Barriers to arteriovenous fistula use in black hemodialysis patients

摘要 为了成功和有效地透析，终末期肾病（ESRD）患者必须具有 可靠的血管通路（血管通路），动静脉瘘（AVF）或 动静脉移植物（AVG）。尽管全国共识血管通路指南强烈建议 由于AVF的优先放置，80%的ESRD患者开始使用中心静脉导管（CVC）进行HD。等 患者--我们赠款的重点--一旦开始， HD，以确保放置永久AVF通路。黑人和白人之间AVF使用的差异开始于 HD开始并在AVF创建后逐渐增加，因此1年时为58.8% vs 67.8%， 这意味着每年黑人的死亡人数增加了5,000人。拟议的赠款将 调查导致AVF使用种族差异的患者、提供者和系统因素。三大 外科护理过程决定血液透析患者AVF的使用。首先，需要创建AVF， 用CVC开始HD的患者。其次，新的AVF必须足够成熟，才能用于HD。 第三，AVF一旦成熟，需要保持长期通畅进行透析，通常需要通路 介入治疗，如血管成形术、血栓切除术或手术翻修。目标1将使用定性研究， 阐明不同年龄段黑人和白色患者对AVF的看法以及AVF护理过程中的障碍 透析护理的各个阶段。我们将对黑人和白色透析患者进行半结构化访谈， 提供者（外科医生、肾脏病学家和透析护士）确定有关决策的共同主题- 围绕初始AVF创建和后续干预进行。目标2将使用定量研究， 确定在实现和维持保健所需的关键过程中是否存在种族差异， AVF用于CVC开始HD患者的透析。我们将追溯查询全国 事件HD患者的USRDS数据库，以确定3种关键AVF手术中的一种或多种 黑人和白人的护理过程不同。与此同时，我们将前瞻性地收集更细粒度的数据 在大型透析中心开始HD的患者的这些护理过程中。目标3将决定 系统水平因素与AVF护理过程之间的关系。目标4将管理经验证的调查 在UAB接受AVF手术的4年期间，发生的黑人和白色血液透析患者，以及 量化患者使用AVF的潜在障碍和促进因素。我们会确定是哪个病人， 提供者和系统因素与AVF护理过程的差异相关（在目标2中确定）， 前瞻性收集该UAB人群的血管结局数据。最后，我们将使用中介 分析以确定与AVF使用相关的最重要的可修改患者、提供者和系统因素 在黑人透析患者中。这些因素将用于开发未来的多水平干预性试验， 评估解决具体障碍是否可以减少AVF使用中的种族差异。

Abstract To successfully and efficiently dialyze, patients with end-stage renal disease (ESRD) patients must have a reliable conduit to access the vasculature (vascular access), either an arteriovenous fistula (AVF) or arteriovenous graft (AVG). Despite national consensus vascular access guidelines that strongly recommend preferential placement of AVFs, 80% of ESRD patients initiate HD with a central vein catheter (CVC). Such patients— the focus of our grant—require timely vascular access planning and surgery once they have initiated HD to ensure a permanent AVF access is placed. Disparities in AVF use between blacks and whites begin at HD initiation and increase progressively following AVF creation, such that at 1 year it is 58.8 vs 67.8%, respectively, which translates to 5,000 excess deaths among blacks annually. The proposed grant will investigate patient, provider, and system factors contributing to racial disparities in AVF use. Three major surgical processes of care determine AVF use in hemodialysis patients. First, an AVF needs to be created in the patient who initiates HD with a CVC. Second, the new AVF has to mature adequately to be used for HD. Third, once the AVF has matured, it needs to maintain long-term patency for dialysis, often requiring access interventions such as angioplasty, thrombectomy, or surgical revision. Aim 1 will use qualitative research to elucidate views on AVFs and barriers to AVF processes of care among black and white patients at various stages of dialysis care. We will use semi-structured interviews of black and white dialysis patients and their providers (surgeons, nephrologists, and dialysis nurses) to identify common themes regarding the decision- making around initial AVF creation and subsequent interventions. Aim 2 will use quantitative research to determine whether there are racial disparities in the key processes of care required to achieve and maintain AVF use for dialysis among patients initiating HD with a CVC. We will retrospectively query the national USRDS database of incident HD patients to determine whether one or more of the 3 key AVF surgical processes of care differ between blacks and whites. In parallel, we will prospectively collect more granular data on these processes of care in patients initiating HD at a large dialysis center. Aim 3 will determine the relationship between system level factors and AVF processes of care. Aim 4 will administer validated surveys to incident black and white hemodialysis patients scheduled for AVF surgery over a 4-year period at UAB, and quantify potential patient barriers to and facilitators of AVF use. We will then determine which specific patient, provider, and system factors are associated with differences in AVF processes of care (identified in Aim 2) by prospectively collecting vascular outcomes data for this UAB population. Finally, we will use mediational analysis to identify the most important modifiable patient, provider, and system factors related to AVF use among black dialysis patients. These factors will be used to develop a future multi-level interventional trial to evaluate whether addressing specific barriers can reduce racial disparities in AVF use.