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Understanding Patients’ Preference for Vascular Access Choice

By Laminate Medical
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Currently the three primary forms of hemodialysis vascular access are central venous catheters, native arteriovenous fistulas such as brachiocephalic fistulas, and synthetic arteriovenous grafts.

Even though matured fistulas are associated with the lowest rates of morbidity and mortality, many patients require immediate vascular access due to urgent dialysis needs with catheters as the predominant choice until either a fistula or a graft can be created. Because this high reliance on catheters is costly to the health care system worldwide and may affect patients’ outcomes, there is an urgent need to better understand patient preference for vascular access choice. A better understanding of patient satisfaction with vascular access is highly relevant to clinical practice, particularly given the emphasis on patient-centered care.

A study was conducted in Canada to understand patients’ perspectives on complications associated with vascular access-related interventions. The study used a multi-stage comprehensive questionnaire administered to 140 in-center hemodialysis patients from May 2011 until July 2014. The questionnaire was divided into three domains: physical complications, disruption to routine, and infection. The level of bother associated with complications was measured using a 5-point Likert scale — a psychometric scale commonly used in questionnaire-based research that measures either positive or negative responses to a statement. The scale ranges from 1 —“not at all bothered” to 5 — “extremely bothered.”

Patients’ preference for vascular access:
Main results of the study

Among the 140 patients involved in the study, the most common type of vascular access was catheters (58.6%), followed by fistulas of all kind such as brachiocephalic (33.6%), and lastly, grafts (13.6%).

The most commonly experienced interventions were angiogram/venogram for fistulas (35.7%), TPA or another lock for catheters (33.6%), and other interventions for catheters (30.0%).

For the first domain — physical complications — the mean Likert value was highest for grafts at 1.92, closely followed by fistulas at 1.87, and catheters at 1.56.

For the second domain — disruption to routine — the mean Likert value was highest for catheters at 1.44, followed by grafts at 1.37, and fistulas at 1.33.

For the third domain — infection — the mean Likert value was highest at 1.76 for catheters, followed by fistulas at 1.23, and grafts at 1.22.

How can we help patients better understand vascular access?

The main finding of this study was that physical vascular access complications (pain, bruising, swelling, and bleeding) were of highest concern for patients, more so than disruption of routine or infectious complications. Physical vascular access complications bother patients more than potential hospitalizations, extended stays on dialysis, or disruption to sleep and day-time routine.

This concern about physical complications is consistent with previous studies that also interviewed patients, nurses, and physicians about vascular access. In one previous study it was found that approximately 35% of patients preferred their catheter but not for “medical reasons.” Patients are much more bothered by the appearance of their access, pain during cannulation, and bruising and swelling.

The same study also found that patients using fistulas (brachiocephalic, radiocephalic, etc.) were more likely to recommend their type of access to others and less likely to want to switch to another type.

This study may help explain the gap between patients’ concerns and the clear clinical and economic data associating catheter-related infections with increased morbidity, rising hospitalization rates, high treatment costs, and poor survival compared to the use of fistulas or grafts. Such insights may assist with future educational efforts to reduce catheter use and thus prevent complications.

Future research should focus on developing methods to effectively: (i) reduce the fear and pain associated with cannulation; and (ii) educate patients about the risks associated with vascular access-related infection.

Our product, VasQ, was designed to improve the maturation and patency rates of AV fistulas, predominantly brachiocephalic fistulas, which may help reduce associated complication rates and thus increase the number of patients using fistulas as their vascular access choice. Read more >>

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