| Abstract|| |
Current guidelines recommend arteriovenous fistula (AVF) as the preferred method of access for hemodialysis (HD) patients; however, its utilization remains low. The attitudes of Jordanian HD patients and perceived barriers toward AVF are unknown and have not been well studied. In-center HD patients in the Jordan Ministry of Health largest dialysis unit were interviewed, and a questionnaire was administered inquiring about their experiences, attitudes, and perceived barriers toward AVF. Of 104 total patients, 93 met the inclusion criteria. Mean age was 50 ± 16 years, with 44% being female. Average body mass index was 25 ± 5. The cause of end-stage renal disease was diabetes mellitus in 28 (30%), hypertension in 28 (30%), and polycystic kidney disease in three (3%). Patients had an average time on dialysis of 72 months (range 1–240). Current method of HD access was AVF in 45 (48%) and central venous catheter in 30 (32%). The most reported perceived cause of no AVF was delayed referral to surgical evaluation in 19 (40%), refusal to undergo AVF surgical procedure in 16 (33%), and poor understanding of disease in 13 (27%). Of the total studied group, only 29 (31%) indicated that they received sufficient education/information about AVF prior to creation of HD access. Seventy-eight patients (84%) reported that they would recommend AVF as method of access for other HD patients. The reason why majority of patients preferred AVF was reported as: easier to care for 51 (65%), better associated hygiene 26 (33%), and perceived less infection risk 24 (31%). In conclusion, in this sample population from HD patients in Jordan, majority would recommend an AVF as mode of access. Perceived barriers include lack of timely referral for vascular surgical evaluation and poor understanding of disease. A systematic assessment of the process that precedes the creation of AVF, with focus on areas of reported barriers may allow for better utilization of AVF.
|How to cite this article:|
Hamadah AM. Attitudes and perceived barriers toward arteriovenous fistula creation and use in hemodialysis patients in Jordan. Saudi J Kidney Dis Transpl 2019;30:905-12
|How to cite this URL:|
Hamadah AM. Attitudes and perceived barriers toward arteriovenous fistula creation and use in hemodialysis patients in Jordan. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2020 May 31];30:905-12. Available from: http://www.sjkdt.org/text.asp?2019/30/4/905/265467
| Introduction|| |
Hemodialysis (HD) access is the lifeline for patients who reach dialysis-requiring end-stage renal disease (ESRD). Arteriovenous fistula (AVF) has been recommended as the access method of choice for patients who choose to undergo HD when ESRD is reached.,,, Compared to arteriovenous graft (AVG) and central venous catheters (CVC), AVF has been associated with lower risk of infection and decreased mortality, among other advantages.,,,,, However, the number of patients starting HD with CVC or AVG remains high. The fistula first initiative was a quality improvement initiative introduced by the United States Center for Medicare and Medicaid in 2003 as the National Access Improvement Initiative to increase utilization of AVF. The initial goal was to increase the prevalence of AVF use to 40% which was later increased to 65% as a projected target goal by 2009. This initiative led to an actual increased utilization of AVF with increase in prevalent use from 33% in all HD patients in 2003 to 62.7% by mid-2016., However, utilization of CVC remains high, especially at initiation of dialysis which, in 2015, represented 80% of access used at initiation of dialysis. Many barriers to the timely creation of AVF have been identified. These include system-based, provider-related, or issues pertaining to patient preferences or perception.
Approximately 5350 Jordanian patients were on dialysis in 2016 according to the Report by the Ministry of Health which is published annually. This is approximately 754 per million of the total Jordanian population in 2016. In this report, 98% of the patients were reported to be on HD and only 2% were on peritoneal dialysis. Although this report details important aspects of pertaining to the dialysis population in Jordan, it does not address issues related to type of access and access utilization. To our knowledge, there has not been formal assessment of most issues relating to vascular access in adult HD patients in Jordan such as incidence and prevalence of AVF use, use of other modalities of access, complications related to access, and patients’ perception of benefit and barriers of use of AVF as a preferred method of access. In this study, we aim to explore the attitudes of Jordanian HD patients toward AVF use for HD access and the perceived barriers to its creation. This information is to be used to improve the fistula creation and utilization process and to also be used in future studies focusing on aspects of change in utilizing AVF in HD patients in Jordan.
| Materials and Methods|| |
Study design and setting
This is a descriptive study of attitudes of HD patients in Jordan toward the AVF and the perceived barriers to its creation. This study was done at Prince Hamza Hospital, which is a part of the Ministry of Health Services in Amman, Jordan. This study was conducted from May to August 2018.
Adult patients, with diagnosis of ESRD, undergoing in center HD on a regular schedule of Tuesday-Thursday-Sunday or Monday- Wednesday-Saturday were included in this study. Patients who were on dialysis acutely, those with mental illness that precludes ability to participate and fully consent to the questionnaire, in addition to those who declined to participate or were unavailable at the time of the study, were excluded. The study was approved by the institutional review boards at both the Hashemite University and Prince Hamzah Hospital.
The data collection was done through face-to- face interviews using a structured questionnaire. The questions were formulated by the researcher and answered by the patient before, after, or during the HD treatment session. Patients’ medical record was used to collect or verify background and demographic information. Demographic data collected included age, sex, weight, height, body mass index (BMI), and home location in reference to dialysis unit (as measured through average time to get to unit from residence). Data on cause of ESRD: diabetes mellitus (DM), hypertension, poly-cystic kidney disease, glomerulonephritis, other, or unknown were recorded. Presence of comorbidities, including DM, hypertension, dyslipidemia, coronary artery disease, or cerebrovascular disease, was also obtained.
Data pertaining to HD initiation and access were collected including date of initiation of dialysis and current access method. Whether patient received education about types of access before creation was explored. In addition, patients were asked if they would recommend AVF as a method of access to their fellow HD patients.
Attitudes toward fistula creation and use were sought. If patient did not have a fistula or had a delay in its creation, patient was asked about the perceived barriers. Patients were asked as to whether they recommend it to others. Patients who indicated that they would recommend it to other patients were asked about why they would recommend it. Patients who had refused a fistula were questioned about their reasons which were explored in detail.
| Statistical Analysis|| |
Data were summarized by calculating means and standard deviation or medians and range for quantitative variables and percentages for categorical variables. Descriptive terms were used where appropriate. The reported attitudes and perceived barriers were analyzed as categorical variables. The analysis was done using JMP® Pro 13.0.0, SAS Institute Inc., Cary, NC, USA.
| Results|| |
A total of 104 patients were undergoing regular HD at the designated unit during the study period. Of these, 93 patients were enrolled in the study. Eleven patients were excluded from the study (4 declined to participate, 3 patients did not have ability to participate due to mental or other illness, 3 patients were not available/hospitalized at the time of the study, and one was a pediatric patient).
The mean age for the study participants was 50 years ± 16. Forty-one (44%) were female. Average BMI was 25 ± 5. The cause of ESRD was DM in 28 (30%), hypertension in 28 (30%), polycystic kidney disease in three (3%), glomerulonephritis in three (3%), other in 17 (18%), and unknown in 14 (15%). Major associated comorbidities were DM in 29 (31%), hypertension in 60 (65%), dyslipidemia in 32 (34%), coronary artery disease in 13 (14%), and cerebrovascular disease in eight (9%). At the time of the study, patients had an average time since starting dialysis of 72 months (range 1–240). Details of demographics are presented in [Table 1]. Current method of HD access was AVF in 45 (48%), AVG in 18 (19%), and CVC in 30 (32%) (of the 30, those with temporary catheter-nontunneled were five and those with permanent-tunneled were 25).
|Table 1: Baseline demographics and characteristics of the study participants.|
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Patient attitudes and perceived barriers toward AVF creation are presented in [Table 2]. The most reported perceived cause of no AVF was delayed referral to surgical evaluation in 19 (40%), refusal to undergo AVF surgical procedure in 16 (33%), poor understanding of disease in 13 (27%), denial of disease or need for HD in six (13%), too long to surgical appointments once referral is made in four (8%), and fear of needles in one (2%). Of the total studied group, 29 (31%) indicated they received what they perceived as sufficient education/information about AVF prior to creation, whereas 64 patients (69%) thought that was not the case. Twenty patients (22%) had vein mapping done prior to attempt at fistula creation. Seventy-eight patients (84%) reported they would recommend AVF as the method of access for other HD patients.
|Table 2: Perceived barriers and attitudes toward arteriovenous fistula creation.|
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The reason why majority of patients reported that they perceived AVF to be preferred and recommended was: easier to care for 51 (65%), better associated hygiene 26 (33%), emphasis on easier shower 24 (31%), and perceived less infection risk 24 (31%). Overall, six patients (6%) reported refusal to use AVF as the method HD access or recommend it to other patients, with cited reasons being concern about appearance in two patients, the invasive nature of AVF creation and use in two patients, in addition to ease of venous catheter access and fear of needles in others [Table 3].
| Discussion|| |
Use of AVF as the access method in HD patients, compared with CVC and AVG, has been associated with improved morbidity and mortality and decreased risk of infection leading to recommendations to increase its utilization in HD patients.,, This was also shown internationally across 12 countries studied in the Dialysis Outcomes and Practice Patterns Study. However, most patients continue to initiate HD through a CVC, and investigation of causes of suboptimal utilization of AVF is of interest. Even when a fistula is placed, many fistulas do not see the light (or the needle) and never mature enough to be used or sustain initial attempts at use., This study is the first to explore the attitudes and perceived barriers to AVF creation and use in HD patients in Jordan. The results of this study clearly showed that the vast majority of patients who had AVF placed believe it is the best modality for a multitude of reported advantages including easier care, better hygiene compared to CVC, easier to shower, and patients also recognized that it carriers less infection risk, likely due to personal experiences as most have started with CVC at initiation of HD, and may have experienced infection risk or suffered complications related to that. Based on this study, the vast majority of patients would recommend AVF for access to their fellow patients who are newly starting dialysis.
In those who were not dialyzing through an AVF, or who thought they had delays in placement, the most reported perceived barriers were poor understanding of disease, denial of disease or need for dialysis, too long of a wait time to surgical appointments, non-attendance at surgical appointments, difficulty with logistics of coming to appoints, refusal to undergo surgical procedure, and with delayed referral to surgical evaluation being the most cited cause. Lopez-Vargas et al investigated the the barriers to timely AVF creation in a group of 319 patients from nine nephrology centers in Australia and New Zealand. They found that perceived barriers to access creation included lack of formal policies for patient referral, absence of patient database for access purposes that could facilitate management, and also long wait times to surgical evaluation and access creation. These factors are also some of the factors that have been previously implicated by care providers (nephrologists and primary care providers) as barriers to adequate preparation of patients for renal replacement therapy.
Kosa et al examined patients’ perspectives on complications of vascular access-related interventions. They found that patients were likely to report more dissatisfaction with physical complications associated with needle cannulation of fistulas and grafts compared to CVC access, whereas infectious complications were not viewed by patients as a major concern when the access modalities are compared. It was previously noted that patients’ knowledge of AVF care after placement may be limited, and this could potentially reflect poor understanding of the AVF and poor education prior to placement about the pros and cons of such access, although other contributors maybe be at play, and indeed close to one-third of the patients in our study reported poor understanding of disease as a cause of not moving forward toward AVF. In another study of 128 patients investigating preferences and concerns regarding HD vascular access, patients’ preferences were of utilization of a superficial access in the forearm which was easy to cannulate, had minimal effect on their appearance, provided quick hemostasis after dialysis, and enabled arm comfort during dialysis, whereas the most common problem was pain during needle insertion. When ESRD patient-reported health status and quality of life scores and vascular access type were compared among a national random sample of 1563 patients at dialysis initiation and at day 60 after initiation, it was found that patients with AVF at initiation and at day 60 (implying they had continued to use AVF for the first 2 months) reported perceived greater physical activity and energy, emotional and social well-being, fewer symptoms, less effect of dialysis and burden of kidney disease, and better sleep compared with patients with persistent CVC use.
In our study, we had six patients who refused to have AVF or reported that they would not recommend AVF to others. The cited reasons where mainly concern about appearance, the invasive nature of AVF creation and use, in addition to ease of venous catheter access and fear of needles. In a related qualitative study, Xi et al performed interviews with patients who have refused creation or use of AVF to investigate the rational for decision-making. Poor previous experience with the fistula such as issues with cannulation or bleeding, issues with knowledge transfer and informed decision-making, and patient acceptance of current status quo without desire for change were main reasons of not wanting or accepting an AVF. Decreasing infection rate or improving morta-lity was not usually the focus of the patients in this small subgroup, and we found that to be same as well our HD population in patients who refused AVF. One of the issues that has been clearly demonstrated is that patients can have a strong preference for the status quo and are reluctant to change treat- ments, which can make transitioning from a CVC to AVF less desirable. In another study, patients cited fear of painful and difficult cannulation and trust in their ability to manage complications of CVC, as reasons for their confidence in the decision to avoid AVF. Most of our patients reported that they did not receive what they perceived to be sufficient education about different types of dialysis access. It was clear in our interaction with patients, that their knowledge about dialysis may have an impact on their choice of access. It has been shown before that patients with less dialysis knowledge were found to be less likely to use an arteriovenous access for dialysis at initiation and transitioning to AVF after starting HD, and it is possible that improving patients’ education about this issue may enhance use of AVF.
| Conclusion|| |
In this sample population from HD patients in Jordan, majority would recommend an AVF as mode of access. Perceived barriers include lack of timely referral for vascular surgical evaluation and poor understanding of disease. A systematic assessment of the process that precedes the creation of AVF with taking into account the reported perceived barriers, with focus on areas that clearly need improvement such as a timely referral to vascular surgery, may allow for better utilization of AVF in HD patients in Jordan. Most patients report insufficient education about HD access methods, which is another potential target for care improvement.
Conflict of interest: None declared.
| References|| |
Tordoir J, Canaud B, Haage P, et al. EBPG on vascular access. Nephrol Dial Transplant 2007;22 Suppl 2:ii88-117.
Polkinghorne KR, Chin GK, MacGinley RJ, et al. KHA-CARI guideline: Vascular access–Central venous catheters, arteriovenous fistulae and arteriovenous grafts. Nephrology (Carlton) 2013;18:701-5.
Navuluri R, Regalado S. The KDOQI 2006 vascular access update and fistula first program synopsis. Semin Intervent Radiol 2009; 26:122-4.
Kukita K, Ohira S, Amano I, et al. 2011 update Japanese society for dialysis therapy guidelines of vascular access construction and repair for chronic hemodialysis. Ther Apher Dial 2015; 19 Suppl 1:1-39.
Lacson E Jr., Wang W, Hakim RM, Teng M, Lazarus JM. Associates of mortality and hospitalization in hemodialysis: Potentially actionable laboratory variables and vascular access. Am J Kidney Dis 2009;53:79-90.
Ishani A, Collins AJ, Herzog CA, Foley RN. Septicemia, access and cardiovascular disease in dialysis patients: The USRDS wave 2 study. Kidney Int 2005;68:311-8.
Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK. Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int 2001;60:1443-51.
Astor BC, Eustace JA, Powe NR, et al. Type of vascular access and survival among incident hemodialysis patients: The choices for healthy outcomes in caring for ESRD (CHOICE) study. J Am Soc Nephrol 2005;16:1449-55.
Polkinghorne KR, McDonald SP, Atkins RC, Kerr PG. Vascular access and all-cause mortality: A propensity score analysis. J Am Soc Nephrol 2004;15:477-86.
Banerjee T, Kim SJ, Astor B, Shafi T, Coresh J, Powe NR. Vascular access type, inflammatory markers, and mortality in incident hemodialysis patients: The choices for healthy outcomes in caring for end-stage renal disease (CHOICE) study. Am J Kidney Dis 2014;64: 954-61.
United States Renal Data System. 2017 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2017.
Lok CE. Fistula first initiative: Advantages and pitfalls. Clin J Am Soc Nephrol 2007;2:1043- 53.
Donca IZ, Wish JB. Systemic barriers to optimal hemodialysis access. Semin Nephrol 2012;32:519-29.
Pisoni RL, Arrington CJ, Albert JM, et al. Facility hemodialysis vascular access use and mortality in countries participating in DOPPS: An instrumental variable analysis. Am J Kidney Dis 2009;53:475-91.
Foley RN, Chen SC, Collins AJ. Hemodialysis access at initiation in the United States, 2005 to 2007: Still “catheter first”. Hemodial Int 2009;13:533-42.
Schinstock CA, Albright RC, Williams AW, et al. Outcomes of arteriovenous fistula creation after the fistula first initiative. Clin J Am Soc Nephrol 2011;6:1996-2002.
Woodside KJ, Bell S, Mukhopadhyay P, et al. Arteriovenous fistula maturation in prevalent hemodialysis patients in the United States: A national study. Am J Kidney Dis 2018;71:793- 801.
Lopez-Vargas PA, Craig JC, Gallagher MP, et al. Barriers to timely arteriovenous fistula creation: A study of providers and patients. Am J Kidney Dis 2011;57:873-82.
Greer RC, Ameling JM, Cavanaugh KL, et al. Specialist and primary care physicians’ views on barriers to adequate preparation of patients for renal replacement therapy: A qualitative study. BMC Nephrol 2015;16:37.
Kosa SD, Bhola C, Lok CE. Hemodialysis patients’ satisfaction and perspectives on complications associated with vascular access related interventions: Are we listening? J Vasc Access 2016;17:313-9.
Pessoa NRCa, Linhares FM. Hemodialysis patients with arteriovenous fistula: Knowledge, attitude and practice. Esc Anna Nery 2015; 19:73-9.
Bay WH, Van Cleef S, Owens M. The hemodialysis access: Preferences and concerns of patients, dialysis nurses and technicians, and physicians. Am J Nephrol 1998;18:379-83.
Wasse H, Kutner N, Zhang R, Huang Y. Association of initial hemodialysis vascular access with patient-reported health status and quality of life. Clin J Am Soc Nephrol 2007; 2:708-14.
Xi W, Harwood L, Diamant MJ, et al. Patient attitudes towards the arteriovenous fistula: A qualitative study on vascular access decision making. Nephrol Dial Transplant 2011;26: 3302-8.
Morton RL, Tong A, Howard K, Snelling P, Webster AC. The views of patients and carers in treatment decision making for chronic kidney disease: Systematic review and thematic synthesis of qualitative studies. BMJ 2010; 340:c112.
Murray MA, Thomas A, Wald R, Marticorena R, Donnelly S, Jeffs L. Are you SURE about your vascular access? Exploring factors influencing vascular access decisions with chronic hemodialysis patients and their nurses. CANNT J 2016;26:21-8.
Cavanaugh KL, Wingard RL, Hakim RM, Elasy TA, Ikizler TA. Patient dialysis knowledge is associated with permanent arterio-venous access use in chronic hemodialysis. Clin J Am Soc Nephrol 2009;4:950-6.
Vassalotti JA, Jennings WC, Beathard GA, et al. Fistula first breakthrough initiative: Targeting catheter last in fistula first. Semin Dial 2012;25:303-10.
Abdurrahman M Hamadah
Department of Internal Medicine, Faculty of Medicine, Hashemite University, Zarqa
[Table 1], [Table 2], [Table 3]