Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
Department of Health Policy and Management, Fielding School of Public Health, UCLA, Los Angeles, CA, USA.
J Gen Intern Med. 2023 Nov;38(14):3198-3208. doi: 10.1007/s11606-023-08290-5. Epub 2023 Jul 5.
The updated 2019 National Kidney Foundation Kidney Disease Outcomes Quality Initiative vascular access guidelines recommend patient-centered, multi-disciplinary construction and regular update of an individualized end-stage kidney disease (ESKD) Life-Plan (LP) for each patient, a dramatic shift from previous recommendations and policy. The objective of this study was to examine barriers and facilitators to implementing the LP among key stakeholders.
Semi-structured individual interviews were analyzed using inductive and deductive coding. Codes were mapped to relevant domains in the Consolidated Framework for Implementation Research (CFIR).
We interviewed 34 participants: 11 patients with end-stage kidney disease, 2 care partners, and 21 clinicians who care for patients with end-stage kidney disease. In both the clinician and the patient/care partner categories, saturation (where no new themes were identified) was reached at 8 participants. We identified significant barriers and facilitators to implementation of the ESKD LP across three CFIR domains: Innovation, Outer setting, and Inner setting. Regarding the Innovation domain, patients and care partners valued the concept of shared decision-making with their care team (CFIR construct: innovation design). However, both clinicians and patients had significant concerns about the complexity of decision-making around kidney substitutes and the ability of patients to digest the overwhelming amount of information needed to effectively participate in creating the LP (innovation complexity). Clinicians expressed concerns regarding the lack of existing evidence base which limits their ability to effectively counsel patients (innovation evidence base) and the implementation costs (innovation cost). Within the Outer Setting, both clinicians and patients were concerned about performance measurement pressure under the existing "Fistula First" policies and had concerns about reimbursement (financing). In the Inner Setting, clinicians and patients stressed the lack of available resources and access to knowledge and information.
Given the complexity of decision-making around kidney substitutes and vascular access, our findings point to the need for implementation strategies, infrastructure development, and policy change to facilitate ESKD LP development.
2019 年更新的美国肾脏病基金会肾脏病预后质量倡议血管通路指南建议以患者为中心，多学科构建并定期更新每位患者的个体化终末期肾脏病（ESKD）生活计划（LP），这与之前的建议和政策有了巨大的转变。本研究的目的是探讨关键利益相关者实施 LP 的障碍和促进因素。
采用归纳和演绎编码对半结构式个体访谈进行分析。将代码映射到实施研究综合框架（CFIR）的相关领域。
我们采访了 34 名参与者：11 名终末期肾病患者、2 名护理伙伴和 21 名照顾终末期肾病患者的临床医生。在临床医生和患者/护理伙伴两个类别中，在采访了 8 名参与者后达到了饱和度（没有发现新的主题）。我们在 CFIR 的三个领域（创新、外部环境和内部环境）中确定了实施 ESKD LP 的重大障碍和促进因素。关于创新领域，患者和护理伙伴非常重视与护理团队共同做出决策的理念（CFIR 结构：创新设计）。然而，临床医生和患者都对围绕肾脏替代物的决策的复杂性以及患者消化有效参与创建 LP 所需的大量信息的能力表示严重关切（创新复杂性）。临床医生对现有证据基础的缺乏表示担忧，这限制了他们有效为患者提供咨询的能力（创新证据基础）以及实施成本（创新成本）。在外层环境中，临床医生和患者都对现行的“瘘管优先”政策下的绩效测量压力以及报销（融资）表示担忧。在内层环境中，临床医生和患者强调缺乏可用资源以及获取知识和信息的途径。
鉴于肾脏替代物和血管通路决策的复杂性，我们的研究结果表明需要实施策略、基础设施开发和政策变革，以促进 ESKD LP 的发展。
