Abstract
Background
Vascular access enables life-sustaining haemodialysis for people who have kidney failure. Clinical guidelines have recently evolved from a longstanding recommendation to prioritise arteriovenous fistula, to a flexible approach underpinned by person-centred care and shared decision-making about vascular access strategies. The aim of this thesis was to generate evidence to support the increased delivery of person-centred vascular access healthcare and shared decision-making for haemodialysis vascular access in Aotearoa New Zealand.
Method
All studies underwent a priori approval by the research advisor for Māori health, University of Otago, Christchurch, and received ethical approval from the University of Otago Human Research Ethics Committee (Health). Study reporting follows international reporting guidelines and the Consolidated Criteria for Strengthening Reporting of Health Research Involving Indigenous peoples (CONSIDER).
Patient-prioritised vascular access outcomes were collated using data linkage across the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry, and the National Minimum Dataset (NMDS). The rate of procedures required for haemodialysis vascular access, and the number of days hospitalised for vascular access complications were described among adult patients who received primary vascular access, using multivariate modelling to identify associations with baseline patient and centre characteristics.
A semi-structured interview methodology was utilised to explore the experiences, values and priorities of patients who had received healthcare for haemodialysis vascular access in New Zealand. Inductive then deductive thematic analyses identified patient-led markers of high-quality vascular access healthcare.
A prototype decision aid to support shared decision-making in patients new to haemodialysis vascular access in New Zealand was developed guided by findings of these studies and International Patient Decision Aids Standards. A multidisciplinary steering group completed iterative cycles of decision aid codesign based on data from patients and clinicians exploring decision aid prototypes during semi-structured interviews and focus groups.
Results
Among 7725 adults, the rate of vascular access procedures were 0.71 (95% CI 0.70, 0.72) procedures per patient-year for the two years prior and two years following haemodialysis initiation. The days hospitalised for vascular access complications were 0.62 days (95% CI 0.56, 0.68) per patient-year. The highest rates of procedures and hospitalisations occurred in the first six months following haemodialysis commencement. Patient sex, peripheral vascular disease, body mass index, treatment centre, and treatment era were associated with vascular access outcomes. Findings were similar in subgroup analysis of Māori patients.
People who had received healthcare for haemodialysis vascular access in New Zealand reported that quality in dialysis vascular access health services was demonstrated by effective clinical processes, support for health literacy development and empathetic interactions with health professionals to build trusting relationships.
A prototype haemodialysis vascular access decision aid was developed based on international decision aid development guidelines, and utilised frameworks for culturally competent health communication and adult health literacy development specific to New Zealand. The prototype decision aid is suitable for further development and evaluation in real-world clinical decision-making settings.
Conclusion
This thesis has generated a body of research to underpin quality improvement of health services that deliver person-centred haemodialysis vascular access healthcare in New Zealand.