Department of Surgery, Southern California Permanente Medical Group, Kaiser Permanente Downey Medical Center, Bellflower, California 90706, USA.
Perit Dial Int. 2010 Mar-Apr;30(2):142-50. doi: 10.3747/pdi.2009.00066. Epub 2010 Jan 15.
Nephrologists are often thwarted in their attempts to grow their peritoneal dialysis programs because of suboptimal surgeon performance in placing catheters. A rallying call is heard among nephrologists to step up to the role of dialysis access providers.
What factors influence the practicability of nephrologists becoming primary dialysis access providers? Why have surgeons failed their task and can anything motivate them to change their performance and improve outcomes?
While the issues are universal, this analysis focuses on current practice data from the United States. Evidence reviewed includes dialysis center size and annual new starts, profile of specialties performing catheter placement, nephrology workforce capacity, catheter implantation methodology, resource utilization for peritoneal access, and surgeon performance.
The current nephrology workforce is running at maximum capacity and fellowship training programs will struggle to meet additional demands. Nephrology training programs are often deficient in providing adequate experience in peritoneal dialysis management. Only 2.3% of peritoneal catheters are placed by nephrologists. The best catheter outcomes are produced by laparoscopic methods used by surgeons. Compared to other catheter placement techniques, laparoscopy enables a larger candidate pool of patients. Nonetheless, suboptimal surgical performances are related to inadequate training, low procedure volume, and poor reimbursement.
It is improbable that nephrologists can expand the scope of their practice to assume the additional role of dialysis access providers. The performance of the existing surgical workforce can be enhanced through medical society-sponsored educational activities, channeling access procedures to designated surgeons, and improved remuneration through outcomes-based incentive programs.
由于外科医生在放置导管方面表现不佳，肾病学家经常在扩大腹膜透析计划方面受阻。肾病学家呼吁加强作为透析通路提供者的角色。
哪些因素影响肾病学家成为主要透析通路提供者的可行性？为什么外科医生未能完成任务，有什么可以激励他们改变表现并改善结果？
虽然这些问题具有普遍性，但本分析侧重于来自美国的当前实践数据。审查的证据包括透析中心的规模和每年的新启动情况、进行导管放置的专业特征、肾病学劳动力能力、导管植入方法、腹膜通路的资源利用情况以及外科医生的表现。
当前的肾病学劳动力已经达到最大容量，并且研究员培训计划将难以满足额外的需求。肾病学培训计划在提供足够的腹膜透析管理经验方面往往存在不足。只有 2.3%的腹膜导管由肾病学家放置。最好的导管结果是由外科医生使用腹腔镜方法产生的。与其他导管放置技术相比，腹腔镜可以为更多的患者提供候选池。尽管如此，手术表现不佳与培训不足、手术量低和补偿不足有关。
肾病学家不太可能扩大其实践范围，承担额外的透析通路提供者角色。通过医学协会赞助的教育活动、将通路程序引导给指定的外科医生以及通过基于结果的激励计划提高报酬，可以提高现有外科医生队伍的表现。
