目标:更新的2019年美国国家肾脏基金会肾脏疾病结局质量倡议血管通路指南建议以患者为中心,多学科建设和定期更新每个患者的个性化终末期肾病(ESKD)生命计划(LP),与以前的建议和政策发生了戏剧性的转变。这项研究的目的是研究关键利益相关者实施LP的障碍和促进者。
方法:使用归纳和演绎编码对半结构化个体访谈进行分析。代码被映射到实施研究综合框架(CFIR)中的相关领域。
结果:我们采访了34名参与者:11名终末期肾病患者,2护理伙伴,21名临床医生照顾终末期肾病患者。在临床医生和患者/护理伙伴类别中,8名参与者达到饱和(未发现新主题).我们确定了在三个CFIR领域实施ESKDLP的重要障碍和促进者:创新,外部设置,和内部设置。关于创新领域,患者和护理合作伙伴重视与他们的护理团队共同决策的概念(CFIR构建:创新设计)。然而,临床医师和患者都对肾脏替代品决策的复杂性以及患者消化有效参与创建LP(创新复杂性)所需的大量信息的能力有重大担忧.临床医生对缺乏现有证据基础表示担忧,这限制了他们有效指导患者的能力(创新证据基础)和实施成本(创新成本)。在外部环境中,临床医生和患者都担心现有的“瘘管病优先”政策下的绩效测量压力,并担心报销(融资)。在内部设置中,临床医生和患者强调缺乏可用的资源以及获得知识和信息的途径.
结论:考虑到围绕肾脏替代品和血管通路的决策的复杂性,我们的发现指出了实施战略的必要性,基础设施建设,和政策变化,以促进ESKDLP的发展。
OBJECTIVE: 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.
METHODS: 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).
RESULTS: 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.
CONCLUSIONS: 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.