Nica Andra, Lok Charmaine E, Harris Jeremy, Lee Timmy C, Mokrzycki Michele H, Maya Ivan D, Vazquez Miguel A, Xi Wang, Moist Louise M
Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.
Semin Dial. 2013 Jul-Aug;26(4):520-6. doi: 10.1111/sdi.12046. Epub 2013 Mar 21.
Understanding healthcare providers' preferences, values, and beliefs around AVF eligibility is important to explain variability in practice. We conducted a survey of international surgeons, using hypothetical patient scenarios, to assess resources used, variables, perceived barriers, and absolute contraindications to access creation. A total of 134 surgeons completed the survey. Venous duplex ultrasound mapping (VDUM) was offered to all patients by 90% of US, 68% Canadian, and 63% European respondents. VDUM altered clinical decision less than 25% of the time for 33% American, 48% Canadian, and 85% European surgeons. Increased comorbidities and previous failed access were deterrents to AVF creation as was vessel size. Second choice access was the AV graft in the US and Europe and the catheter in Canada. Absolute contraindications to AVF creation included patient life expectancy <1 year, left ventricular ejection fraction (LVEF) <15%, and a history of dementia, while 42% surgeons reported no absolute contraindications. Perceived barriers included patient preferences, long wait times for surgery, and late referral to a Nephrologist. Significant variability exists in the surgical preoperative assessment of patients, and the eligibility criteria used for fistula creation. Understanding surgeons' preferences can aid in establishing standardization for VA access eligibility, including surgical assessment.
了解医疗服务提供者对于动静脉内瘘（AVF）适用性的偏好、价值观和信念，对于解释实践中的差异很重要。我们使用假设的患者场景对国际外科医生进行了一项调查，以评估建立通路所使用的资源、变量、感知到的障碍以及绝对禁忌证。共有134名外科医生完成了调查。90%的美国受访者、68%的加拿大受访者和63%的欧洲受访者会为所有患者提供静脉双功超声造影（VDUM）。对于33%的美国外科医生、48%的加拿大外科医生和85%的欧洲外科医生而言，VDUM改变临床决策的次数不到25%。合并症增加、既往通路建立失败以及血管大小都是建立AVF的阻碍因素。在美国和欧洲，第二选择的通路是AV移植物，在加拿大则是导管。建立AVF的绝对禁忌证包括患者预期寿命<1年、左心室射血分数（LVEF）<15%以及有痴呆病史，而42%的外科医生报告没有绝对禁忌证。感知到的障碍包括患者偏好、手术等待时间长以及肾病科医生转诊延迟。患者术前手术评估以及用于造瘘的适用性标准存在显著差异。了解外科医生的偏好有助于建立VA通路适用性的标准化，包括手术评估。
