Wong Susan P Y, Vig Elizabeth K, Taylor Janelle S, Burrows Nilka R, Liu Chuan-Fen, Williams Desmond E, Hebert Paul L, O'Hare Ann M
Department of Medicine, University of Washington, Seattle.
Department of Medicine, University of Washington, Seattle2Department of Medicine, VA Puget Sound Healthcare System, Seattle, Washington.
JAMA Intern Med. 2016 Feb;176(2):228-35. doi: 10.1001/jamainternmed.2015.7412.
There is often considerable uncertainty about the optimal time to initiate maintenance dialysis in individual patients and little medical evidence to guide this decision.
To gain a better understanding of the factors influencing the timing of initiation of dialysis in clinical practice.
DESIGN, SETTING, AND PARTICIPANTS: A qualitative analysis was conducted using the electronic medical records from the Department of Veterans Affairs (VA) of a national random sample of 1691 patients for whom the decision to initiate maintenance dialysis occurred in the VA between January 1, 2000, and December 31, 2009. Data analysis took place from June 1 to November 30, 2014.
Central themes related to the timing of initiation of dialysis as documented in patients' electronic medical records.
Of the 1691 patients, 1264 (74.7%) initiated dialysis as inpatients and 1228 (72.6%) initiated dialysis with a hemodialysis catheter. Cohort members met with a nephrologist during an outpatient clinic visit a median of 3 times (interquartile range, 0-6) in the year prior to initiation of dialysis. The mean (SD) estimated glomerular filtration rate at the time of initiation for cohort members was 10.4 (5.7) mL/min/1.73 m(2). The timing of initiation of dialysis reflected the complex interplay of at least 3 interrelated and dynamic processes. The first was physician practices, which ranged from practices intended to prepare patients for dialysis to those intended to forestall the need for dialysis by managing the signs and symptoms of uremia with medical interventions. The second process was sources of momentum. Initiation of dialysis was often precipitated by clinical events involving acute illness or medical procedures. In these settings, the imperative to treat often seemed to override patient choice. The third process was patient-physician dynamics. Interactions between patients and physicians were sometimes adversarial, and physician recommendations to initiate dialysis sometimes seemed to conflict with patient priorities.
The initiation of maintenance dialysis reflects the care practices of individual physicians, sources of momentum for initiation of dialysis, interactions between patients and physicians, and the complex interplay of these dynamic processes over time. Our findings suggest opportunities to improve communication between patients and physicians and to better align these processes with patients' values, goals, and preferences.
对于个体患者开始维持性透析的最佳时机，通常存在很大的不确定性，且几乎没有医学证据来指导这一决策。
更好地了解临床实践中影响开始透析时机的因素。
设计、背景和参与者：采用定性分析方法，使用美国退伍军人事务部（VA）的电子病历，这些病历来自2000年1月1日至2009年12月31日期间在VA决定开始维持性透析的1691名患者的全国随机样本。数据分析于2014年6月1日至11月30日进行。
患者电子病历中记录的与开始透析时机相关的核心主题。
在1691名患者中，1264名（74.7%）作为住院患者开始透析，1228名（72.6%）通过血液透析导管开始透析。队列成员在开始透析前一年的门诊就诊中，与肾病专家见面的中位数为3次（四分位间距为0 - 6次）。队列成员开始透析时的平均（标准差）估计肾小球滤过率为10.4（5.7）mL/min/1.73 m²。开始透析的时机反映了至少3个相互关联且动态的过程之间的复杂相互作用。第一个是医生的做法，范围从旨在让患者为透析做准备的做法到通过医疗干预管理尿毒症症状以避免透析需求的做法。第二个过程是动力来源。透析的开始往往由涉及急性疾病或医疗程序的临床事件引发。在这些情况下，治疗的紧迫性似乎常常凌驾于患者的选择之上。第三个过程是患者与医生的动态关系。患者与医生之间的互动有时是对抗性的，医生建议开始透析有时似乎与患者的优先事项相冲突。
维持性透析的开始反映了个体医生的护理实践、透析开始的动力来源、患者与医生之间的互动，以及这些动态过程随时间的复杂相互作用。我们的研究结果表明，存在改善患者与医生之间沟通以及使这些过程更好地与患者价值观、目标和偏好保持一致的机会。
