#6634 Patients' Perspectives on Haemodialysis Access: A Qualitative Study

Abstract

Background and Aims There is high quality evidence that favours the use of arteriovenous fistulas (AVFs) over central venous catheters (CVCs) for haemodialysis access, based on the association with lowest mortality and fewest complications [1]. However, less is known regarding patient and nurse preferences concerning access choices and the drivers underlying these preferences. One previous study [2] identified physical concerns regarding fistulas as the predominant barrier preventing patients with a CVC from switching to an AVF. Here we provide an expansion on these barriers, alongside novel exploration of nursing opinion on access choice. Methods Data was collected through individually administered patient surveys across 4 regional dialysis sites in East Anglia (n = 380), and anonymised online survey requests to nursing staff at the sites. Deductive and inductive strategies were employed for analysis of the qualitative data. The aim of the thematic analysis of the data was to determine the preferred access modality of patients and nurses, and the drivers for the preferences. Results 63% (n = 238) of patients responded to the questionnaire. Patient responses fell into one of four categories; drivers toward, or barriers against AVFs or CVCs. The largest of these categories was the barriers for AVFs, within which four main themes were identified: ‘Fear’, ‘difficult AVF surgery’, ‘patient preference for lines’ or ‘patients awaiting AVF surgery or transplant’. A smaller theme of ‘insufficient information’ regarding access choice was also identified. ‘Fear’ was the largest theme, within which five subthemes were identified: fear of needles, pain, bleeding, fistula appearance, or fear of complications heard from other patients on the dialysis unit. ‘Difficult AVF surgery’ encompassed two subthemes; those who have had previous failed traumatic attempts or those whose current vascular architecture was not amenable to fistula surgery. The other three categories received far fewer responses. The AVF driver category focussed on fistulas being preferred medically with reduced infection risk, whilst drivers for lines included it being ‘comfortable’ and patients saying that the line works for them. The one comment in the CVC barrier category cited difficulties experienced with lines like blockages and infections. 13 responses were received from dialysis nurses. All respondents were aware of the medical preference for patients to have a fistula, and the reasons why. Nurses themselves also preferred their patients to have fistulas, referencing the same reasons. However, most nurses thought patients preferred CVCs, and were able to cite the same reasons as the patients themselves. Lastly, nurses reported that they convey the benefits and risks of different access types correctly when asked by patients at the dialysis units. Conclusion These findings highlight that, whilst doctors and nurses focus on long-term health benefits of AVF when discussing vascular access choices, patients are focussed on the immediate potential risks of an AVF. We hypothesise that, whilst dialysing, patients share stories of fistula-related complications that drive short-term fear of AVFs, with such impact that the messages conveyed by health professionals are often negated. This difference in agendas is essential to acknowledge. The relationship between clinician, nurse and patient in the haemodialysis setting is unique given its longevity, frequency of contact, and holistic nature. Implementing a strategy to bridge this agenda gap could strengthen this relationship and provide a basis for optimum, evidence-based treatment. We therefore suggest the use of positive patient AVF experiences, delivered via peer education sessions, as a tool to introduce drivers for, and uptake of, AVF for dialysis patients in the future.