, 8.71; P < 0.001). Characteristics of the best performing centers included the presence of a formalized predialysis pathway with a centralized patient database and low nephrologist and surgeon to patient ratios. LIMITATIONS: A limited number of patient-based barriers was assessed. Cross-sectional data only. CONCLUSIONS: A formalized predialysis pathway including patient education and eGFR thresholds for access placement is associated with improved permanent vascular access placement.
BACKGROUND: Current clinical practice guidelines recommend a native arteriovenous fistula (AVF) as the vascular access of first choice. Despite this, most patients in western countries start hemodialysis therapy using a catheter. Little is known regarding specific physician and system characteristics that may be responsible for delays in permanent access creation. STUDY DESIGN: Multicenter cohort study using mixed methods; qualitative and quantitative analysis. SETTING & PARTICIPANTS: 9 nephrology centers in Australia and New Zealand, including 319 adult incident hemodialysis patients. PREDICTOR: Identification of barriers and enablers to AVF placement. OUTCOMES: Type of vascular access used at the start of hemodialysis therapy. MEASUREMENTS: Prospective data collection included data concerning predialysis education, interviews of center staff, referral times, and estimated glomerular filtration rate (eGFR) at AVF creation and dialysis therapy start. RESULTS: 319 patients started hemodialysis therapy during the 6-month period, 39% with an AVF and 59% with a catheter. Perceived barriers to access creation included lack of formal policies for patient referral, long wait times for surgical review and access placement, and lack of a patient database for management purposes. eGFR thresholds at referral for and creation of vascular accesses were considerably lower than appreciated (in both cases, median eGFR of 7 mL/min/1.73 m(2)), with median wait times for access creation of only 3.7 weeks. First assessment by a nephrologist less than 12 months before dialysis therapy start was an independent predictor of catheter use (OR, 8.71; P < 0.001). Characteristics of the best performing centers included the presence of a formalized predialysis pathway with a centralized patient database and low nephrologist and surgeon to patient ratios. LIMITATIONS: A limited number of patient-based barriers was assessed. Cross-sectional data only. CONCLUSIONS: A formalized predialysis pathway including patient education and eGFR thresholds for access placement is associated with improved permanent vascular access placement.
Authors: J A Green; P L Ephraim; F F Hill-Briggs; T Browne; T S Strigo; C L Hauer; R A Stametz; J D Darer; U D Patel; K Lang-Lindsey; B L Bankes; S A Bolden; P Danielson; S Ruff; L Schmidt; A Swoboda; P Woods; B Vinson; D Littlewood; G Jackson; J F Pendergast; J St Clair Russell; K Collins; E Norfolk; I D Bucaloiu; S Kethireddy; C Collins; D Davis; J dePrisco; D Malloy; C J Diamantidis; S Fulmer; J Martin; D Schatell; N Tangri; A Sees; C Siegrist; J Breed; A Medley; E Graboski; J Billet; M Hackenberg; D Singer; S Stewart; A Alkon; N A Bhavsar; L Lewis-Boyer; C Martz; C Yule; R C Greer; M Saunders; B Cameron; L E Boulware Journal: Contemp Clin Trials Date: 2018-09-12 Impact factor: 2.226
Authors: Ahmed A Al-Jaishi; Charmaine E Lok; Amit X Garg; Joyce C Zhang; Louise M Moist Journal: Clin J Am Soc Nephrol Date: 2015-01-07 Impact factor: 8.237
Authors: Matthew J Oliver; Robert R Quinn; Amit X Garg; S Joseph Kim; Ron Wald; J Michael Paterson Journal: Clin J Am Soc Nephrol Date: 2012-02-16 Impact factor: 8.237
Authors: Meera N Harhay; Dawei Xie; Xiaoming Zhang; Chi-Yuan Hsu; Eric Vittinghoff; Alan S Go; Stephen M Sozio; Jacob Blumenthal; Stephen Seliger; Jing Chen; Rajat Deo; Mirela Dobre; Sanjeev Akkina; Peter P Reese; James P Lash; Kristine Yaffe; Manjula Kurella Tamura Journal: Am J Kidney Dis Date: 2018-05-02 Impact factor: 8.860
Authors: Hui Xue; Joachim H Ix; Weiling Wang; Steven M Brunelli; Michael Lazarus; Raymond Hakim; Eduardo Lacson Journal: Am J Kidney Dis Date: 2012-11-16 Impact factor: 8.860