Psychosocial Factors, Intentions to Pursue Arteriovenous Dialysis Access, and Access Outcomes: A Cohort Study

Rationale & Objective: Suboptimal dialysis preparation of patients with chronic kidney disease (CKD) is common, but little is known about its relationship to psychosocial factors. This study aimed to assess patients' attitudes about access creation and to identify factors associated with patients' intentions regarding dialysis access creation and outcomes.Study Design: Prospective cohort study.Setting & Participants: 190 patients with stage 4/5 CKD not receiving dialysis treated at 2 hospitals in Singapore and 128 of their family members.Predictors: Self-reported measures of illness perception, health-related quality of life, and attitudes toward access creation. Sociodemographic and clinical measures were also obtained.Outcome: Intention to create an arteriovenous fistula (AVF; ie, proceed with access vs wait and see) and time to creation of a functional AVF.Analytical Approach: Exploratory factor analysis (EFA) was undertaken to construct internally consistent subscales for a newly developed questionnaire about attitudes toward access creation. Logistic regression and cause-specific hazards models were conducted to identify psychosocial factors associated with patients' access creation intentions and access outcomes, respectively.Results: EFA (explained 50.1% variance) revealed 4 domains: access and dialysis concerns, need for dialysis, worry about cost, and value of access. A high risk of intention to delay access creation (51.1%) was found among patients despite early referral and education. Multi-variable analysis (R-2 = 0.45) showed that the intention to proceed with access creation was associated with greater perceived value from access (odds ratio, 2.61; 95% CI, 1.46-4.65; P < 0.001).Limitations: Limited generalization, as only those already receiving nephrology care were studied.Conclusions: Approximately half of the patients studied planned to delay access creation. The questionnaire developed to evaluate attitudes about access creation may help identify individuals for whom decision-support programs would be useful. These findings highlight the need to understand and address patients' concerns about access creation.