Osterlund Katherine, Mendelssohn David, Clase Catherine, Guyatt Gordon, Nesrallah Gihad
The Lawson Health Research Institute, Western University, London, Ontario, Canada.
Semin Dial. 2014 Mar;27(2):160-72. doi: 10.1111/sdi.12183. Epub 2014 Feb 17.
Home dialysis (home HD or home PD) remains underutilized in most jurisdictions. Physicians, advanced-practice nurses, and policy makers working with chronic kidney disease populations can provide insights into patient, healthcare professional, and system-level barriers to home dialysis selection by suitable patients. We used in-depth interviews, with a purposive sampling strategy until informational redundancy was achieved, to elicit barriers and facilitators to home dialysis selection from thirteen informants. We triangulated these data against qualitative data collected in a related survey of nephrologist attitudes. We used a modified grounded theory approach to construct a taxonomy of barriers and facilitators. Informants included nephrologists (n = 11), an advanced-practice nurse, and a health administrator with a provincial renal care organization. We constructed separate taxonomies of barriers and related facilitators that were specific to PD, specific to home HD, and common to both. We distinguished between factors favoring, modifiable factors opposing, and nonmodifiable factors opposing home dialysis selection. Several major themes emerged, including: medical factors, home physical environment, psychological and cognitive factors (knowledge, attitudes, coping styles), social factors (supports, lifestyle), dialysis program, local hospital or regional factors (expertise, resources, local culture), healthcare professional-related factors (knowledge, attitudes, reimbursement), health system-related factors (funding models), and exogenous factors (late referral, technology). We identified several modifiable practices at the level of patient, healthcare professional, dialysis facility, and healthcare system to increase appropriate use of home dialysis. We discuss potential facilitating factors, knowledge gaps, and priorities for future research, and propose potential applications for this novel taxonomy of determinants of dialysis modality choice.
在大多数司法管辖区，家庭透析（家庭血液透析或家庭腹膜透析）的利用率仍然较低。从事慢性肾病患者治疗工作的医生、高级执业护士和政策制定者可以深入了解患者、医疗保健专业人员以及系统层面存在的阻碍，这些阻碍使得合适的患者无法选择家庭透析。我们采用深度访谈，并运用目的抽样策略，直至实现信息饱和，以从13名受访者中获取家庭透析选择的阻碍因素和促进因素。我们将这些数据与在一项关于肾病学家态度的相关调查中收集的定性数据进行了三角互证。我们采用改良的扎根理论方法构建了阻碍因素和促进因素的分类体系。受访者包括肾病学家（n = 11）、一名高级执业护士以及省级肾脏护理组织的一名卫生管理人员。我们构建了分别针对腹膜透析、家庭血液透析以及两者共有的阻碍因素和相关促进因素的分类体系。我们区分了有利于家庭透析选择的因素、可改变的反对因素以及不可改变的反对因素。出现了几个主要主题，包括：医学因素、家庭物理环境、心理和认知因素（知识、态度、应对方式）、社会因素（支持、生活方式）、透析项目、当地医院或地区因素（专业知识、资源、当地文化）、医疗保健专业人员相关因素（知识、态度、报销）、卫生系统相关因素（资金模式）以及外部因素（转诊延迟、技术）。我们确定了在患者、医疗保健专业人员、透析机构和卫生系统层面的几种可改变做法，以增加家庭透析的合理使用。我们讨论了潜在的促进因素、知识差距以及未来研究的重点，并提出了这种新颖的透析方式选择决定因素分类体系的潜在应用。
