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Am J Kidney Dis. 2011 Jun;57(6):873-82. doi: 10.1053/j.ajkd.2010.12.020. Epub 2011 Mar 15.

Barriers to timely arteriovenous fistula creation: a study of providers and patients.

Author information

1
Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia.

Abstract

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.

PMID:
21411202
DOI:
10.1053/j.ajkd.2010.12.020
[Indexed for MEDLINE]

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