Patient-Related Barriers to Timely Dialysis Access Preparation: A Qualitative Study of the Perspectives of Patients, Family Members, and Health Care Providers

Perceptions of peritonitis risk, prevention, diagnosis and stigma: Findings from a mixed methods study with patients and relatives using peritoneal dialysis

BACKGROUND

Peritonitis is the main treatment-related complication of peritoneal dialysis and a primary concern for patients and their relatives. Therefore, understanding their perceptions of peritonitis is important.

OBJECTIVES

To explore patients' and relatives' perceptions of peritoneal dialysis-associated peritonitis risk, prevention measures and experiences of diagnosis, and experience of perceived stigma.

DESIGN

A sequential mixed methods study design was used, including a questionnaire and semi-structured interviews.

PARTICIPANTS

Patients using peritoneal dialysis and relatives (n = 75) from six National Health Service organisations from the United Kingdom.

MEASUREMENTS

A structured questionnaire was administered with patients and relatives (n = 75) using peritoneal dialysis; data were analysed using descriptive statistics. Thirty questionnaire respondents were then purposively sampled and interviewed in-depth; data were analysed thematically. Data were collected 2017-2018. Ethical and governance approvals were gained.

RESULTS

Qualitative and quantitative analyses were integrated and three themes presented: • Perceptions of risk: participants assessed their risk of developing peritonitis and possible implications on their health and relatives. Participants felt greatly responsible for preventing infection. • Preventing peritonitis: participants reported similar and some differing measures to minimise their risk of developing peritonitis. Participants wanted to be seen as "clean". • Diagnosis of peritonitis: peritonitis diagnosis was embarrassing and stigmatising for many individuals. This was influenced by the response of healthcare professionals and the cause of peritonitis.

CONCLUSIONS

It is important that healthcare professionals are aware of how responsible patients and relatives feel about preventing peritonitis, the emotional effect of this responsibility and crucially the impact this may have on seeking help.

Utilizing a Tailored Approach to Standardized Screening of Health-Related Social Needs

BACKGROUND

Despite the increased awareness of social determinants of health (SDoH), integrating social needs screening into health care practice has not consistently occurred.

LOCAL PROBLEM

No social needs screening using recommended standardized questions was available at an outpatient hemodialysis clinic.

METHODS

Plan-Do-Study-Act cycles, based on the Model for Improvement, were used to implement the Core 5 SDoH screening tool, a staff referral process, and an evaluation of the implementation process.

INTERVENTION

A standardized social needs screening tool and a staff referral process were implemented. An evaluation of the implementation process also occurred.

RESULTS

Of 73 patients screened, 21 reported 32 unmet social needs; all received referrals to community resources. Nurses demonstrated high acceptance and usability of the tool and the referral process.

CONCLUSIONS

Implementing a standardized screening and referral process customized to clinical workflow enhanced the identification of social needs in patients undergoing hemodialysis.

Predicting recurrent interventions after radiocephalic arteriovenous fistula creation with machine learning and the PREDICT-AVF web app

OBJECTIVE

Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines discourage ongoing access salvage attempts after two interventions prior to successful use or more than three interventions per year overall. The goal was to develop a tool for prediction of radiocephalic arteriovenous fistula (AVF) intervention requirements to help guide shared decision-making about access appropriateness.

METHODS

Prospective cohort study of 914 adult patients in the United States and Canada undergoing radiocephalic AVF creation at one of the 39 centers participating in the PATENCY-1 or -2 trials. Clinical data, including demographics, comorbidities, access history, anatomic features, and post-operative ultrasound measurements at 4-6 and 12 weeks were used to predict recurrent interventions required at 1 year postoperatively. Cox proportional hazards, random survival forest, pooled logistic, and elastic net recurrent event survival prediction models were built using a combination of baseline characteristics and post-operative ultrasound measurements. A web application was created, which generates patient-specific predictions contextualized with the KDOQI guidelines.

RESULTS

Patients underwent an estimated 1.04 (95% CI 0.94-1.13) interventions in the first year. Mean (SD) age was 57 (13) years; 22% were female. Radiocephalic AVFs were created at the snuffbox (2%), wrist (74%), or proximal forearm (24%). Using baseline characteristics, the random survival forest model performed best, with an area under the receiver operating characteristic curve (AUROC) of 0.75 (95% CI 0.67-0.82) at 1 year. The addition of ultrasound information to baseline characteristics did not substantially improve performance; however, Cox models using either 4-6- or 12-week post-operative ultrasound information alone had the best discrimination performance, with AUROCs of 0.77 (0.70-0.85) and 0.76 (0.70-0.83) at 1 year. The interactive web application is deployed at https://predict-avf.com.

CONCLUSIONS

The PREDICT-AVF web application can guide patient counseling and guideline-concordant shared decision-making as part of a patient-centered end-stage kidney disease life plan.

Tunnelled central venous catheters for incident haemodialysis patients: a Victorian survey exploring reasons for use

BACKGROUND

Tunnelled central venous catheters (T-CVCs) are used globally as vascular access for patients on haemodialysis (HD) but are associated with increased sepsis, mortality, cost and length of hospitalisation compared with more permanent HD vascular access. The reasons for using T-CVC are varied and poorly understood. A significant and increasing proportion of incident HD patients in Victoria, Australia, have required T-CVC over the last decade.

AIM

To explore reasons for a significant and increasing proportion of incident HD patients in Victoria, Australia, having required T-CVC over the last decade.

METHODS

With rates of starting HD with definitive vascular access consistently below a Victorian quality indicator target of 70%, an online survey was developed to explore reasons why the rate remained lower than desired and to help inform future decisions about this quality indicator. The survey was completed by dialysis access coordinators over an 8-month period and involved all public nephrology services in Victoria.

RESULTS

Of the 125 surveys completed, 101 incident HD patients had no attempt at permanent vascular access prior to T-CVC insertion. For almost half of these (48 patients), there was no active medical decision not to create permanent vascular access prior to commencing dialysis. Reasons for insertion of the T-CVC included deterioration of kidney function faster than anticipated, surgical referral being overlooked, complications related to peritoneal dialysis requiring a change in dialysis modality and changes to initial decisions regarding dialysis modality for kidney failure.

CONCLUSIONS

These survey results provide an opportunity for quality improvement initiatives with respect to dialysis access planning and care.

Systems Innovations to Increase Home Dialysis Utilization

Globally, there is an interest to increase home dialysis utilization. The most recent United States Renal Data System (USRDS) data report that 13.3% of incident dialysis patients in the United States are started on home dialysis, while most patients continue to initiate KRT with in-center hemodialysis. To effect meaningful change, a multifaceted innovative approach will be needed to substantially increase the use of home dialysis. Patient and provider education is the first step to enhance home dialysis knowledge awareness. Ideally, one should maximize the number of patients with CKD stage 5 transitioning to home therapies. If this is not possible, infrastructures including transitional dialysis units and community dialysis houses may help patients increase self-care efficacy and eventually transition care to home. From a policy perspective, adopting a home dialysis preference mandate and providing financial support to recuperate increased costs for patients and providers have led to higher uptake in home dialysis. Finally, respite care and planned home-to-home transitions can reduce the incidence of transitioning to in-center hemodialysis. We speculate that an ecosystem of complementary system innovations is needed to cause a sufficient change in patient and provider behavior, which will ultimately modify overall home dialysis utilization.

Hybrid Method for Peritoneal Dialysis Catheter Insertion: A New Technique for Improved Outcomes and Reduced Costs

INTRODUCTION

Peritoneal dialysis (PD) is a well-established treatment choice for end-stage kidney disease (ESKD). While there are several methods for PD catheter insertion, they each have limitations. In this study, we present a new hybrid method for PD catheter insertion and compare it to the conventional laparoscopic method.

METHODS

This retrospective study included 171 patients who were undergoing their first PD catheter insertion, and a total of 20% of the enrolled patients had a past medical history of abdominal surgery. Out of these, 101 patients underwent the laparoscopic method and 70 underwent a new invented hybrid method. The study aimed to compare the surgical outcomes, incidence of early and late complications, hospital stay, and medical expenses between the two groups.

RESULTS

There were no notable differences in basic demographic features and comorbid conditions between the two groups. The results of our data revealed that the hybrid group had a significantly shorter break-in period and did not require temporary hemodialysis. Additionally, length of hospital stay and medical costs were significantly lower in the hybrid group (all p < 0.05). The incidence of early complications was lower in the hybrid group, while the incidence of late complications was comparable between the two groups.

CONCLUSION

Our study demonstrates that the hybrid method of PD catheter insertion provides a safe and efficient alternative to the traditional laparoscopic method, enabling urgent-start PD and reducing hospital stays and medical expenses. Our findings support the use of the hybrid method as a new standard of care for ESKD patients undergoing PD catheter insertion.

Predictors of Self-Management Behaviors After Discharge Among Unplanned Dialysis Patients

BACKGROUND

Patients with unplanned dialysis must perform self-management behaviors to maintain their health in the community after discharge. Understanding the factors that predict the postdischarge self-management behaviors of patients with unplanned dialysis can assist nurses to implement appropriate discharge plans for this population.

PURPOSE

This study was designed to predict the effects of uncertainty in illness, self-care knowledge, and social-support-related needs during hospitalization on the self-management behaviors of patients with unplanned dialysis during their first 3 months after discharge from the hospital.

METHODS

One hundred sixty-nine patients with unplanned dialysis from the nephrology department of a medical center in Taiwan were enrolled in this prospective study using convenience sampling. At hospital admission, demographic, uncertainty in illness, self-care knowledge, and social support information was collected using a structured questionnaire. Information on self-management behavior was collected at 3 months postdischarge when the patients visited outpatient clinics.

RESULTS

Hierarchical multiple regression analyses showed that self-care knowledge, uncertainty in illness, and social support were important predictors of self-management behaviors at 3 months postdischarge, explaining 65.6% of the total variance in self-management behaviors. Social support increased the variance in self-management behaviors by 27.9%.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Comprehensive discharge planning to improve the postdischarge self-management behaviors of patients with unplanned dialysis should involve interventions to improve self-care knowledge, reduce uncertainty in illness, and increase social support. Building social support should be given priority attention.

Peritoneal dialysis after shared decision-making: the disparity between reality and patient expectations

Background

The current health policy in Taiwan favors peritoneal dialysis (PD) at home. Policy objectives may make healthcare providers give more consideration to the introduction of PD treatment. This study aimed to explore the process of information acquisition and consideration during shared decision-making (SDM) for patients undergoing PD and compare their quality of life expectations before and after PD at home.

Methods

In this qualitative study, 15 patients undergoing PD for < 12 months were purposively recruited from one large PD unit in Taichung, Taiwan. Data were collected between August 2020 and December 2020 using a semi-structured interview. All transcripts were evaluated using thematic analysis.

Results

Three themes and seven subthemes were identified following data analysis: 1. sources for information on dialysis treatment, including (a) effect of others’ experiences and (b) incomplete information from healthcare providers (HCPs); 2. considerations for choosing PD, including (a) trusting physicians, and (b) maintaining pre-dialysis life; and 3. disparity between pre-and post-PD reality and expectation, including (a) limitation by time and place, (b) discrepancies in expected freedom and convenience, and (c) regret versus need to continue.

Conclusion

HCPs played an important role in SDM, providing key information that influenced the process. Patients undergoing initial PD at home exhibited a disparity between expectation and reality, which was exacerbated by incomplete information.

Healthcare Professionals' Views of Factors Influencing Diabetes Self-Management and the Utility of a mHealth Application and Its Features to Support Self-Care

INTRODUCTION

The perspectives of healthcare professionals (HCPs) are pivotal to co-development of self-management strategies for patients with diabetes. However, literature has been largely limited to perspectives of patients within the context of a Western healthcare setting. This study aims to explore factors influencing diabetes self-management in adult patients with diabetes from the perspectives of HCPs and their views of the value of mHealth application for diabetes self-management.

MATERIALS AND METHODS

We conducted focus group discussions (FGD) with purposively selected HCPs in Singapore. All FGDs were audio-recorded and transcribed verbatim. Thematic analysis was conducted using NVivo 12.

RESULTS

A total of 56 HCPs participated in the study. Barriers to self-management included limited patient commitment to lifestyle changes, suboptimal adherence to medication and treatment, patient resistance to insulin initiation and insufficient rapport between patients and HCPs. Patients' perceived susceptibility to complications, social support from family and community, multidisciplinary team care and patient's understanding of the benefits of self-care were viewed as facilitating self-management. HCPs saw mHealth apps as a vital opportunity to engage patients in the self-management of conditions and empower them to foster behavior changes. Yet, there were concerns regarding patient's limited digital literacy, lack of integration into routine electronic system and reluctance.

DISCUSSION

We identified a set of factors influencing self-management in adult patients with diabetes and useful app features that can empower patients to manage their conditions. Findings will inform the development of a mHealth application, and its features designed to improve self-care.

Treatment-related decisional conflict in pre-dialysis chronic kidney disease patients in Singapore: Prevalence and determinants

BACKGROUND

In advanced chronic kidney disease (CKD), patients face complex decisions related to renal replacement modality that can cause decisional conflict and delay. This study aimed to evaluate the prevalence of severe decisional conflict across decision types and to identify the psychosocial and clinical factors associated with decisional conflict in this population.

DESIGN

Observational cross-sectional study.

METHODS

Patients with CKD in renal care were recruited. The Decisional Conflict Scale (DCS), Functional, Communicative, and Critical Health Literacy (FCCHL), Health Literacy Questionnaire (HLQ), Hospital Anxiety and Depression Scale (HADS), Brief Illness Perception Questionnaire (BIPQ), and the Kidney-disease Quality of Life (KDQOL) questionnaires were used. Clinical data were obtained from medical records. Bivariate and multivariable logistic regression models were used to identify predictors of severe decisional conflict (DCS score ≥ 37.5).

RESULTS

Participants (N = 190; response rate = 56.7%; mean age = 62.8 ± 10.8) reported moderate levels of decisional conflict (29.7 ± 14.5). The overall prevalence of severe decisional conflict was 27.5% (n = 46) with no significant differences across decision types (dialysis, modality, access). Ethnicity (Chinese), marital status (married), BIPQ treatment control, coherence, KDQOL staff encouragement, and all health literacy domains, except functional health literacy, were significant predictors of decisional conflict in the unadjusted models. In the multivariable model, only the health literacy domains of FCCHL Communicative, and HLQ Active Engagement remained significant.

CONCLUSION

Even after pre-dialysis education, many CKD patients in this study still report severe decisional conflict, with rates remaining substantial across decision junctures. The associations of decisional conflict and health literacy skills related to communication and engagement with healthcare providers indicate that more collaborative and patient-centric pre-dialysis programs may support patient activation and resolve decisional conflict.

Effectiveness of a brief positive skills intervention to improve psychological adjustment in patients with end-stage kidney disease newly initiated on haemodialysis: protocol for a randomised controlled trial (HED-Start)

INTRODUCTION

Initiation onto haemodialysis is a critical transition that entails multiple psychosocial and behavioural demands that can compound mental health burden. Interventions guided by self-management and cognitive-behavioural therapy to improve distress have been variably effective yet are resource-intensive or delivered reactively. Interventions with a focus on positive affect for patients with end-stage kidney disease are lacking. This study will seek (1) to develop a positive life skills intervention (HED-Start) combining evidence and stakeholder/user involvement and (2) evaluate the effectiveness of HED-Start to facilitate positive life skills acquisition and improve symptoms of distress and adjustment in incident haemodialysis patients.

METHODS AND ANALYSIS

This is a single/assessor-blinded randomised controlled trial (RCT) to compare HED-Start to usual care. In designing HED-Start, semistructured interviews, a codesign workshop and an internal pilot will be undertaken, followed by a two-arm parallel RCT to evaluate the effectiveness of HED-Start. A total of 148 incident HD patients will be randomised using a 1:2 ratio into usual care versus HED-Start to be delivered in groups by trained facilitators between January 2021 and September 2022. Anxiety and depression will be the primary outcomes; secondary outcomes will be positive and negative affect, quality of life, illness perceptions, self-efficacy, self-management skills, benefit finding and resilience. Assessments will be taken at 2 weeks prerandomisation (baseline) and 3 months postrandomisation (2 weeks post-HED-Start completion). Primary analyses will use an intention-to-treat approach and compare changes in outcomes from baseline to follow-up relative to the control group using mixed-effect models.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Nanyang Technological University Institutional Review Board (IRB-2019-01-010). Written informed consent will be obtained before any research activities. Trial results will be disseminated via publications in peer-reviewed journals and conference presentations and will inform revision(s) in renal health services to support the transition of new patients to haemodialysis.

TRIAL REGISTRATION NUMBER

NCT04774770.

The Voices of Black South African Men on Renal Dialysis at a Tertiary Hospital: A Phenomenological Inquiry

The study explored the psychosocial experiences of rural black South African men undergoing renal dialysis in a tertiary hospital. Twenty men aged between 20 and 59 years (Meanage = 40.65 yrs; SD = 12.52) participated in the study. Participants were recruited purposefully. Data were collected over a period of 4 months through in-depth face-to-face interviews and analyzed using the Interpretative Phenomenological Analytical method. The following three key themes were extracted from the interviews: (a) the emotional pain and fear of death following a diagnosis of ESRD; (b) living on dialysis interferes with the management and handling of "manly" responsibilities and duties and, (c) dialysis as a challenging yet life-saving measure. The findings further suggest that renal dialysis has an impact on men's sense of masculinity and has the potential to complicate the management of renal failure. The paper concludes by recommending that cultural and community factors be taken into account when considering interventions to manage the health of men living with renal conditions.

A qualitative study on shared decision-making of patients with chronic kidney disease

Aim

This study aims to explore the change process among chronic kidney disease patients in shared decision‐making.

Design

Qualitative research is the design applied.

Method

Original transcripts from an earlier study involving a purposive sample of 31 patients with chronic kidney disease provided a source of information. The data collection was conducted from August 2017–January 2018. Data analysis applied the thematic analysis method.

Results

Three themes were identified: from avoidance to being forced to accept, decision‐making process of action and facilitating factors. After making the psychological adjustments necessary for undergoing dialysis treatment, participants experience the process of decision‐making action. The improvement of knowledge and ability increases the patient's self‐determination consciousness and strengthens confidence in decision‐making. The nurse and the patient's family are both important facilitating factors, and they assist through the entire SDM process.

International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in Western Europe

Populations in the high-income countries of Western Europe are aging due to increased life expectancy. As the prevalence of diabetes and obesity has increased, so has the burden of kidney failure. To determine the global capacity for kidney replacement therapy and conservative kidney management, the International Society of Nephrology conducted multinational, cross-sectional surveys and published the findings in the International Society of Nephrology Global Kidney Health Atlas. In the second iteration of the International Society of Nephrology Global Kidney Health Atlas, we aimed to describe the availability, accessibility, quality, and affordability of kidney failure care in Western Europe. Among the 29 countries in Western Europe, 21 (72.4%) responded, representing 99% of the region's population. The burden of kidney failure prevalence varied widely, ranging from 760 per million population (pmp) in Iceland to 1612 pmp in Portugal. Coverage of kidney replacement therapy from public funding was nearly universal, with the exceptions of Germany and Liechtenstein where part of the costs was covered by mandatory insurance. Fourteen (67%) of 21 countries charged no fees at the point of care delivery, but in 5 countries (24%), patients do pay some out-of-pocket costs. Long-term dialysis services (both hemodialysis and peritoneal dialysis) were available in all countries in the region, and kidney transplantation services were available in 19 (90%) countries. The incidence of kidney transplantation varied widely between countries from 12 pmp in Luxembourg to 70.45 pmp in Spain. Conservative kidney care was available in 18 (90%) of 21 countries. The median number of nephrologists was 22.9 pmp (range: 9.47-55.75 pmp). These data highlight the uniform capacity of Western Europe to provide kidney failure care, but also the scope for improvement in disease prevention and management, as exemplified by the variability in disease burden and transplantation rates.

Innovations to Increase Home Hemodialysis Utilization: The Transitional Care Unit

A large proportion of patients undergoing incident dialysis start in-center hemodialysis with suboptimal preparation and predialysis education. Transitional care units deliver a structured program by dedicated staff, with less patient-to-staff ratios than in regular in-center dialysis care, with the goals of supporting the emotional and physical well-being of patients while providing them with education and equipping them with the right tools to start their journey on dialysis. Key components of these programs include an emphasis on patient activation and self-management, educating and supporting patients to make informed modality choices, timely coordination of care, and an integrated approach to formation and use of the dialysis access. While data are still limited on best practices and on outcomes of these programs at a large scale, endorsing the model of transitional care units is a step in the right direction to fill the gap in our current care system.

"What do we fear the most?": Exploring fears and concerns of patients, family members and dyads in end-stage renal disease

INTRODUCTION

End-stage renal disease (ESRD) and the need for haemodialysis (HD) treatment are increasing. The course of the disease and all the life readjustments needed may generate a multitude of fears in patients and families.

AIM

This study aimed to explore the main fears and concerns of patients with ESRD undergoing HD and their family members.

STUDY DESIGN

A qualitative study was performed.

METHODS

Individual semi-structured interviews were conducted with three groups: 20 patients, 14 family caregivers and 15 patient-family dyads. Interviews were audiotaped, transcribed verbatim and submitted to thematic analysis.

FINDINGS

Five major themes emerged: (i) fear of death (fear of earlier death, fear of a sudden death and fear of dying); (ii) fear of problems during HD (fears related to the vascular access, and fear of complications during HD); (iii) concerns related to the disease (fear of loss of autonomy, fears of getting worse, fears related to renal transplantation and concerns about dietary restrictions); (iv) fear about the future; and (v) absence of fears and concerns.

DISCUSSION

Patients with ESRD undergoing HD and their family members expressed different fears related to the disease and the treatments required. Renal care staff must acknowledge and understand such concerns and help patients and families to cope. This is important to improving people's quality of life (QoL), the dialogue between health professionals, patients, and family members, and the care offered by the dialysis care settings. Moreover, this study highlights the impact this disease has at a familial level. Future family-based interventions should acknowledge possible fears and concerns of this population and integrate them into their programs.

Psychosocial Factors, Intentions to Pursue Arteriovenous Dialysis Access, and Access Outcomes: A Cohort Study

RATIONALE & OBJECTIVE

Suboptimal dialysis preparation of patients with chronic kidney disease (CKD) is common, but little is known about its relationship to psychosocial factors. This study aimed to assess patients' attitudes about access creation and to identify factors associated with patients' intentions regarding dialysis access creation and outcomes.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

190 patients with stage 4/5 CKD not receiving dialysis treated at 2 hospitals in Singapore and 128 of their family members.

PREDICTORS

Self-reported measures of illness perception, health-related quality of life, and attitudes toward access creation. Sociodemographic and clinical measures were also obtained.

OUTCOME

Intention to create an arteriovenous fistula (AVF; ie, proceed with access vs wait and see) and time to creation of a functional AVF.

ANALYTICAL APPROACH

Exploratory factor analysis (EFA) was undertaken to construct internally consistent subscales for a newly developed questionnaire about attitudes toward access creation. Logistic regression and cause-specific hazards models were conducted to identify psychosocial factors associated with patients' access creation intentions and access outcomes, respectively.

RESULTS

EFA (explained 50.1% variance) revealed 4 domains: access and dialysis concerns, need for dialysis, worry about cost, and value of access. A high risk of intention to delay access creation (51.1%) was found among patients despite early referral and education. Multivariable analysis (R²=0.45) showed that the intention to proceed with access creation was associated with greater perceived value from access (odds ratio, 2.61; 95% CI, 1.46-4.65; P<0.001).

LIMITATIONS

Limited generalization, as only those already receiving nephrology care were studied.

CONCLUSIONS

Approximately half of the patients studied planned to delay access creation. The questionnaire developed to evaluate attitudes about access creation may help identify individuals for whom decision-support programs would be useful. These findings highlight the need to understand and address patients' concerns about access creation.

How do patients and health professionals perceive the role of family members in the decision-making process regarding the choice of a dialysis method? A qualitative study

BACKGROUND

Therapeutic decisions often seem to be the product of interaction between health professionals and patients alone. However, some realities make it essential to consider family members when examining care of patients, especially in the construction of therapeutic choices. Implementation of measures such as therapeutic patient education to make the patient an actor in his own healthcare, and the impact of disease on the patient's social and professional activities mean there is an important place for family members in a patient's care pathway. This study aims to examine the role of family members and the family environment in decision-making on treatment for patients with chronic kidney disease. It also analyzes how they contribute to the construction of patients' choices on dialysis methods through their involvement in a therapeutic patient education program.

METHODS

This study involved thirty-six semi-structured interviews: sixteen with patients and twenty with health professionals. Therapeutic patient education sessions, interactions and information exchanges between patients and health professionals, as well as participant behaviours, were also observed. Analysis was thematic.

RESULTS

Results indicate that the factors influencing the patient's choice of dialysis methods include the family environment as the place where the disease is experienced, the need to maintain family ties, the advice provided by family members and their active participation in therapeutic patient education sessions and partnership between family members and health professionals in the decision-making process.

CONCLUSION

This study highlights the reality of decision-making processes that can start from a non-hospital setting. Furthermore, it argues for greater consideration of the needs, values, and preferences of family members in mechanisms designed to promote patient participation in therapeutic decisions.

“Más que dolor”: experiencia de pacientes dializados respecto a su punción en hemodiálisis

Introducción: El dolor a la punción de la fístula arterio-venosa es una constante en todos los pacientes en hemo-diálisis.Objetivo: El propósito del estudio fue explorar la per-cepción del dolor a la punción en los pacientes en hemo-diálisis, analizando tanto emociones como ideas sobre su calidad de vida.Material y Método: Se realizó un estudio cualitativo, de carácter fenomenológico, en el Hospital Universitario Reina Sofía de Córdoba, en la Unidad de Nefrología y en el Servicio de Consultas Externas “El Perpetuo Socorro” (que también pertenece al mismo hospital). Se realiza-ron entrevistas semiestructuradas a diez pacientes, hom-bres y mujeres, que sufrían de Insuficiencia Renal Cróni-ca bajo tratamiento de hemodiálisis.Resultados: Se llevó a cabo un análisis de contenido del que emergieron tres categorías principales asociadas a distintas subcategorías: 1) Doler, duele ¿eh? Pero... (Mejora con el tiempo; Cuando duele lo hace de verdad; ¿Duele? Ni te enteras); 2) Ansiedad y miedos relaciona-dos con la intervención (Cuestión de mentalizarse; Ansie-dad anticipatoria; Desesperación e inseguridad ante com-plicaciones y desinformación; ¡Por Dios, que no se rompa la fístula!; Las manos de la enfermera); 3) Una calidad de vida comprometida (Muchas limitaciones; Pero no tie-ne tanto impacto; ¿Catéter o fístula?).Conclusiones: El estudio permitió describir las percep-ciones de los pacientes en hemodiálisis en torno a la pun-ción, su contexto y consecuencias, posibilitando, primero, una mayor comprensión y empatía en los profesionales de la salud y, después, una base para otras aproximaciones indagatorias al fenómeno en cuestión

Causes of the delay in creating permanent vascular access in hemodialysis patients

Majority of the chronic kidney disease (CKD) patients undergo hemodialysis (HD) with central venous catheter which has multiple complications. This study aims to identify the physicians' perspectives regarding the reasons of delayed arteriovenous fistula (AVF) creation in the Kingdom of Saudi Arabia to improve the quality of CKD patients' care and prognosis and prevent complications. A cross-sectional descriptive study was conducted on KSA nephrologists using a questionnaire which includes factors associated with delay in AVF creation, which were categorized into patient, physician, and hospital factors. The optimal timing of starting dialysis was also assessed. In a total of 212 participants, 131 (61.8%) were of consultant level, with the largest numbers being from the Central region (52.4%). The most important patient factors associated with delay in AVF creation were denial of kidney disease or the need of AVF (76.4%), dialysis fears and practical concern (75.9%), and patient refusal (73.1%). The most important physician and hospital factors were insufficient conduction of predialysis care and education (63.7%) and late referral to a nephrologist (56.6%). Participants would create AVF when the patient reaches Stage 4 CKD (69.3%) or Stage 5 (27.4%), and 88.7% of the participants would do so 3-6 months before the anticipated start of HD. Over two-thirds of the participants (68.4%) chose patient as the main factor contributing to the delay of permanent vascular access. A validated approach to patient selection, patient-centered predialysis care, and referral to vascular access creation that could be applied on different types of patients in different regions is required.