Patient and Clinician Perspectives on Shared Decision Making in Vascular Access Selection: A Qualitative Study

Vascular Access Type and Survival Outcomes in Hemodialysis Patients: A Seven-Year Cohort Study

Background and Objectives: Arteriovenous fistulas (AVFs) are the preferred vascular access for hemodialysis due to their impact on patient outcomes, including survival, infection rates, and overall quality of life. Despite strong recommendations favoring AVF, gaps in AVF utilization remain, influenced by clinical, demographic, and systemic factors. This study is the first to analyze survival outcomes associated with different dialysis vascular access types, adjusting for key clinical, demographic variables, and other comorbidities over extended periods. Materials and Methods: This ambispective cohort study followed 428 hemodialysis patients over seven years. Patients were categorized based on their access type: AVF (n = 189), tunneled central venous catheter (CVC) (n = 178), and non-tunneled CVC (n = 61). Kaplan-Meier survival analysis was used to estimate survival curves, and Cox proportional hazards regression adjusted for potential confounders, including age, diabetes, and hypertension. Results: The 2-year survival rates were as follows: AVF 94.1%, tunneled CVC 70.0%, and non-tunneled CVC 36.6%. The 7-year survival rates were as follows: AVF 65.5%, tunneled CVC 26.4%, and non-tunneled CVC 11.0%. Compared to AVF, tunneled CVC use was associated with a 2.8-fold increased risk of mortality (adjusted hazard ratio [AdHR] 2.8, 95% CI 2.0-4.1), while non-tunneled CVC increased the risk 5-fold (AdHR 5.0, 95% CI 3.3-7.6). Notably, older adults, women, and diabetic patients were disproportionately represented in the groups with tunneled and non-tunneled catheters. Conclusions: Adjusted survival analyses highlight the significantly lower survival rates associated with CVC use compared to AVF. Non-tunneled catheters are generally not used for prolonged periods, and this cohort provides evidence of their prognosis for long-term use. These findings reinforce the need to prioritize AVF placement whenever feasible, reinforcing health education on this topic, to improve long-term outcomes for hemodialysis patients.

Designing qualitative research with value in the clinical and epidemiological context: what, why and how

Clinical and epidemiological research is indispensable for improvements in evidence-based healthcare and health outcomes, but it also leaves important gaps in our understanding of health and illness. Qualitative research has been increasingly recognized as a key to addressing some of these gaps, using both exploratory (to gain a more complete and in-depth understanding of problems) and explanatory (to explain quantitative results) approaches. By finding out 'what's going on' and bringing people's stories to light, qualitative research is widely advocated as crucial in enhancing patient-centered research and healthcare. To date, most clinicians, clinical researchers and epidemiologists are relatively unfamiliar with and untrained in qualitative research-a type of research that, compared with quantitative research, requires different research skills and uses a different jargon, type of reasoning, and methods. This article aims to equip them with the basic knowledge necessary to appraise and design qualitative research. Specifically, we provide a comprehensive overview of (i) what qualitative research is, including various examples of qualitative research questions and explanations of the contrasting properties of quantitative and qualitative research; (ii) what constitutes the added value of qualitative research in the clinical and epidemiological context, illustrated using numerous research studies conducted within nephrology; and (iii) practical guidelines for designing qualitative research within this context, including a self-developed checklist containing essential information to include in qualitative research protocols. In doing so, we hope to enrich clinical and epidemiological research with complementary qualitative evidence-amongst others, invaluable insights into patients' lived experiences and perceptions-and thereby greatly enhance patient-centered research and evidence-based healthcare.

Forearm Versus Upper Arm Location of Arteriovenous Access Used at Hemodialysis Initiation: Temporal Trends and Racial Disparities

RATIONALE & OBJECTIVE

Race and ethnicity differences exist in the type of arteriovenous access (AVA, including fistulas and grafts) used at hemodialysis (HD) initiation. The preferred anatomic location for the creation of an initial HD AVA is typically in the forearm We evaluated race and ethnicity differences in the use of an AVA in the forearm location at HD initiation.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Using records from DaVita Kidney Care linked to the US Renal Data System (USRDS), we evaluated patients aged≥16 years who initiated in-center HD with an AVA between 2006 and 2019.

PREDICTOR

Race and ethnicity, categorized as non-Hispanic White, non-Hispanic Black, Hispanic, or Other.

OUTCOME

Forearm versus upper arm AVA location.

ANALYTICAL APPROACH

Multivariable modified Poisson regression to estimate adjusted trends in AVA location over time and race and ethnicity differences in AVA location. Nested models helped assess the relative confounding by groups of variables on estimates of race and ethnicity differences.

RESULTS

Among 70,147 patients (51.7% White, 28.8% Black, 12.6% Hispanic, 6.9% Other), White patients were older and more likely to have peripheral vascular disease but less likely to have diabetes compared with the other groups. The proportion initiating HD using a forearm AVA decreased from 49% in 2006 to 29% in 2019 and by 3.6% (95% CI, 3.3%-3.9%) annually, with no difference in this trend among groups (race and ethnicity by calendar year interaction P=0.32). Black patients were 13% (95% CI, 10%-15%) less likely and Hispanic patients were 5% (95% CI, 1%-9%) less likely than White patients to initiate HD with a forearm AVA.

LIMITATIONS

Findings may not apply to home HD.

CONCLUSIONS

Use of a forearm AVA for HD initiation has declined and racial differences have persisted, with Black and Hispanic patients being less likely than White patients to have an AVA in the forearm location. Research toward understanding the causes and consequences of these trends and disparities is warranted.

Information needs in vascular access decision-making: A qualitative study of patient and clinical stakeholder perspectives

BACKGROUND

The information and decision support needs required to embed a patient-centred strategy are challenging, as several haemodialysis vascular access strategies are possible with significant differences in short- and long-term outcomes of potential treatment options. We aimed to explore and describe stakeholder perspectives on information needs when making decisions about vascular access (VA) for haemodialysis.

METHODS

We performed thematic analysis of seven (six online, one in person) focus group discussions including transcripts, post-it phrases and text responses with 14 patients and 12 vascular access professionals (four nephrologists, three surgeons and five nurses - Vascular access nurse specialists/Education and dialysis nurses) who participated in at total of six online and one in person focus group.

RESULTS

All patients had experience of haemodialysis and 50% had experience with at least one other modality of RRT. Ten patients had experience of more than one VA modality and 4/14 had experience of AVG, 13/14 had experience of AVF and 8/14 had experience of TCVC. We identified four semantic themes and two latent themes. The themes and their subthemes reflected information needs of patients when making vascular access decisions: Knowledge, Risks and Benefits of Relevant options, long-term treatment strategy and Personal Impact of VA. The latent themes, identified across all stakeholders, were of the need for consistent and trustworthy information.

DISCUSSION

All recent vascular access guidelines propose a shared decision-making approach to vascular access. The ability to implement this in practice carries an information need for both patients and clinicians. This study describes a framework model which can be applied during co-design and assessment of vascular access educational resources to facilitate a patient centred perspective.

Patient Perspectives on Arteriovenous Fistula Placement, Maturation, and Use: A Qualitative Study

Rationale & Objective

Arteriovenous fistula (AVF) use among US hemodialysis (HD) patients is suboptimal, especially among Black patients. We interviewed a group of predominantly Black HD patients to probe experiences and perspectives surrounding steps along the AVF care continuum, which includes placement, maturation, and use of AVFs.

Study Design

Individual semistructured interviews.

Setting & Participants

Patients with kidney failure receiving HD in Birmingham, Alabama.

Analytical Approach

Transcripts were coded and thematically analyzed.

Results

We interviewed 53 Black and 6 White patients at different steps of the AVF care continuum: 29 were dialyzing with a central venous catheter (15 had not undergone AVF placement, 9 had a maturing AVF, and 5 had a nonfunctional AVF) and 30 were dialyzing with an AVF. We coded transcripts using qualitative thematic analysis. Three themes emerged: (1) the circumstances of dialysis initiation sometimes altered the timeline of AV access placement; (2) patients had variable levels of knowledge of steps along the AVF continuum; and (3) the life impacts of dialysis access were a significant factor in patients' experience of dialysis.

Limitations

Single-institution study; low number of non-Black participants limited comparison of patient experiences by race.

Conclusions

Among a group of predominantly Black HD patients, perspectives surrounding the AVF care continuum included consideration of the circumstances of dialysis initiation, patient knowledge, and the life impacts of dialysis access. These findings may inform targeted interventions aimed at optimizing dialysis access use and addressing disparities across the AVF continuum.

Experience of Diagnosis and Initiation of Renal Replacement Therapy in Women with Chronic Kidney Disease

Chronic kidney disease (CKD) has considerable effects on the quality of life of female patients. Receiving the diagnosis and beginning renal replacement therapy (RRT) has a great personal impact on patients. The purpose of this study was to describe the experience of female patients with CKD at an ambulatory dialysis unit regarding diagnosis, life changes, and initiation of RRT. A qualitative exploratory study was conducted based on a social contructivism framework. Participants were recruited using purposeful sampling. In total, 18 women who received treatment for CKD with RRT were included. The women were attending the Ambulatory Dialysis Unit at a hospital belonging to the public health system of Madrid (Spain). Unstructured and semi-structured in-depth interviews, researchers' field notes, and women's personal letters were used. A systematic text condensation analysis was performed. The criteria used to control trustworthiness were credibility, transferability, dependability, and confirmability. Two themes emerged from the data: (a) A turning point in their lives, and (b) The emotional journey of beginning RRT. The diagnosis of CKD and the beginning of treatment implies changing routines and adapting to a new life with CKD. The first dialysis and puncture of the arteriovenous fistula is a major experience. Support from other CKD patients with more experience is perceived as a necessity and a tool to share their experiences and resolve doubts among peers. The diagnosis and initiation of RRT leads to numerous changes in the lives of women with CKD, which may influence the acceptance of treatment.

Exploring Health Literacy and Vascular Access Decision Making: A Scoping Review

One in seven adults in the United States has chronic kidney disease (CKD) and individuals with the most severe form, end stage kidney disease (ESKD), may require renal replacement therapy with hemodialysis. Despite well-established guidelines indicating that arteriovenous access is the preferred type of vascular access for hemodialysis, in 2021, 85.4% of patients initiated dialysis with a CVC. While the reasons for this evidence-practice gap are unclear, health literacy and patient disease-specific knowledge may play an important role. Importantly, 25% of patients with CKD have limited health literacy. While there is an abundance of research regarding the presence of poor health literacy, poor kidney disease-specific knowledge, and their association with health outcomes in patients with CKD, there is currently a paucity of data about the relationship between health literacy, vascular access-specific knowledge, and vascular access outcomes. The aim of this narrative review is to describe the relationship between health literacy, disease-specific knowledge, and vascular access in patients with CKD. A better understanding of health literacy in this population will help inform the development of strategies to assess patient vascular access-specific knowledge and aid in vascular access decision making.

Decision-Making Engagement Preferences among Older Adults with CKD

Key Points

Clinicians’ uncertainty about the degree to which older patients prefer to engage in decision making remains a key barrier to shared decision making. Most older adults with advanced CKD preferred a collaborative or active role in decision making.

Background

Older adults with kidney failure face preference-sensitive decisions regarding dialysis initiation. Despite recommendations, few older patients with kidney failure experience shared decision making. Clinician uncertainty about the degree to which older patients prefer to engage in decision making remains a key barrier.

Methods

This study follows a mixed-methods explanatory, longitudinal, sequential design at four diverse US centers with patients (English-fluent, aged ≥70 years, CKD stages 4–5, nondialysis) from 2018 to 2020. Patient preferences for engagement in decision making were assessed using the Control Preferences Scale, reflecting the degree to which patients want to be involved in their decision making: active (the patient prefers to make the final decision), collaborative (the patient wants to share decision making with the clinician), or passive (the patient wants the clinician to make the final decision) roles. Semistructured interviews about engagement and decision making were conducted in two waves (2019, 2020) with purposively sampled patients and clinicians. Descriptive statistics and ANOVA were used for quantitative analyses; thematic and narrative analyses were used for qualitative data.

Results

Among 363 patient participants, mean age was 78±6 years, 42% were female, and 21% had a high school education or less. Control Preferences Scale responses reflected that patients preferred to engage actively (48%) or collaboratively (43%) versus passively (8%). Preferred roles remained stable at 3-month follow-up. Seventy-six participants completed interviews (45 patients, 31 clinicians). Four themes emerged: control preference roles reflect levels of decisional engagement; clinicians control information flow, especially about prognosis; adapting a clinical approach to patient preferred roles; and clinicians' responsiveness to patient preferred roles supports patients' satisfaction with shared decision making.

Conclusions

Most older adults with advanced CKD preferred a collaborative or active role in decision making. Appropriately matched information flow with patient preferences was critical for satisfaction with shared decision making.

Clinical Trial registry name and registration number:

Decision Aid for Renal Therapy (DART), NCT03522740 .

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

OBJECTIVES

In order to improve the degree of shared decision making (SDM) experienced by patients, it is necessary to gain insight into the explanations for the differences in these degrees.

METHODS

A scoping review of the literature on the explanations for differences in the degree of SDM experienced by patients was conducted. We assessed 21,329 references. Ultimately, 308 studies were included. The explanations were divided into micro, meso, and macro levels.

RESULTS

The explanations are mainly related to the micro level. They include explanations related to the patient and healthcare professionals, the relationship between the patient and the physician, and the involvement of the patient's relatives. On the macro level, explanations are related to restrictions within the healthcare system such as time constraints, and adequate information about treatment options. On the meso level, explanations are related to the continuity of care and the involvement of other healthcare professionals.

CONCLUSIONS

SDM is not an isolated process between the physician and patient. Explanations are connected to the macro, meso, and micro levels.

PRACTICE IMPLICATIONS

This scoping review suggests that there could be more focus on explanations related to the macro and meso levels, and on how explanations at different levels are interrelated.

Patient-Centered Research and Innovation in Nephrology

Patient involvement in research can improve the relevance of research, consequently enhancing the recruitment, retention, and uptake of interventions and policies impacting patient outcomes. Despite this, patients are not often involved in the design and conduct of research. The research agenda and innovations are frequently determined by the interest of health and industry professionals rather than proactively aligning with the priorities of patients. It is now being encouraged and recommended to engage patients in research priority setting to ensure interventions and trials report outcomes valuable to patients, moving away from a history of overlooking the outcomes that reflect the feel and function of patients. Involving patients ensures constant innovative research in nephrology, as this broader depth of evidence fortifies reliability and validity through knowledge gained from lived experience. Findings from such research can enhance clinical practice and strengthen decision-making and policy to support better outcomes. We aim to outline principles and strategies for patient involvement in research, including setting research priorities, identifying and designing interventions, selecting outcomes, and disseminating and translating research. Principles and strategies including engagement, education and training, empowerment, and connection and community provide guidance in patient involvement. There are increasing efforts to involve patients across all stages of research including setting research priorities. Efforts are rising to involve patients across all stages of research including priority setting, identifying and designing interventions, selecting outcomes, and dissemination and translation. Patient involvement throughout the research cycle drives innovative investigations ensuring funding, efforts, and resources are directed toward priorities of patients, contributing to catalyst advancements in care and outcomes.

Alignment Among Patient, Caregiver, and Health Care Provider Perspectives on Hemodialysis Vascular Access Decision-Making: A Qualitative Study

Background

Updates to the Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access emphasize the "right access, in the right patient, at the right time, for the right reasons." Although this implies a collaborative approach, little is known about how patients, their caregivers, and health care providers engage in vascular access (VA) decision-making.

Objective

To explore how the perspectives of patients receiving hemodialysis, their caregivers, and hemodialysis care team align and diverge in relation to VA selection.

Design

Qualitative descriptive study.

Setting

Five outpatient hemodialysis centers in Calgary, Alberta.

Participants

Our purposive sample included 19 patients receiving maintenance hemodialysis, 2 caregivers, and 21 health care providers (7 hemodialysis nurses, 6 VA nurses, and 8 nephrologists).

Methods

We conducted semi-structured interviews with consenting participants. Using an inductive thematic analysis approach, we coded transcripts in duplicate and characterized themes addressing our research objective.

Results

While participants across roles shared some perspectives related to VA decision-making, we identified areas where views diverged. Areas of alignment included (1) optimizing patient preparedness-acknowledging decisional readiness and timing, and (2) value placed on trusting relationships with the kidney care team-respecting decisional autonomy with guidance. Perspectives diverged in the following aspects: (1) differing VA priorities and preferences-patients' emphasis on minimizing disruptions to normalcy contrasted with providers' preferences for fistulas and optimizing biomedical parameters of dialysis; (2) influence of personal and peer experience-patients preferred pragmatic, experiential knowledge, whereas providers emphasized informational credibility; and (3) endpoints for VA review-reassessment of VA decisions was prompted by access dissatisfaction for patients and a medical imperative to achieve a functioning access for health care providers.

Limitations

Participation was limited to individuals comfortable communicating in English and from urban, in-center hemodialysis units. Few informal caregivers of people receiving hemodialysis and younger patients participated in this study.

Conclusions

Although patients, caregivers, and healthcare providers share perspectives on important aspects of VA decisions, conflicting priorities and preferences may impact the decisional outcome. Findings highlight opportunities to bridge knowledge and readiness gaps and integrate shared decision-making in the VA selection process.

Patient Perspectives on Clotting in the Extracorporeal Circuit and Decision-Making Regarding Anticoagulation Therapy

Clotting of the extracorporeal circuit is a complication in the process of hemodialysis that can result in missed or shortened dialysis sessions, higher nursing workload, and elevated cost of treatment. Repercussions of inadequate dialysis may include patient blood loss, fluid overload, build-up of minerals, higher hospitalization rates, and poor quality of life, contributing to increased patient distress. Preventing clotting through anticoagulation therapy is the key to maintaining patency of the dialysis circuit and supporting dialysis adequacy. Despite the severe consequences of clotting in the extracorporeal circuit patients encounter, their perspectives on decision-making regarding anticoagulation therapy are not well known. In this article, we discuss patients' perspectives and priorities around clotting and anticoagulation therapy and outline ways to support their treatment through shared decision-making. Insights into patients' perspectives on addressing thrombotic complications of the extracorporeal circuit can inform strategies to improve care and outcomes for patients receiving hemodialysis.

Shared decision-making for renal replacement treatment and illness perception in patients with advanced chronic kidney disease

BACKGROUND

Current healthcare trends emphasize the use of shared decision-making (SDM) for renal replacement treatment (RRT) in patients with chronic kidney disease (CKD). This is crucial to understand the relationship between SDM and illness perception of CKD patients. Few studies have focused on SDM and illness perception status of CKD patients and the impact of illness perception on RRT after SDM.

METHODS

In this cross-sectional study, we used a questionnaire with purposive sampling from March 2019 to February 2020 at the nephrology outpatient department of a medical center in southern Taiwan. The nephrology medical team in this study used the SHARE five-step model of SDM to communicate with the patients about RRT and Brief Illness Perception Questionnaire (BIPQ) was applied to evaluate illness perception of these patients at the beginning of SDM. According to the SDM decision time, the study participants were classified general and delayed SDM groups. The distribution between SDM groups was estimated using independent two sample t-test, chi-squared test or Fisher's exact test. The correlation between illness perception and SDM decision time were illustrated and evaluated using Spearman's correlation test. A p-value less than 0.05 is statistically significant.

RESULTS

A total of 75 patients were enrolled in this study. The average time to make a dialysis decision after initiating SDM was 166.2 ± 178.1 days. 51 patients were classified as general group, and 24 patients were classified as delayed group. The median SDM decision time of delayed group were significantly longer than general group (56 vs. 361 days, P < 0.001). Our findings revealed that delayed group was significantly characterized with not created early surgical assess (delayed vs. general: 66.7% vs. 27.5%, p = 0.001) compared to general group. The average BIPQ score was 54.0 ± 8.1 in our study. We classified the patients into high and low illness perception group according to the median score of BIPQ. The total score of BIPQ in overall participants might increase by the SDM decision time (rho = 0.83, p = 0.830) and the linear regression line also showed consistent trends between BIPQ and SDM decision time in correspond cohorts. However, no statistically significant findings were found.

CONCLUSIONS

The patients with advanced chronic kidney disease took an average of five and a half months to make a RRT decision after undergoing SDM. Although there is no statistical significance, the trend of illness perception seems correlated with decision-making time. The stronger the illness perception, the longer the decision-making time. Furthermore, shorter decision times may be associated with earlier establishment of surgical access. We need more research exploring the relationship between illness perception and SDM for RRT in CKD patients.