Background and Aims There is high quality evidence that favours the use of arteriovenous fistulas (AVFs) over central venous catheters (CVCs) for haemodialysis access, based on the association with lowest mortality and fewest complications [1]. However, less is known regarding patient and nurse preferences concerning access choices and the drivers underlying these preferences. One previous study [2] identified physical concerns regarding fistulas as the predominant barrier preventing patients with a CVC from switching to an AVF. Here we provide an expansion on these barriers, alongside novel exploration of nursing opinion on access choice. Methods Data was collected through individually administered patient surveys across 4 regional dialysis sites in East Anglia (n = 380), and anonymised online survey requests to nursing staff at the sites. Deductive and inductive strategies were employed for analysis of the qualitative data. The aim of the thematic analysis of the data was to determine the preferred access modality of patients and nurses, and the drivers for the preferences. Results 63% (n = 238) of patients responded to the questionnaire. Patient responses fell into one of four categories; drivers toward, or barriers against AVFs or CVCs. The largest of these categories was the barriers for AVFs, within which four main themes were identified: ‘Fear’, ‘difficult AVF surgery’, ‘patient preference for lines’ or ‘patients awaiting AVF surgery or transplant’. A smaller theme of ‘insufficient information’ regarding access choice was also identified. ‘Fear’ was the largest theme, within which five subthemes were identified: fear of needles, pain, bleeding, fistula appearance, or fear of complications heard from other patients on the dialysis unit. ‘Difficult AVF surgery’ encompassed two subthemes; those who have had previous failed traumatic attempts or those whose current vascular architecture was not amenable to fistula surgery. The other three categories received far fewer responses. The AVF driver category focussed on fistulas being preferred medically with reduced infection risk, whilst drivers for lines included it being ‘comfortable’ and patients saying that the line works for them. The one comment in the CVC barrier category cited difficulties experienced with lines like blockages and infections. 13 responses were received from dialysis nurses. All respondents were aware of the medical preference for patients to have a fistula, and the reasons why. Nurses themselves also preferred their patients to have fistulas, referencing the same reasons. However, most nurses thought patients preferred CVCs, and were able to cite the same reasons as the patients themselves. Lastly, nurses reported that they convey the benefits and risks of different access types correctly when asked by patients at the dialysis units. Conclusion These findings highlight that, whilst doctors and nurses focus on long-term health benefits of AVF when discussing vascular access choices, patients are focussed on the immediate potential risks of an AVF. We hypothesise that, whilst dialysing, patients share stories of fistula-related complications that drive short-term fear of AVFs, with such impact that the messages conveyed by health professionals are often negated. This difference in agendas is essential to acknowledge. The relationship between clinician, nurse and patient in the haemodialysis setting is unique given its longevity, frequency of contact, and holistic nature. Implementing a strategy to bridge this agenda gap could strengthen this relationship and provide a basis for optimum, evidence-based treatment. We therefore suggest the use of positive patient AVF experiences, delivered via peer education sessions, as a tool to introduce drivers for, and uptake of, AVF for dialysis patients in the future.

Background and Aims Vascular access is an essential requirement for haemodialysis (HD). There is strong evidence that an arteriovenous fistula (AVF) is preferable to access via a central venous catheter (CVC) for long term haemodialysis, yet many patients opt for access via a CVC. We performed a cross-sectional study to assess patient preferences regarding vascular access. The quantitative component of this work is presented here. Method Questionnaires were administered to patients attending dialysis at four sites in the East Anglia region of the UK (n = 380). Additional patient data was collected from medical records. Analysis was performed using the R software. Results 63% (n = 238) of patients completed the survey. The median age of respondents was 75 years (range 24-95 years), 64% were male (n = 153), the median length of time on dialysis was 23 months, and 64% (n = 152) were using an AVF. There was no significant association between age and form of access (p = 0.11). 65% of respondents believed that an AVF was the best access route for health, 10% believed a CVC was the best route, and 25% were unsure. This was not significantly affected by the participant's access route at the time of the study (p = 0.91) or self-reported pre-dialysis education (p = 0.09). Respondents who believed that the health professionals caring for them preferred AVFs were significantly more likely to believe that AVFs were best for their health (p < 0.0001 for both medical and nursing staff preference). However, overall, there was uncertainty about the preferred haemodialysis access of health professionals, with 40% and 47% of respondents unsure regarding the preference of medical and nursing staff, respectively. These patients were also more likely to respond as ‘unsure’ as to which access type was better for their health. We asked participants to rate 16 possible concerns they may have about access on a 1-9 scale (Figure 1). The most highly rated concerns were related to sleeping, pain, bleeding and access longevity, each receiving a rating of ≥2 in nearly 40% of participants. Notably, infection risk was rated as the lowest priority concern, only receiving a rating of ≥2 in 5% of participants. Concerns were similar regardless of the active form of access. 63% (n = 54) of respondents with a CVC would not consider changing to an AVF. The decision to switch from CVC to AVF was not significantly associated with age (p = 0.69), or the number of AVF operations a patient had undergone in the six years prior to the study year (p = 0.94). The decision was also not associated with respondent belief regarding the best access type for health (p = 0.84). Differences in access concerns could not significantly explain the decision to or not to switch from CVC to AVF. However, analysis of free-text responses identified peer experiences as a strong influence on the decision to switch. Conclusion Most HD patients are aware that an AVF is associated with better health outcomes than a CVC. Despite this, a large proportion of patients dialysing via a CVC do not wish to change their access, with many reporting concerns of bleeding, needling pain, and difficulty sleeping. Infection risk was not a consideration for most patients. Additionally, we found that patients reported significant uncertainty about doctor and nurse preference for haemodialysis access. These findings are mirrored by analysis of the free text responses to the questions in this study. In particular, peer experiences were a significant determinant of the decision to switch from a CVC to AVF. The findings suggest that when we discuss vascular access with patients, a broad scope of topics should be addressed, beyond health outcomes alone, to allow for effective shared decision making. They also suggest that there is room to improve the communication of our perspectives as healthcare workers, both from a nursing and medical perspective.

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