Targeting Patient and Health System Barriers To Improve Rates of Hemodialysis Initiation with an Arteriovenous Access

Abstract

Background: Guidelines recommend pre-emptive creation of arteriovenous (AV) access. However, <20% of US patients initiate hemodialysis (HD) with a functional AV access. We implemented a quality improvement (QI) program to improve pre-HD vascular access care.

Methods: After conducting qualitative research with key informants, we implemented a 7-month vascular access support QI program at Geisinger Health. The program targeted patient and health system barriers to AV access through education, needs assessment, peer support, care navigation, and electronic supports. We performed pre-, intra-, and postprogram stakeholder interviews to identify program barriers and facilitators and to assess acceptability. In a research substudy, we compared pre- and postprogram self-efficacy, knowledge, and confidence navigating vascular access care.

Results: There were 37 patient and 32 clinician/personnel participants. Of the 37 patients, 34 (92%) completed vascular access-specific education, 33 (89%) underwent needs assessment, eight (22%) engaged with peer mentors, 21 (57%) had vein mapping, 18 (49%) had an initial surgical appointment, 15 (40%) underwent AV access surgery, and six (16%) started HD during the 7-month program. Qualitative findings demonstrated program acceptability to participants and suggested that education provision and emotional barrier identification were important to engaging patients in vascular access care. Research findings showed pre- to postprogram improvements in patient self-efficacy (28.1-30.8, P=0.05) and knowledge (4.9-6.9, P=0.004), and trends toward improvements in confidence among patients (8.0-8.7, P=0.2) and providers (7.5-7.8, P=0.1).

Conclusions: Our intervention targeting patient and health system barriers improved patient vascular access knowledge and self-efficacy.

Clinical trial registry name and registration number: Breaking Down Care Process and Patient-level Barriers to Arteriovenous Access Creation Prior to Hemodialysis Initiation, NCT04032613.

Keywords: arteriovenous access; barriers; dialysis; hemodialysis; mixed methods; quality improvement; vascular access.

Conflict of interest statement

L.E. Boulware reports serving as a scientific advisor for or member of the Association for Clinical and Translational Science, on the editorial board for JAMA and JAMA Network Online, and on the Robert Wood Johnson Clinical Scholars National Advisory Committee; and receiving honoraria from the Robert Wood Johnson Clinical Scholars Program and from various universities for visiting professorships. In the last 2 years, J.E. Flythe reports receiving speaking honoraria from the American Society of Nephrology and multiple universities; receiving consulting fees from AstraZeneca and Fresenius Kidney Care North America; serving on the medical advisory board for NxStage Medical, now owned by Fresenius Kidney Care North America; and receiving investigator-initiated research funding from the Renal Research Institute, a subsidiary of Fresenius Kidney Care North America. J. F. Pendergast reports receiving honoraria from the National Institutes of Health National Institute on Aging/National Institute of Mental Health Advanced Research Institute for training junior scholars to get their first R01 ($1000 for 3 days of mentoring). S. Peskoe reports serving as a statistical reviewer for JAMA Network Open. All remaining authors have nothing to disclose.

Copyright © 2021 by the American Society of Nephrology.

Figures

Graphical abstract

Figure 1.

The figure displays project development, implementation, and assessment activities.aFormal stakeholder input was obtained pre-, intra-, and post-QI program implementation via semistructured interviews with key stakeholders. Informal feedback was collected throughout the program through in-person and email interactions with program participants. These interviews were conducted as part of QI program implementation and assessment, and were approved as QI by Geisinger Health. bEligible patients were enrolled in the QI program on a rolling basis for the first 6 months of the program (15 in October 2019, two in November 2019, one in December 2019, seven in January 2020, seven in February 2020, and five in March 2020). All QI participants were offered the opportunity to enroll in the research substudy at the time of QI program enrollment. cClinical outcome data (e.g., number of completed vascular access care steps, number and type of patient-level barriers to vascular access care, number and type of peer mentoring contacts, and vascular access type at HD initiation) were collected on all QI program patient participants. Research substudy participants completed pre- and postprogram questionnaires assessing patient self-efficacy, knowledge, and confidence, and medical provider/personnel confidence. EHR, electronic health record; QI, quality improvement.

Figure 2.

The figure displays a flowchart of QI program and research substudy patient participants.aIn addition to the displayed patient QI and research substudy participants, there were 32 medical provider/personnel QI participants and 25 medical provider/personnel research substudy participants. bThe EHR population-based kidney disease registry (i.e., continually updated electronic list, called the “Kidney Transitions Registry”) incorporates an automated risk prediction tool (KFRE) alongside the Geisinger EHR platform. Outpatient data from the EHR are processed nightly to identify qualifying patients. The KFRE is a well-validated algorithm designed to help providers identify individuals with a high predicted risk of developing kidney failure within 2 years on the basis of their age, sex, eGFR, urine albumin-creatinine ratio, calcium, phosphate, albumin, and bicarbonate) (26,27). cAssessment ongoing at the end of the program indicates the navigator was awaiting nephrologist approval for program enrollment. In many cases, nephrologists were waiting for an upcoming appointment to discuss the program with the patient before agreeing to program enrollment. AV, arteriovenous; KFRE, Kidney Failure Risk Equation.

Figure 3.

Patient- and care team–reported outcomes before and after program implementation.aScores from the 16 patients and 23 providers/clinic personnel who completed both pre- and postprogram surveys are reported as means. Differences in pre- and postprogram scores were assessed with paired t tests.