Barriers to arteriovenous fistula use in black hemodialysis patients

黑人血液透析患者使用动静脉内瘘的障碍

基本信息

批准号：
10084716
负责人：
MICHAEL ALLON
金额：
$ 45.36万
依托单位：
UNIVERSITY OF ALABAMA AT BIRMINGHAM
依托单位国家：
美国
项目类别：
财政年份：
2019
资助国家：
美国
起止时间：
2019-06-10 至 2024-01-31
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/10084716
关键词：
Address Affect Angioplasty Arteries Arteriovenous fistula Blood Vessels Blood flow Caring Catheters Central Vein Cessation of life Chronic Clinical Consensus Data Databases Decision Making Dependence Dialysis patients Dialysis procedure End stage renal failure Ensure Fistula Future Grant Guidelines Hemodialysis Infection Insurance Coverage Intervention Intervention Trial Interview Life Nurses Operative Surgical Procedures Outcome Patient Preferences Patient Schedules Patients Plant Roots Population Procedures Process Provider Qualitative Research Quality of life Race Reporting Research Sample Size Second Look Surgery Services Structure Surgeon Surveys System Testing Thrombectomy Time Translating Veins Venous arteriovenous graft black/white disparity design experience follow-up improved insight patient-level barriers programs prospective racial disparity

项目摘要

Abstract To successfully and efficiently dialyze, patients with end-stage renal disease (ESRD) patients must have a reliable conduit to access the vasculature (vascular access), either an arteriovenous fistula (AVF) or arteriovenous graft (AVG). Despite national consensus vascular access guidelines that strongly recommend preferential placement of AVFs, 80% of ESRD patients initiate HD with a central vein catheter (CVC). Such patients— the focus of our grant—require timely vascular access planning and surgery once they have initiated HD to ensure a permanent AVF access is placed. Disparities in AVF use between blacks and whites begin at HD initiation and increase progressively following AVF creation, such that at 1 year it is 58.8 vs 67.8%, respectively, which translates to 5,000 excess deaths among blacks annually. The proposed grant will investigate patient, provider, and system factors contributing to racial disparities in AVF use. Three major surgical processes of care determine AVF use in hemodialysis patients. First, an AVF needs to be created in the patient who initiates HD with a CVC. Second, the new AVF has to mature adequately to be used for HD. Third, once the AVF has matured, it needs to maintain long-term patency for dialysis, often requiring access interventions such as angioplasty, thrombectomy, or surgical revision. Aim 1 will use qualitative research to elucidate views on AVFs and barriers to AVF processes of care among black and white patients at various stages of dialysis care. We will use semi-structured interviews of black and white dialysis patients and their providers (surgeons, nephrologists, and dialysis nurses) to identify common themes regarding the decision- making around initial AVF creation and subsequent interventions. Aim 2 will use quantitative research to determine whether there are racial disparities in the key processes of care required to achieve and maintain AVF use for dialysis among patients initiating HD with a CVC. We will retrospectively query the national USRDS database of incident HD patients to determine whether one or more of the 3 key AVF surgical processes of care differ between blacks and whites. In parallel, we will prospectively collect more granular data on these processes of care in patients initiating HD at a large dialysis center. Aim 3 will determine the relationship between system level factors and AVF processes of care. Aim 4 will administer validated surveys to incident black and white hemodialysis patients scheduled for AVF surgery over a 4-year period at UAB, and quantify potential patient barriers to and facilitators of AVF use. We will then determine which specific patient, provider, and system factors are associated with differences in AVF processes of care (identified in Aim 2) by prospectively collecting vascular outcomes data for this UAB population. Finally, we will use mediational analysis to identify the most important modifiable patient, provider, and system factors related to AVF use among black dialysis patients. These factors will be used to develop a future multi-level interventional trial to evaluate whether addressing specific barriers can reduce racial disparities in AVF use.

抽象的为了成功有效地进行透析，终末期肾病 (ESRD) 患者必须具备进入脉管系统（血管通路）的可靠导管，无论是动静脉瘘（AVF）还是尽管国家共识血管通路指南强烈推荐动静脉移植（AVG）。由于优先放置 AVF，80% 的 ESRD 患者通过中心静脉导管 (CVC) 开始 HD。患者（我们资助的重点）一旦开始就需要及时的血管通路规划和手术 HD 确保永久 AVF 访问黑人和白人之间 AVF 使用的差异始于。 HD 开始并在 AVF 创建后逐渐增加，因此 1 年时为 58.8% vs 67.8%，分别意味着每年有 5,000 名黑人超额死亡。调查导致 AVF 使用种族差异的患者、提供者和系统因素。手术护理过程决定了 AVF 在血液透析患者中的使用。首先，需要创建 AVF。其次，新的 AVF 必须充分成熟才能用于 HD。第三，一旦 AVF 成熟，就需要保持透析的长期通畅，通常需要通路目标 1 将使用定性研究来进行血管成形术、血栓切除术或手术修复等干预措施。阐明不同地区黑人和白人患者对 AVF 的看法以及 AVF 护理过程中的障碍我们将对黑人和白人透析患者及其患者进行半结构化访谈。提供者（外科医生、肾脏科医生和透析护士）确定有关决策的共同主题- 围绕最初的 AVF 创建和后续干预，目标 2 将使用定量研究来实现。确定实现和维持所需的关键护理过程中是否存在种族差异 AVF 在使用 CVC 启动 HD 的患者中的使用情况我们将回顾性询问全国。 USRDS 事件 HD 患者数据库确定是否需要进行 3 个关键 AVF 手术中的一项或多项同时，黑人和白人的护理过程有所不同，我们将前瞻性地收集更精细的数据。目标 3 将确定在大型透析中心开始 HD 的患者的这些护理过程。目标 4 将管理经过验证的调查计划在 4 年内在 UAB 进行 AVF 手术的黑人和白人血液透析患者，以及然后我们将确定哪个特定患者，提供者和系统因素与 AVF 护理过程的差异相关（在目标 2 中确定）：最后，我们将使用中介方法前瞻性地收集该 UAB 人群的血管结果数据。分析以确定与 AVF 使用相关的最重要的可修改患者、提供者和系统因素这些因素将用于开发未来的多层次干预试验评估解决特定障碍是否可以减少 AVF 使用中的种族差异。