Supplementary Material for: Effect of a Dialysis Access Coordinator on Preemptive Access Placement among Veterans: A Quality Improvement Initiative

<i>Background and Objectives:</i> Preemptive placement of permanent dialysis access is recommended in order to reduce the morbidity associated with central venous catheters. We assessed the effect of a dialysis access coordinator on preemptive access placement in veterans who are at high risk for end-stage renal disease (ESRD). <i>Design, Setting, Participants, and Measurements:</i> Pre-post evaluation of a dialysis access coordinator in the nephrology clinics of the Veterans Affairs Palo Alto. The access coordinator streamlined access referrals, prioritized surgical waiting lists and addressed patient barriers. We compared the frequency of preemptive access referral, surgery, and use for dialysis during the intervention period, July 1, 2013 to May 31, 2016, to a pre-intervention period, January 1, 2011 to December 31, 2013, among all patients with a predicted 1-year risk for ESRD ≥20%. <i>Results:</i> There were 156 patients in the historical cohort and 131 in the intervention cohort. The mean age was 69.9 ± 11.6 years and the mean estimated glomerular filtration rate was 14.5 ± 5.7 ml/min/1.73 m2. The intervention was associated with an 11.8% increase in access referral (p value = 0.03), and a 9.4% increase in completed access surgery (p value = 0.05). Increases in permanent access at the start of dialysis (15.2%), and functional permanent access at the start of dialysis (12.4%) did not reach statistical significance. Among patients who received access surgery, there was no significant difference in the prevalence of unused access. <i>Conclusions:</i> Implementation of an access coordinator was associated with a modest increase in preemptive access placement among patients who are at high risk for ESRD without increasing the prevalence of unused access.

研究背景与目的：为降低中心静脉导管（central venous catheter）相关并发症，临床推荐预先置入永久透析通路（permanent dialysis access）。本研究针对终末期肾病（End-Stage Renal Disease, ESRD）高风险退伍军人群体，评估透析通路协调员（dialysis access coordinator）对预先通路置入的干预效果。
研究设计、研究场所、研究对象与测量指标：本研究在美国退伍军人事务部帕洛阿尔托分院肾病诊所开展透析通路协调员的前后对照评估。该协调员负责优化通路转诊流程、优先排序外科等候名单，并解决患者就诊障碍。我们对比了干预期（2013年7月1日至2016年5月31日）与干预前期（2011年1月1日至2013年12月31日）中，所有预估终末期肾病1年风险≥20%的患者的预先通路转诊率、通路手术完成率及透析通路使用率。
研究结果：历史队列纳入156例患者，干预队列纳入131例患者。两组患者平均年龄为69.9±11.6岁，平均估算肾小球滤过率（estimated glomerular filtration rate, eGFR）为14.5±5.7 ml/min/1.73 m²。干预措施可使通路转诊率提升11.8%（P=0.03），通路手术完成率提升9.4%（P=0.05）。透析启动时永久通路置入率提升15.2%、透析启动时功能型永久通路使用率提升12.4%，但上述提升均未达到统计学显著性。在接受通路手术的患者中，未使用通路的占比无显著差异。
研究结论：部署透析通路协调员可使终末期肾病高风险患者的预先永久透析通路置入率小幅提升，且未增加未使用通路的占比。