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Saudi J Kidney Dis Transpl 2019;30(4):905-912

© 2019 Saudi Center for Organ Transplantation Saudi Journal
of Kidney Diseases
and Transplantation

Renal Data from the Arab World

Attitudes and Perceived Barriers toward Arteriovenous Fistula

Creation and Use in Hemodialysis Patients in Jordan
Abdurrahman M. Hamadah

Department of Internal Medicine, Faculty of Medicine, Hashemite University, Zarqa, Jordan

ABSTRACT. Current guidelines recommend arteriovenous fistula (AVF) as the preferred

method of access for hemodialysis (HD) patients; however, its utilization remains low. The
attitudes of Jordanian HD patients and perceived barriers toward AVF are unknown and have not
been well studied. In-center HD patients in the Jordan Ministry of Health largest dialysis unit
were interviewed, and a questionnaire was administered inquiring about their experiences,
attitudes, and perceived barriers toward AVF. Of 104 total patients, 93 met the inclusion criteria.
Mean age was 50 ± 16 years, with 44% being female. Average body mass index was 25 ± 5. The
cause of end-stage renal disease was diabetes mellitus in 28 (30%), hypertension in 28 (30%), and
polycystic kidney disease in three (3%). Patients had an average time on dialysis of 72 months
(range 1–240). Current method of HD access was AVF in 45 (48%) and central venous catheter in
30 (32%). The most reported perceived cause of no AVF was delayed referral to surgical
evaluation in 19 (40%), refusal to undergo AVF surgical procedure in 16 (33%), and poor
understanding of disease in 13 (27%). Of the total studied group, only 29 (31%) indicated that
they received sufficient education/information about AVF prior to creation of HD access.
Seventy-eight patients (84%) reported that they would recommend AVF as method of access for
other HD patients. The reason why majority of patients preferred AVF was reported as: easier to
care for 51 (65%), better associated hygiene 26 (33%), and perceived less infection risk 24 (31%).
In conclusion, in this sample population from HD patients in Jordan, majority would recommend
an AVF as mode of access. Perceived barriers include lack of timely referral for vascular surgical
evaluation and poor understanding of disease. A systematic assessment of the process that
precedes the creation of AVF, with focus on areas of reported barriers may allow for better
utilization of AVF.

Correspondence to: Introduction

Dr. Abdurrahman Hamadah, Hemodialysis (HD) access is the lifeline for

Department of Internal Medicine, patients who reach dialysis-requiring end-
Faculty of Medicine, Hashemite University, stage renal disease (ESRD). Arteriovenous
Zarqa, Jordan. fistula (AVF) has been recommended as the
E-mail: hamadah.abdurrahman@gmail.com access method of choice for patients who
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906
choose to undergo HD when ESRD is
reached.1-4 Compared to arteriovenous graft
(AVG) and central venous catheters (CVC),
AVF has been associated with lower risk of
infection and decreased mortality, among
other advantages.5-10 However, the number of
patients starting HD with CVC or AVG
remains high.11 The fistula first initiative was a
quality improvement initiative introduced by
the United States Center for Medicare and
Medicaid in 2003 as the National Access
Improvement Initiative to increase utilization
of AVF.3 The initial goal was to increase the
prevalence of AVF use to 40% which was
later increased to 65% as a projected target
goal by 2009.12 This initiative led to an actual
increased utilization of AVF with increase in
prevalent use from 33% in all HD patients in
2003 to 62.7% by mid-2016.3,11 However,
utilization of CVC remains high, especially at
initiation of dialysis which, in 2015, repre-
sented 80% of access used at initiation of
dialysis.11 Many barriers to the timely creation
of AVF have been identified. These include
system-based, provider-related, or issues per-
taining to patient preferences or perception.13
Approximately 5350 Jordanian patients were
on dialysis in 2016 according to the Report by
the Ministry of Health which is published
annually.14 This is approximately 754 per
million of the total Jordanian population in
2016.14 In this report, 98% of the patients were
reported to be on HD and only 2% were on
peritoneal dialysis. Although this report details
important aspects of pertaining to the dialysis
population in Jordan, it does not address issues
related to type of access and access utilization.
To our knowledge, there has not been formal
assessment of most issues relating to vascular
access in adult HD patients in Jordan such as
incidence and prevalence of AVF use, use of
other modalities of access, complications
related to access, and patients’ perception of
benefit and barriers of use of AVF as a
preferred method of access. In this study, we
aim to explore the attitudes of Jordanian HD
patients toward AVF use for HD access and
the perceived barriers to its creation. This
information is to be used to improve the fistula
Hamadah AM
creation and utilization process and to also be
used in future studies focusing on aspects of
change in utilizing AVF in HD patients in
Jordan.
Materials and Methods
Study design and setting
This is a descriptive study of attitudes of HD
patients in Jordan toward the AVF and the
perceived barriers to its creation. This study
was done at Prince Hamza Hospital, which is a
part of the Ministry of Health Services in
Amman, Jordan. This study was conducted
from May to August 2018.
Participants
Adult patients, with diagnosis of ESRD,
undergoing in center HD on a regular schedule
of Tuesday-Thursday-Sunday or Monday-
Wednesday-Saturday were included in this
study. Patients who were on dialysis acutely,
those with mental illness that precludes ability
to participate and fully consent to the question-
naire, in addition to those who declined to
participate or were unavailable at the time of
the study, were excluded. The study was
approved by the institutional review boards at
both the Hashemite University and Prince
Hamzah Hospital.
Data collection
The data collection was done through face-to-
face interviews using a structured question-
naire. The questions were formulated by the
researcher and answered by the patient before,
after, or during the HD treatment session.
Patients’ medical record was used to collect or
verify background and demographic informa-
tion. Demographic data collected included age,
sex, weight, height, body mass index (BMI),
and home location in reference to dialysis unit
(as measured through average time to get to
unit from residence). Data on cause of ESRD:
diabetes mellitus (DM), hypertension, poly-
cystic kidney disease, glomerulonephritis,
other, or unknown were recorded. Presence of
comorbidities, including DM, hypertension,
dyslipidemia, coronary artery disease, or
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Perceived barriers toward arteriovenous fistula creation and use
cerebrovascular disease, was also obtained.
Data pertaining to HD initiation and access
were collected including date of initiation of
dialysis and current access method. Whether
patient received education about types of
access before creation was explored. In
addition, patients were asked if they would
recommend AVF as a method of access to
their fellow HD patients.
Attitudes toward fistula creation and use
were sought. If patient did not have a fistula or
had a delay in its creation, patient was asked
about the perceived barriers. Patients were
asked as to whether they recommend it to
others. Patients who indicated that they would
recommend it to other patients were asked
about why they would recommend it. Patients
who had refused a fistula were questioned
about their reasons which were explored in
detail.
Statistical Analysis
Data were summarized by calculating means
and standard deviation or medians and range
for quantitative variables and percentages for
categorical variables. Descriptive terms were
used where appropriate. The reported attitudes
and perceived barriers were analyzed as
categorical variables. The analysis was done
using JMP® Pro 13.0.0, SAS Institute Inc.,
Cary, NC, USA.
Results
A total of 104 patients were undergoing
regular HD at the designated unit during the
study period. Of these, 93 patients were
enrolled in the study. Eleven patients were
excluded from the study (4 declined to
participate, 3 patients did not have ability to
participate due to mental or other illness, 3
patients were not available/hospitalized at the
time of the study, and one was a pediatric
patient).
The mean age for the study participants was
50 years ± 16. Forty-one (44%) were female.
Average BMI was 25 ± 5. The cause of ESRD
was DM in 28 (30%), hypertension in 28
907
(30%), polycystic kidney disease in three
(3%), glomerulonephritis in three (3%), other
in 17 (18%), and unknown in 14 (15%). Major
associated comorbidities were DM in 29
(31%), hypertension in 60 (65%), dyslipidemia
in 32 (34%), coronary artery disease in 13
(14%), and cerebrovascular disease in eight
(9%). At the time of the study, patients had an
average time since starting dialysis of 72
months (range 1–240). Details of demogra-
phics are presented in Table 1. Current method
of HD access was AVF in 45 (48%), AVG in
18 (19%), and CVC in 30 (32%) (of the 30,
those with temporary catheter-nontunneled
were five and those with permanent-tunneled
were 25).
Patient attitudes and perceived barriers
toward AVF creation are presented in Table 2.
The most reported perceived cause of no AVF
was delayed referral to surgical evaluation in
19 (40%), refusal to undergo AVF surgical
procedure in 16 (33%), poor understanding of
disease in 13 (27%), denial of disease or need
for HD in six (13%), too long to surgical
appointments once referral is made in four
(8%), and fear of needles in one (2%). Of the
total studied group, 29 (31%) indicated they
received what they perceived as sufficient
education/information about AVF prior to
creation, whereas 64 patients (69%) thought
that was not the case. Twenty patients (22%)
had vein mapping done prior to attempt at
fistula creation. Seventy-eight patients (84%)
reported they would recommend AVF as the
method of access for other HD patients.
The reason why majority of patients reported
that they perceived AVF to be preferred and
recommended was: easier to care for 51
(65%), better associated hygiene 26 (33%),
emphasis on easier shower 24 (31%), and
perceived less infection risk 24 (31%).
Overall, six patients (6%) reported refusal to
use AVF as the method HD access or
recommend it to other patients, with cited
reasons being concern about appearance in two
patients, the invasive nature of AVF creation
and use in two patients, in addition to ease of
venous catheter access and fear of needles in
others (Table 3).
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908 Hamadah AM

Table 1. Baseline demographics and characteristics of the study participants.

Patient characteristics Overall (n = 93)
Baseline demographics
Age (years) mean±SD 50±16
Gender
Male, n (%) 52 (56)
Female, n (%) 41 (44)
Weight (kg), mean±SD 69±17
Height (m), mean±SD 1.66±0.1
BMI (kg/m2), mean±SD 25±5
Commute to dialysis unit (min)±SD 18±12
Cause of ESRD
Diabetes mellitus, n (%) 28 (30)
Hypertension, n (%) 28 (30)
Adult polycystic kidney disease, n (%) 3 (3)
Glomerulonephritis, n (%) 3 (3)
Other, n (%) 17 (18)
Unknown, n (%) 14 (15)
Associated comorbidities
Diabetes mellitus, n (%) 29 (31)
Hypertension, n (%) 60 (65)
Dyslipidemia, n (%) 32 (34)
Coronary artery disease, n (%) 13 (14)
Cerebrovascular disease, n (%) 8 (9)
Peripheral vascular disease, n (%) 3 (3)
Time in months from HD initiation median (range) 72 (1–240)
Current access method
Temporary CVC, n (%) 5 (5.4)
Permanent CVC, n (%) 25 (27)
AVF, n (%) 45 (48)
AVG, n (%) 18 (19)
BMI: Body mass index, ESRD: End-stage renal disease, HD: Hemodialysis, CVC: Central venous
catheter, AVF: Arteriovenous fistula, AVG: Arteriovenous graft, SD: Standard deviation.

Discussion to be used or sustain initial attempts at use.17,18

Use of AVF as the access method in HD
patients, compared with CVC and AVG, has
been associated with improved morbidity and
mortality and decreased risk of infection
leading to recommendations to increase its
utilization in HD patients.5-7 This was also
shown internationally across 12 countries
studied in the Dialysis Outcomes and Practice
Patterns Study.15 However, most patients
continue to initiate HD through a CVC,16 and
investigation of causes of suboptimal utili-
zation of AVF is of interest. Even when a
fistula is placed, many fistulas do not see the
light (or the needle) and never mature enough
This study is the first to explore the attitudes
and perceived barriers to AVF creation and
use in HD patients in Jordan. The results of
this study clearly showed that the vast majority
of patients who had AVF placed believe it is
the best modality for a multitude of reported
advantages including easier care, better
hygiene compared to CVC, easier to shower,
and patients also recognized that it carriers less
infection risk, likely due to personal expe-
riences as most have started with CVC at
initiation of HD, and may have experienced
infection risk or suffered complications related
to that. Based on this study, the vast majority
of patients would recommend AVF for access
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Perceived barriers toward arteriovenous fistula creation and use 909

Table 2. Perceived barriers and attitudes toward arteriovenous fistula creation.

Reported outcome Number (%)
Perceived barrier to AVF*
Late referral to surgical evaluation 19 (40)
Refusal to undergo AVF surgery 16 (33)
Poor understanding of disease 13 (27)
Denial of disease or need for HD 6 (13)
Too long to surgical appointments after referral 4 (8)
Fear of needles 1 (2)
Unsure/could not specify 7 (15)
Previously received sufficient education about AVF?
Yes 29 (31)
No 64 (69)
Previous vein mapping done?
Yes 20 (22)
No 73 (78)
Would you recommend it to other HD patients
Yes 78 (84)
No 6 (6)
Not reported/not certain 9 (10)
If answer to above question is yes, why would you recommend it?
Easier to care for 51 (65)
Better hygiene 26 (33)
Easier showering 24 (31)
Less infection 19 (24)
Other 10 (21)
* Out of 48 patients with non-AVF dialysis access. AVF: Arteriovenous fistula, HD: Hemodialysis.

to their fellow patients who are newly starting
dialysis.
In those who were not dialyzing through an
AVF, or who thought they had delays in
placement, the most reported perceived
barriers were poor understanding of disease,
denial of disease or need for dialysis, too long
of a wait time to surgical appointments, non-
attendance at surgical appointments, difficulty
with logistics of coming to appoints, refusal to
undergo surgical procedure, and with delayed
referral to surgical evaluation being the most
cited cause. Lopez-Vargas et al investigated the
the barriers to timely AVF creation in a group
of 319 patients from nine nephrology centers
in Australia and New Zealand.19 They found
that perceived barriers to access creation
included lack of formal policies for patient
referral, absence of patient database for access
purposes that could facilitate management, and
also long wait times to surgical evaluation and
access creation. These factors are also some of
the factors that have been previously impli-
cated by care providers (nephrologists and
primary care providers) as barriers to adequate
preparation of patients for renal replacement

Table 3. Characteristics of those who refused fistula.

Characteristics of those who refused fistula Number
Total number of those who refused 6
Reason for refusing AVF
Concern about appearance 2
AVF is invasive 2
CVC is easier to access 1
Fear of needles 1
AVF: Arteriovenous fistula, CVC: Central venous catheter.
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910
therapy.20
Kosa et al examined patients’ perspectives on
complications of vascular access-related
interventions.21 They found that patients were
likely to report more dissatisfaction with
physical complications associated with needle
cannulation of fistulas and grafts compared to
CVC access, whereas infectious complications
were not viewed by patients as a major
concern when the access modalities are com-
pared. It was previously noted that patients’
knowledge of AVF care after placement may
be limited,22 and this could potentially reflect
poor understanding of the AVF and poor
education prior to placement about the pros
and cons of such access, although other
contributors maybe be at play, and indeed
close to one-third of the patients in our study
reported poor understanding of disease as a
cause of not moving forward toward AVF. In
another study of 128 patients investigating
preferences and concerns regarding HD vascu-
lar access, patients’ preferences were of utili-
zation of a superficial access in the forearm
which was easy to cannulate, had minimal
effect on their appearance, provided quick
hemostasis after dialysis, and enabled arm
comfort during dialysis, whereas the most
common problem was pain during needle
insertion.23 When ESRD patient-reported
health status and quality of life scores and
vascular access type were compared among a
national random sample of 1563 patients at
dialysis initiation and at day 60 after initiation,
it was found that patients with AVF at
initiation and at day 60 (implying they had
continued to use AVF for the first 2 months)
reported perceived greater physical activity
and energy, emotional and social well-being,
fewer symptoms, less effect of dialysis and
burden of kidney disease, and better sleep
compared with patients with persistent CVC
use.24
In our study, we had six patients who refused
to have AVF or reported that they would not
recommend AVF to others. The cited reasons
where mainly concern about appearance, the
invasive nature of AVF creation and use, in
addition to ease of venous catheter access and
Hamadah AM
fear of needles. In a related qualitative study,
Xi et al performed interviews with patients
who have refused creation or use of AVF to
investigate the rational for decision-making.25
Poor previous experience with the fistula such
as issues with cannulation or bleeding, issues
with knowledge transfer and informed decision-
making, and patient acceptance of current
status quo without desire for change were
main reasons of not wanting or accepting an
AVF. Decreasing infection rate or improving
morta-lity was not usually the focus of the
patients in this small subgroup, and we found
that to be same as well our HD population in
patients who refused AVF. One of the issues
that has been clearly demonstrated is that
patients can have a strong preference for the
status quo and are reluctant to change treat-
ments,26 which can make transitioning from a
CVC to AVF less desirable. In another study,
patients cited fear of painful and difficult
cannulation and trust in their ability to manage
complications of CVC, as reasons for their
confidence in the decision to avoid AVF.27
Most of our patients reported that they did not
receive what they perceived to be sufficient
education about different types of dialysis
access. It was clear in our interaction with
patients, that their knowledge about dialysis
may have an impact on their choice of access.
It has been shown before that patients with
less dialysis knowledge were found to be less
likely to use an arteriovenous access for
dialysis at initiation and transitioning to AVF
after starting HD,28 and it is possible that
improving patients’ education about this issue
may enhance use of AVF.29
Conclusion
In this sample population from HD patients
in Jordan, majority would recommend an AVF
as mode of access. Perceived barriers include
lack of timely referral for vascular surgical
evaluation and poor understanding of disease.
A systematic assessment of the process that
precedes the creation of AVF with taking into
account the reported perceived barriers, with
focus on areas that clearly need improvement
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Perceived barriers toward arteriovenous fistula creation and use
such as a timely referral to vascular surgery,
may allow for better utilization of AVF in HD
patients in Jordan. Most patients report insu-
fficient education about HD access methods,
11.
which is another potential target for care
improvement.
Conflict of interest: None declared.
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Date of manuscript receipt: 25 October 2018.
Date of final acceptance: 28 November 2018.