Breaking down care process and patient-level barriers to arteriovenous access creation prior to hemodialysis initiation

项目摘要/摘要 血管通路是血液透析护理中最具挑战性和最昂贵的方面之一。使用一种 动静脉通路(瘘或移植物)与生活质量的改善和住院时间的减少有关 和死亡率。然而，在美国，20%的人开始血液透析时使用的是AV通道。最早的 提高动静脉曲率的努力主要集中在透析开始后建立动静脉动静脉通路。到目前为止，几乎没有人 在开始透析之前，努力确定和解决创建动静脉动静脉通路的关键障碍 承担了。低的AV访问创建率可以归因于一系列患者(例如，知识， 信念、恐惧、共病)、提供者(例如，知识、信念、实践模式)和护理过程(例如， 碎片化、等待时间长)因素。以护理流程为基础的干预措施仅显示出适度 在先发制人的反病毒访问创建方面的改进，表明仅靠这些策略是不够的。 患者担心的问题，如恐惧、不愿透析以及担心身体毁容和插管疼痛 可能会限制以护理流程为基础的干预措施的成功。然而，针对这两种护理的干预措施 流程和患者级别的障碍可能会提高AV访问创建率。识别和分解病人 和护理流程障碍，在透析开始之前，我们建议：1)确定 患者、照顾者和卫生保健提供者对创建反病毒途径的常见障碍的看法 使用定性研究方法启动透析，目的2)表征护理过程的关联 使用来自大型医疗保健系统的数据，透析开始时的因素和血管通路类型。在目标3中，我们 将针对透析前AV的关键患者和护理流程障碍进行一项新干预的试行测试 创建准入，以研究干预的可行性和潜力，以改善AV准入的使用情况。至 为了实现这些目标，我们将在很大程度上利用现有的慢性肾脏疾病护理导航计划 卫生系统和研究基础设施由PCORI奖支持。这项研究的发现将奠定 为随后的R01等效申请奠定基础，以资助临床试验以评估 以患者和护理流程为重点的视听通路干预对视听通路使用率、生活质量等的影响 在美国发起血液透析的个人的临床结果。

PROJECT SUMMARY/ ABSTRACT Vascular access is one of the most challenging and expensive aspects of hemodialysis care. Use of an arteriovenous (AV) access (fistula or graft) is associated with improved quality of life and lower hospitalization and mortality rates. However, <20% of individuals in the US start hemodialysis with an AV access. Most prior efforts to improve AV access rates have focused on AV access creation after dialysis initiation. To date, few efforts to identify and address key barriers to AV access creation prior to dialysis initiation have been undertaken. Low rates of AV access creation may be attributable to a range of patient (e.g., knowledge, beliefs, fears, comorbidity), provider (e.g., knowledge, beliefs, practice patterns), and care process (e.g., fragmentation, long wait times) factors. Care process-based interventions have demonstrated only modest improvements in preemptive AV access creation, suggesting that such strategies on their own are not enough. Patient concerns such as fear, dialysis reluctance, and worries about body disfigurement and cannulation pain may limit the success of care process-based interventions. However, interventions that target both care process and patient-level barriers may improve AV access creation rates. To identify and break-down patient and care process barriers to AV access creation prior to dialysis initiation, we propose to: Aim 1) identify patients’, caregivers’ and health care providers’ perceptions of common barriers to AV access creation prior to dialysis initiation using qualitative research methods, and Aim 2) characterize the associations of care process factors and vascular access type at dialysis initiation using data from a large health care system. In Aim 3, we will conduct a pilot test of a novel intervention targeting key patient and care process barriers to pre-dialysis AV access creation to study intervention feasibility and potential to yield AV access use improvements. To accomplish these aims, we will leverage an existing chronic kidney disease care navigator program in a large health system and research infrastructure supported by a PCORI award. The findings of this research will lay the groundwork for a subsequent R01-equivalent application to fund a clinical trial to evaluate the effect of a patient and care process-focused AV access intervention on AV access use rates, quality of life and other clinical outcomes among individuals initiating hemodialysis in the US.