title: Timing of Initiation of Maintenance Dialysis: A Qualitative Analysis of the Electronic Medical Records of a National Cohort of Patients From the Department of Veterans Affairs.
abstract: OBJECTIVE
  There is often considerable uncertainty about the optimal time to initiate maintenance dialysis in individual patients and little medical evidence to guide this decision.
  
  
  OBJECTIVE
  To gain a better understanding of the factors influencing the timing of initiation of dialysis in clinical practice.
  
  
  METHODS
  A qualitative analysis was conducted using the electronic medical records from the Department of Veterans Affairs (VA) of a national random sample of 1691 patients for whom the decision to initiate maintenance dialysis occurred in the VA between January 1, 2000, and December 31, 2009. Data analysis took place from June 1 to November 30, 2014.
  
  
  METHODS
  Central themes related to the timing of initiation of dialysis as documented in patients' electronic medical records.
  
  
  RESULTS
  Of the 1691 patients, 1264 (74.7%) initiated dialysis as inpatients and 1228 (72.6%) initiated dialysis with a hemodialysis catheter. Cohort members met with a nephrologist during an outpatient clinic visit a median of 3 times (interquartile range, 0-6) in the year prior to initiation of dialysis. The mean (SD) estimated glomerular filtration rate at the time of initiation for cohort members was 10.4 (5.7) mL/min/1.73 m(2). The timing of initiation of dialysis reflected the complex interplay of at least 3 interrelated and dynamic processes. The first was physician practices, which ranged from practices intended to prepare patients for dialysis to those intended to forestall the need for dialysis by managing the signs and symptoms of uremia with medical interventions. The second process was sources of momentum. Initiation of dialysis was often precipitated by clinical events involving acute illness or medical procedures. In these settings, the imperative to treat often seemed to override patient choice. The third process was patient-physician dynamics. Interactions between patients and physicians were sometimes adversarial, and physician recommendations to initiate dialysis sometimes seemed to conflict with patient priorities.
  
  
  CONCLUSIONS
  The initiation of maintenance dialysis reflects the care practices of individual physicians, sources of momentum for initiation of dialysis, interactions between patients and physicians, and the complex interplay of these dynamic processes over time. Our findings suggest opportunities to improve communication between patients and physicians and to better align these processes with patients' values, goals, and preferences.
authors.affiliation: Department of Medicine, University of Washington, Seattle.
authors.forename: Susan P Y
authors.initials: SP
authors.lastname: Wong
authors.affiliation: Department of Medicine, University of Washington, Seattle2Department of Medicine, VA Puget Sound Healthcare System, Seattle, Washington.
authors.forename: Elizabeth K
authors.initials: EK
authors.lastname: Vig
authors.affiliation: Department of Anthropology, University of Washington, Seattle.
authors.forename: Janelle S
authors.initials: JS
authors.lastname: Taylor
authors.affiliation: Chronic Kidney Disease Initiative, Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Nilka R
authors.initials: NR
authors.lastname: Burrows
authors.affiliation: Health Service Research and Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, Washington6Department of Health Services, University of Washington, Seattle.
authors.forename: Chuan-Fen
authors.initials: CF
authors.lastname: Liu
authors.affiliation: Liberia Country Office, Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Desmond E
authors.initials: DE
authors.lastname: Williams
authors.affiliation: Health Service Research and Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, Washington6Department of Health Services, University of Washington, Seattle.
authors.forename: Paul L
authors.initials: PL
authors.lastname: Hebert
authors.affiliation: Department of Medicine, University of Washington, Seattle2Department of Medicine, VA Puget Sound Healthcare System, Seattle, Washington.
authors.forename: Ann M
authors.initials: AM
authors.lastname: O'Hare
mesh_terms: D000368:Aged; D000066491:Clinical Decision-Making; D015331:Cohort Studies; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000523:psychology*; D014481:United States; D014493:United States Department of Veterans Affairs
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