Dissertation
Dialysis modality decision-making in adults with end-stage renal disease: a mixed-methods study
University of Iowa
Doctor of Philosophy (PhD), University of Iowa
Summer 2022
DOI: 10.25820/etd.006734
Abstract
To sustain life, patients with end-stage kidney disease (ESKD) require renal replacement therapy to take the place of their damaged kidneys. Approximately 97% of incident ESKD cases in the US report using dialysis as their treatment modality. Dialysis may be conducted in-center or at home. Home dialysis is associated with benefits such as greater quality of life and financial savings. Despite these benefits, uptake of home dialysis has been minimal in the US compared to in-center hemodialysis. Previous interventions and clinical recommendations aimed at improving the dialysis modality decision-making process have primarily focused on factors at the individual- and interpersonal-level. The present objective was to explore individual-, interpersonal-, organizational/community-, and policy/national-level factors, as described by the Social Ecological Framework (SEF), that facilitated selection of home dialysis and in-center hemodialysis, generalize some of these differences in a larger sample of patients with ESKD using survey materials, and test new hypotheses. To do this, a mixed-methods (qualitative and quantitative) sequential exploratory approach was conducted.
Study 1 utilized semi-structured in-depth qualitative interviews to determine the knowledge, attitudes, and beliefs of patients undergoing dialysis for ESKD, using interviews with questions and prompts informed by the SEF. Forty participants were recruited (in-center dialysis = 20; home dialysis = 20 Interview findings suggested that healthcare access and engagement before entering nephrology care, after entering nephrology care, and following dialysis initiation influenced patients’ awareness regarding their kidney disease status, progression toward ESKD, and dialysis options. An important category that emerged and was associated with varied healthcare experiences and differences in dialysis modality was race and ethnicity; language barriers among primarily Spanish-speaking participants within the clinic also seemed to contribute to awareness of dialysis modality options. Most participants adopted a passive-approach during decision-making regardless of modality. Finally, factors that contributed to overall satisfaction with one’s dialysis modality included fatigue severity, concerns regarding one’s dialyzing schedule, and problems with fistula/catheter access sites.
Study 2 utilized survey measures to examine statistical associations between various individual-, interpersonal-, and healthcare-related factors to outcomes including dialysis modality, decisional satisfaction, and satisfaction with dialysis, among ninety participants undergoing dialysis (in-center = 46; home = 44). Only race and ethnicity predicted the odds of undergoing home dialysis, in which White and non-Hispanic race was associated with greater odds of undergoing home dialysis. Further analysis showed that undergoing home dialysis, greater satisfaction with dialysis, and greater perceived quality of nephrology care predicted decisional satisfaction. Additionally, undergoing in-center dialysis, greater decisional satisfaction, lower fatigue severity, lower perceived discrimination in healthcare, and reporting no pre-nephrology barriers to healthcare was associated with greater satisfaction with dialysis.
Key findings from this dissertation identified an association between dialysis modality and race and ethnicity, the influence of fatigue severity on satisfaction with dialysis, the impact nephrology providers may have on dialysis decision-making, and the potential for post dialysis initiation as a critical timeframe to introduce interventions for improving dialysis outcomes. This dissertation provided much needed preliminary work that has begun to lay a foundation for future directions in research, interventions, clinical practice, and public health efforts aiming to further understand and improve dialysis modality decision-making as well as dialysis outcomes.
Details
- Title: Subtitle
- Dialysis modality decision-making in adults with end-stage renal disease: a mixed-methods study
- Creators
- Miriam E. Vélez-Bermúdez
- Contributors
- Alan J Christensen (Advisor)Susan K Lutgendorf (Advisor)Mark W Vander Weg (Committee Member)Natoshia M Askelson (Committee Member)Michelle W Voss (Committee Member)Mony Fraer (Committee Member)
- Resource Type
- Dissertation
- Degree Awarded
- Doctor of Philosophy (PhD), University of Iowa
- Degree in
- Psychology
- Date degree season
- Summer 2022
- DOI
- 10.25820/etd.006734
- Publisher
- University of Iowa
- Number of pages
- xii, 175 pages
- Copyright
- Copyright 2022 Miriam E. Vélez-Bermúdez
- Language
- English
- Description illustrations
- Charts, graphs, tables
- Description bibliographic
- Includes bibliographical references (pages 110-122).
- Public Abstract (ETD)
The objective of this dissertation was to explore micro- and macro-level factors, as defined by the Social Ecological Framework, that led to a dialysis modality decision, and whether there were decision-making differences between patients undergoing home versus in-center dialysis. A mixed-methods sequential exploratory approach was utilized.
Study 1 used qualitative interviews among forty participants undergoing dialysis (in-center dialysis = 20; home dialysis = 20). Interview findings suggested that healthcare access and engagement before entering nephrology care, after entering nephrology care, and following dialysis initiation influenced patient awareness regarding their kidney disease status, progression toward ESKD, and dialysis options. Potential modifiers of these outcomes include race, ethnicity, and language barriers. Most participants adopted a passive-approach during decision-making. Overall satisfaction with one’s dialysis modality was influenced by fatigue, concerns regarding one’s dialyzing schedule, and problems with fistula/catheter access sites.
Study 2 used survey measures among ninety participants undergoing dialysis (in-center = 46; home = 44). Findings suggested that race and ethnicity predicted the odds of undergoing home dialysis. Undergoing home dialysis, greater satisfaction with dialysis, and greater perceived quality of nephrology care predicted decisional satisfaction. Additionally, undergoing in-center dialysis, greater decisional satisfaction, lower fatigue severity, lower perceived discrimination in healthcare, and reporting no pre-nephrology barriers to healthcare was associated with greater satisfaction with dialysis.
This dissertation provided some preliminary data that has begun to lay a foundation for future directions aiming to further understand and improve dialysis modality decision-making as well as dialysis outcomes.
- Academic Unit
- Psychological and Brain Sciences
- Record Identifier
- 9984285153102771
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