Barriers to Timely Arteriovenous Fistula Creation: A Study of Providers and Patients

Abstract

Current clinical practice guidelines recommend a native arteriovenous fistula (AVF) as the vascular access of first choice. Despite this, most patients in western countries start hemodialysis therapy using a catheter. Little is known regarding specific physician and system characteristics that may be responsible for delays in permanent access creation. Multicenter cohort study using mixed methods; qualitative and quantitative analysis. 9 nephrology centers in Australia and New Zealand, including 319 adult incident hemodialysis patients. Identification of barriers and enablers to AVF placement. Type of vascular access used at the start of hemodialysis therapy. Prospective data collection included data concerning predialysis education, interviews of center staff, referral times, and estimated glomerular filtration rate (eGFR) at AVF creation and dialysis therapy start. 319 patients started hemodialysis therapy during the 6-month period, 39% with an AVF and 59% with a catheter. Perceived barriers to access creation included lack of formal policies for patient referral, long wait times for surgical review and access placement, and lack of a patient database for management purposes. eGFR thresholds at referral for and creation of vascular accesses were considerably lower than appreciated (in both cases, median eGFR of 7 mL/min/1.73 m(2)), with median wait times for access creation of only 3.7 weeks. First assessment by a nephrologist less than 12 months before dialysis therapy start was an independent predictor of catheter use (OR, 8.71; P < 0.001). Characteristics of the best performing centers included the presence of a formalized predialysis pathway with a centralized patient database and low nephrologist and surgeon to patient ratios. A limited number of patient-based barriers was assessed. Cross-sectional data only. A formalized predialysis pathway including patient education and eGFR thresholds for access placement is associated with improved permanent vascular access placement.