TITLE: Impact of pre-dialysis nephrology care engagement and decision-making on provider and patient action toward permanent vascular access.
BACKGROUND: While catheters are often thought the result of emergency hemodialysis (HD) initiation among patients with little or no pre-dialysis nephrology care, the role of patient level of engagement in care and modality decision-making have not been fully explored.
METHODS: This is a retrospective medical record review of adults (age 18-89 years) who received care in academically affiliated private practice, public hospital, or Veterans Administration settings prior to initiating HD with a catheter between 10/1/2011 and 9/30/2012. Primary predictors were level of patient engagement in nephrology care within 6 months of HD initiation and timing of modality decision-making. Primary outcomes were provider action (referral) and any patient action (evaluation by a vascular surgeon, vein mapping or vascular surgery) toward [arteriovenous fistula or graft, (AVF/AVG)] creation.
RESULTS: Among 92 incident HD patients, 66% (n = 61) initiated HD via catheter, of whom 34% (n = 21) had ideal engagement in care but 42% (n = 25) had no documented decision. Providers referred 48% (n = 29) of patients for AVF/AVG, of whom 72% (n = 21) took any action. Ideal engagement in care predicted provider action (adjusted OR 13.7 [95% CI 1.08, 175.1], p = 0.04), but no level of engagement in care predicted patient action (p > 0.3). Compared to patients with no documented decision, those with documented decisions within 3, 3-12, or more than 12 months before initiating dialysis were more likely to have provider action toward AVF/AVG (adjusted OR [95% CI]: 9.0 [1.4,55.6], p = 0.2, 37.6 [3.3423.4] p = 0.003, and 4.8 [0.8, 30.6], p = 0.1, respectively); and patient action (adjusted OR [95% CI]: 18.7 [2.3, 149.0], p = 0.006, 20.4 [2.6, 160.0], p = 0.004, and 6.2 [0.9, 44.0], p = 0.07, respectively).
CONCLUSIONS: Timing of patient modality decision-making, but not level of engagement in pre-dialysis nephrology care, was predictive of patient and provider action toward AVF/AVG Interventions addressing patients' psychological preparation for dialysis are needed.
SOURCE: Grubbs V, Jaar BG, Cavanaugh KL, et al. 2021. Impact of pre-dialysis nephrology care engagement and decision-making on provider and patient action toward permanent vascular access. BMC Nephrol. 22(1): 60.
背景：虽然人们通常认为很少或没有透析前肾病学护理的患者中紧急血液透析（HD）启动的结果，但尚未充分探讨患者在护理和模式决策中参与水平的作用。
方法：这是一项回顾性医疗记录，回顾了在2011年10月1日至2012年9月30日期间开始使用导管进行HD，在学院附属于私人诊所，公立医院或退伍军人管理局的医疗机构接受治疗的成年人（18-89岁）。主要的预测指标是患者在HD开始6个月内以及模态决策时机内的肾脏病护理水平。主要结局是提供者的行动（转诊）和任何患者对（动静脉瘘或移植物（AVF / AVG））建立的行动（由血管外科医师进行评估，静脉作图或血管外科手术评估）。
结果：在92例HD患者中，有66％（n = 61）通过导管启动HD，其中34％（n = 21）有理想的护理参与，但42％（n = 25）尚无记录。提供者转介了48％（n = 29）的AVF / AVG患者，其中72％（n = 21）采取了任何行动。理想地参与护理可预测提供者的行为（调整后的OR 13.7 [95％CI 1.08，175.1]，p = 0.04），但参与护理水平不可预测患者的行为（p> 0.3）。与没有记录的决定的患者相比，在开始透析前3、3-12或12个月以上有记录的决定的患者更有可能对AVF / AVG采取提供者的行动（调整后OR [95％CI]：9.0 [1.4， 55.6]，p = 0.2，37.6 [3.3423.4] p = 0.003和4.8 [0.8、30.6]，p = 0.1）；以及患者的行动（调整后的OR [95％CI]：18.7 [2.3、149.0]，p = 0.006、20.4 [2.6、160.0]，p = 0.004和6.2 [0.9、44.0]，p = 0.07）。
结论：患者模式决策的时机选择，可以预测患者和提供者对AVF / AVG的作用，而不是透析前肾脏病护理水平的参与，需要采取干预措施来解决患者的心理透析准备。
启发:在合适的时机给予正确的决策建议，对患者的影响更大。3-12月（暂且理解为6月）也符合我们临床的要求，过早和过晚的干预往往对结局不会发生明显的影响。
