Barriers to arteriovenous fistula use in black hemodialysis patients

摘要 为了成功和有效地进行透析，终末期肾病患者必须有 进入血管系统的可靠管道(血管通路)，动静脉瘘(AVF)或 动静脉移植(AVG)。尽管全国达成一致的血管通路指南强烈建议 优先放置动静脉瘘，80%的终末期肾病患者使用中心静脉导管(CVC)启动HD。是这样的 患者--我们资助的重点--一旦启动，就需要及时的血管通路规划和手术 高清，以确保放置永久AVF通道。黑人和白人使用AVF的差异始于 随着aVF的创建，HD开始和逐渐增加，1年时为58.8%比67.8%， 这相当于每年黑人死亡人数增加5000人。拟议的拨款将 调查导致AVF使用中种族差异的患者、提供者和系统因素。三大 手术护理过程决定了血液透析患者使用AVF的情况。首先，需要在中创建AVF 使用CVC启动HD的患者。其次，新的AVF必须足够成熟，才能用于高清。 第三，一旦动静脉动静脉瘘成熟，它需要保持长期的透析通畅性，通常需要进入 介入治疗，如血管成形术、血栓切除术或外科翻修术。目标1将使用定性研究来 阐明黑人和白人患者对AVF的看法和AVF护理过程的障碍 透析护理的各个阶段。我们将使用半结构化访谈的黑人和白人透析患者和他们的 提供者(外科医生、肾科医生和透析护士)，以确定与决策有关的共同主题- 围绕最初的AVF创建和后续干预进行。目标2将使用定量研究来 确定在实现和维持所需的关键护理过程中是否存在种族差异 AVF用于使用CVC启动HD的患者的透析。我们将追溯查询国家 USRDS事件HD患者数据库，以确定3个关键AVF手术中是否有一个或多个 黑人和白人的护理过程是不同的。同时，我们将前瞻性地收集更细粒度的数据 关于在大型透析中心开始透析的患者的这些护理过程。目标3将决定 系统层面因素与AVF护理过程的关系。AIM 4将管理经过验证的调查 对计划在UAB接受AVF手术的黑白血液透析患者进行为期4年的事件，以及 量化使用AVF的潜在患者障碍和促进者。然后我们将确定具体的患者， 提供者，以及系统因素与AVF护理流程的差异(在目标2中确定)相关 前瞻性收集这一UAB人群的血管结果数据。最后，我们将使用调解 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。这些因素将被用于开发未来的多水平干预试验，以 评估解决特定障碍是否可以减少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.