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Initiation of maintenance hemodialysis through central venous catheters: study of patients' perceptions based on a
Tanya T Tang1,2, Murray L Levin3,4, Shubhada N Ahya1
1Division of Nephrology/Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, IL, 60611, USA.
Insights
Many US patients start hemodialysis with central venous catheters due to lapses in care. Improving physician-nephrologist communication and patient follow-up can increase fistula and graft use for better dialysis access.
Area of Science:
- Nephrology
- Vascular Surgery
- Healthcare Quality Improvement
Background:
- Arteriovenous fistulae and grafts are preferred for hemodialysis access.
- Central venous catheters are associated with higher morbidity, mortality, and costs.
- Many US patients initiate hemodialysis via central venous catheters despite recommendations.
Purpose of the Study:
- To identify reasons for high central venous catheter use in hemodialysis patients.
- To determine breakdowns in the process of creating arteriovenous fistulae or grafts.
- To inform strategies for reducing central venous catheter use.
Main Methods:
- Developed and administered a questionnaire to 52 hospitalized patients initiating dialysis via catheter.
- Investigated pre-dialysis care, physician referrals, and patient follow-through.
- Assessed reasons for failure to attend appointments with nephrologists or access surgeons.
Main Results:
- Two primary issues identified: patients failing to see nephrologists/surgeons and physicians failing to refer patients to surgeons.
- 20% of patients did not follow up with referred specialists.
- Only 38% of nephrology patients were referred to a surgeon.
Conclusions:
- Healthcare quality is compromised by poor physician referral and patient follow-through.
- Enhanced communication between physicians, nephrologists, and patients is crucial.
- Improved patient and physician follow-up is recommended to increase appropriate dialysis access placement.
Background:
Despite well-publicized suggestions to utilize arteriovenous fistulae and grafts to initiate hemodialysis, too many patients in the United States start dialysis via central venous catheters despite their well-known association with increased morbidity, mortality, and cost.
Methods:
To determine the reasons for this high rate of catheter use, and, ultimately, ways to reduce it, we developed a questionnaire designed to determine where in the process of patient care the process to fistula or graft placement was not completed, thus requiring the use of central venous catheters. The questionnaire was reviewed by several nephrologists not involved with the study. We administered the questionnaire to 52 consecutive hospitalized patients who started maintenance dialysis with catheters at a University-affiliated Hospital and referral center. The questionnaire asked each patient to provide details pertaining to pre-dialysis care, referrals, and follow-through on recommended referrals. If the patient did not see the physician to whom he/she was referred, we asked the reason(s) for such failure.
Results:
Patient responses showed that there were two major lapses in the transition from diagnosis of advanced kidney disease to construction of appropriate dialysis access: failure by the patients to see a nephrologist and/or an access surgeon, and failure by physicians to refer patients to an access surgeon. Twenty percent of the patients failed to follow up with either a nephrologist or a surgeon. Only 38% (15/40) of those seen by a nephrologist had been referred to a surgeon.
Conclusions:
The quality of care was impaired by lack of referral to surgeons by nephrologists and by lack of follow-through by patients. Areas for improvement include improved communications between physicians and patients and more careful follow-up by both physicians and patients. Several methods of providing better patient care and communication between patients and nephrologists are recommended.
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