| Abstract|| |
This study was performed to find out the trends in the demand for regular maintenance hemodialysis (HD) and to assess the utilization with reference to selected variables. In a retrospective cohort study, data from a single in-center HD unit of a secondary care hospital located in the south-western part of the Kingdom of Saudi Arabia, were analyzed. Cases of endstage renal failure (ESRF) registered for regular maintenance HD from the commencement of the HD services in this center (1987 to 2000) formed the subjects of this study. Utilization of the incenter HD was assessed by annual growth rate, death rate, renal transplantation rate and utilization rate. Simple descriptive statistics were used for data analysis. During the study period, 393 cases were registered for regular maintenance HD. There were 183 males (46.6%) and 210 females (53.4%). The mean and median ages of the patients at the initiation of HD were 40.7 and 35 years respectively. Saudis constituted 75.1%(295) over the years studied. The mean annual growth rate, death rate, renal transplantation rate and utilization rate were 7.44, 9.3, 4.33 and 139.57% respectively. Demand for maintenance HD was more from young individuals, which is similar to the national figures. Annual growth rate of those requiring HD was far higher than population growth of this region during the period of study caused primarily by an increased number of new entries coupled with low death and transplantation rates. We conclude that HD utilization studies help to unearth the problems, understand the needs, communicate with the authorities (with facts and figures), find out solutions, and create a network between providers and consumers.
Keywords: Hemodialysis utilization, Health care indicators, Demands,
Performance measurement, Growth rate, Death rate,
Transplantation rate Utilization rate Saudi Arabia
|How to cite this article:|
Subramanian P T, Jamal A, Shah MY. Hemodialysis Utilization in a Single in-Center Dialysis Unit, in the Kingdom of Saudi Arabia. Saudi J Kidney Dis Transpl 2001;12:64-74
|How to cite this URL:|
Subramanian P T, Jamal A, Shah MY. Hemodialysis Utilization in a Single in-Center Dialysis Unit, in the Kingdom of Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2001 [cited 2020 May 29];12:64-74. Available from: http://www.sjkdt.org/text.asp?2001/12/1/64/33889
| Introduction|| |
Dialysis and renal transplantation have revolutionized the health care of patients with end-stage renal failure (ESRF). Although the technology is complex and expensive, it provides a second life to such patients. Therapy for ESRF, thus becomes a life sustaining one and any denial of such therapy means death in days, weeks or months. 
In the Kingdom of Saudi Arabia (KSA), dialysis is available to all patients regardless of age, gender, employment status or comorbid conditions. The demand for dialysis is growing fast and is well reflected in the data published by the Saudi Center for Organ Transplantation (SCOT), ,, which was formerly known as the National Kidney Foundation.  Moreover, the awareness, acceptability, availability and accessibility of dialysis have increased since the inception of the dialysis program in the KSA in 1970. 
The expenses incurred per patient towards dialysis in the KSA are almost on par with other countries. , In fact, the amount spent for each patient on dialysis per year in the KSA is nearly five times its GNP and 25 times the per capita annual health budget of the Ministry of Health.  In spite of this, dialysis is provided free of cost 10 to the citizens of this country in 124 state-run dialysis centers. 
Thus, ESRF not only has an effect on health-care financial allocations, but also has a devastating effect on social and economical aspects of the patients and their families.  In view of the enormous cost involved, one has to find out how far the dialysis program or, for that matter, the various forms of renal replacement therapy (RRT) are utilized in different centers. Also, such type of evaluation helps to convince the funding agencies/organizations and draws their attention for further expansion as well as assisting them to introduce alternative measures effectively.
Review of the Saudi Medbase (a CD-ROM sponsored by Saudi Medical Journal) 1979-1995 and Saudi medical literature till 1998 on ESRF and HD revealed that over the past two decades extensive work has been carried out on epidemiology, ,,, etiology, ,, evolution  and clinical aspects ,,,,,,,,,,,,,,,,,,,,,,,,,,,, of patients on HD. The latter included various infections, ,, fluoride levels,  carnitine concentrations,  uremic deafness,  pregnancy,  nail changes,  pruritus,  renal cysts,  renal osteodystrophy, , cardiac status  and vascular access, ,,,, therapeutic aspects, ,,,, attitude towards dialysis,  pediatric HD,  adequacy of HD,  alternatives to HD  and survival of individuals on HD.  There were also a few studies on economical aspects , quality of life  and some historical aspects. , However, there seems to be a gap on critical evaluation of in-center HD utilization.
Hence, the present work was undertaken with the following objectives: a) to find out the trends in the demand for regular maintenance HD and b) to assess utilization with reference to selected variables.
| Materials and Methods|| |
Samtah and Samtah General Hospital
Samtah is one of the oldest towns of the Gizan province of KSA. This town is on the international highway connecting KSA to Yemen. It is located on the south-western part of KSA with the Red Sea on the west, and Yemen on the south and south-eastern aspects. The population of Samtah and the villages of this region is 172,446 (Saudi 165,156 and non-Saudi 7,290) as per 19992000 statistics.
Samtah General Hospital (SGH) is a secondary care hospital with full-fledged facilities.  The HD unit of this hospital was inaugurated in June 1987 to provide HD for a fixed number of a stabilized patients.  To begin with, the dialysis unit had five machines. As the demand for regular maintenance dialysis (MHD) increased, the number of dialysis machines was increased to eight in early 1988.
The HD unit in Samtah had three regular shifts on all days except Fridays. In addition to regular registered cases for maintenance HD, it also caters to transit patients. Apart from this, emergency HD is also available.
In May 2000, the dialysis unit was upgraded to have a total of 16 machines. The services were run by two specialists in nephrology, a resident doctor, 11 nurses, two cleaners and a bio-medical engineer.
A retrospective analysis of ESRF patients registered for regular MHD in the SGH from the commencement of the HD unit (1987) till 2000 was made for the purpose of this study.
To find out the trends in demand, selected demographic variables of the patients such as age, sex and nationality were considered. To assess the dialysis utilization, the data were gathered from entry to exit for those on regular MHD. From the data on entry and exit, various other indicators such as annual growth rate, death rate, transplantation rate and utilization rate were calculated (Annexe 1). Some of the pooled national data of SCOT, KSA, and other published reports were used for comparative analysis.
| Statistics|| |
Simple descriptive statistics were used for analysis. The mean age was calculated and the median age was identified for those cases registered for MHD each year, and again for all cases put together over the study period.
| Criteria, Definitions and Limitations|| |
Reduplication: Care was taken to avoid reduplication of cases during data collection.
Exclusion: All cases with acute renal failure as well as ESRF patients belonging to visitor or emergency category were excluded from analysis.
Entry into MHD program: For study purposes, entry into MHD program means those cases of ESRF registered for regular MHD in this center either after a diagnosis of ESRF was made at SGH and inducted to HD or the patient was referred from some other hospital in the KSA for continuing his/her regular MHD. All such cases were registered and assigned a schedule for regular MHD.
Exit from MHD: For analytical purposes, we considered three forms of exit for the MHD patients i.e., a) natural exit: because of death; b) exit by successful renal transplantation; and c) self exit. Self exit was considered when the patients left the unit to their countries or to other HD units in KSA or when a registered MHD patient failed to report for a consecutive 10 to 12 HD sessions without prior information.
Death: Death of a patient was confirmed if the death occurred inside the hospital or at another hospital. Death was also considered if more than one person from the same dwelling place as of the patient ascertained the statement of death.
Limitations: a) In this center, right from the inception, only HD was practiced for regular MHD. Hence the present study is confined to HD utilization. b) During the years 19871989, a large number of cases on MHD belonging to Samtah region were transferred from other HD centers of the KSA to this center for regular MHD. This had resulted in an abnormal increase of HD population during those years. As this will influence the analysis of annual growth rate, the annual growth rate was calculated for the years 1990 to 1999 for each year, from which the mean annual growth rate was deduced.
| Results|| |
During the period considered for the study, the total number of ESRF patients who qualified for analysis was 393. There were 183 (46.6%) males and 210 (53.4%) females. Their ages ranged from 10 to 93 years. The mean and median ages of the study-group at the time of initiation of regular MHD were 40.7 and 35 years respectively. There were 295 (75.1%) Saudi and 98 (24.9%) non-Saudi patients.
The number of patients registered for regular MHD at the end of the first year of the study (1987) was 15. This increased to 100 active patients by the end of the year 2000. An average of two to three new patients was registered for regular MHD per month. The annual growth rate varied from 1.16 to 19.56% with a mean of 7.44%. The annual death rate varied from 3.49 to 19.81 % with a mean of 9.3%. Among the 393 registered cases, 53 patients underwent renal transplantation. On the whole, the transplantation rate came to 13.49%. Analysis of the annual transplantation rate revealed a peak in the year 1991. The mean transplantation rate per year was 4.33% [Table - 1]. Utilization rate was 50% to begin with. After that it was almost always above 100% and varied from 95.83 to 179.17% with a mean of 139.57%. A total of 113 patients left this center (self-exit) and their current status could not be ascertained.
| Discussion|| |
Of the currently available forms of RRT, incenter HD is the one that is most easily accessible to all citizens of KSA. HD has three dimensions: a) human dimension i.e., various aspects of patient care related services; b) technical dimension i.e., relating to machines; and c) intellectual dimension i.e., identification of the problems and deficiencies, assessment and expansion of services, research and development, and preventive aspects. Of them, assessment of services provided by the health-care providers is important for allocation of funds and expansion of services. This becomes essential especially when one is dealing with a chronic illness. Naturally, health administrators and planners ask many questions before allocating funds. Thus, it becomes necessary to evaluate the work carried out and show that the results achieved are worth the expenditure.
To assess any program, we need indicators. Measurement of HD services is not as simple as in nutritional, or environmental assessment where, we have certain quantitative markers. Moreover, ESRF patients on regular MHD are not uniform genetically, physically, clinically, behaviorally or socioenvironmentally. Under such circumstances, we need some indicators for the purpose of reproducibility and comparability. From a more general viewpoint, the indicators should also comply with the basic requirements of validity and reliability.  Hence, we preferred the assessment that based on growth rate, death rate, transplantation rate and utilization rate. Demands were identified based on demographic data.
Analysis of the trends in demand for regular MHD with reference to age revealed that more than 50% of the patients belonged to the agegroup 15-44 years. The mean and median age of the study population at the time of initiation of MHD was 40.7 and 35 years respectively. Thus, the demand for HD was more from young people, which is similar to the SCOT data. ,, In contrast, in the United States of America (USA) and Canada, the demand for HD was more from the elderly.  Predominance of young patients in the KSA requires further explorative studies in order to introduce suitable interventional methods.
The age at initiation of HD in SGH from year 1987 to 2000, shows a rightward shift (higher age). Moreover, the popularity of the HD program among the society has made people accept the program irrespective of advancing age and other limitations or co-morbid conditions. Thus, in the years to come, one may expect the drift more and more to the right.
Demand for HD was more from women in our center as the females constituted 53.4% which is in contrast to national data ,, where females were less than 45% [Table - 2].
When the demand for HD was analyzed by coupling the age and sex parameters together, it was clear that women dominated in the younger age group of 15-44 years whereas males were more in the age-group of 45 and above.
Analysis of our records and SCOT data indicated that non-Saudis living in the KSA had access to the HD services available at the Ministry of Health hospitals in the Kingdom. Comparison of the ratio between Saudis to non-Saudis at our center and national data [Table - 2] showed that non-Saudis benefited more from our center compared to other centers in the Kingdom.
This may be due to the geographical proximity of this center to Yemen, where facilities for RRT are limited.  However, the registration of non-Saudis to the HD program in our center has come down in recent times.
A look into the number of new cases registered every year in this center revealed a bimodal pattern. There are several possible explanations for this. It is likely that many original Samtah patients were transferred from other centers to this center when our HD unit was first initiated. Also, in the initial phase, a relatively large number of non-Saudi patients were accepted for free HD. Moreover, there has been an observable improvement in patients' co-operation, compliance and acceptance of the treatments offered over time. Year by year, the demand for HD is increasing all over the world, perhaps because of a universal increase in the incidence of ESRF,  and hence, one should expect a constant increase in the annual growth rate in every HD center. The annual increase (i.e., annual growth rate) in the HD population in the USA and Canada was found to be 5 to 10%.  The mean annual growth rate of HD population at Samtah was 7.44%. This universal trend is because of increased life span of individuals because of better control of various communicable and non-communicable diseases as well as a decline in the various chronic and acute medical complications. Similarly, better control of diabetes and hypertension, pushes the susceptible persons to develop ESRF, who might otherwise have died of one or the other complications of the disease before developing ESRF.
Interestingly, when we compared the annual growth rate of the demand for HD services at Samtah in the year 1999-2000 to a decade before (1990-91), the increase was to the tune of 66.7%. In contrast, the population increase in the same period which was only 9.9% [Table - 3]. Definitely, the annual increase of those requiring MHD was far higher than the increase in population. Mendelssohn and Chery made similar observations in Canada.  Thus, the increase with reference to population is in an arithmetic proportion and those requiring HD is in an algebraic manner.
The death rate per annum varied from 3.5 to 19.8% over the period considered for the study [Table - 1] with a mean of 9.3%, which is comparable with national figures and published reports [Table - 4]. The influencing factors for the variation in the death rate are: age at which patients are inducted for MHD pro Tam, associated co-morbid conditions,  late arrival with complications 58 at the time of initiation of HD, and compliance with HD.  The possible reasons for low mortality in this center could be due to the relatively young age at initiation of HD compared to the west, no reuse of hollow fiber kidney and blood lines, and good compliance to HD schedules. Some of the other factors  that could have contributed to the reduced morality are introduction of erythropoietin therapy, greater use of ultrafiltration control devices, other medical treatment facilities such as broader use of angiotensin converting enzyme inhibitors, and overall better medical care.
Successful transplantation offers high quality of life at a lower cost than any other modality of RRT.  The mean transplantation rate per annum among those getting HD in our center was 4.3%.
Despite enormous achievements in the organ transplantation program in the KSA,  there still lies a large gap between demand and supply. Efforts are being made constantly to improve the donor aspects and bridge the gap. Failure to narrow down the gap will have an impact on the dialysis centers and also cause stress to the funding organizations. Though the number of patients requiring organ transplantation is increasing, recent press reports clearly highlight the nonavailability of organs for transplantation not only in KSA,  but also in the USA.  Thus, bold public policies, such as mandated choice or presumed consent may be necessary to meet the increasing demand for donor organs. 
While analyzing the demands and trends, we also noticed that 113 (28.7%) patients left this HD center (self-exit) which was comparable to another center in the KSA  where 35.8% had left. The reasons for this self-exit possibly include expatriate patients going back to their own countries or social and technical reasons for others.
The overall utilization rate in Samtah exceeded 100% [Table - 1] and caused a strain on human and technical dimensions of HD. Overburden and strain at small HD centers, which are usually less optimally equipped and manned, contribute to less than optimal care  provided to the HD population. The ever-increasing HD population, often to unmanageable levels, was voiced already.  Hence, the centers providing HD should necessarily take up various measures to reduce the demand. Some of the measures are efforts to arrest/slow down the progress of chronic renal failure (CRF) in established cases,  introducing pre-dialysis educational program to CRF patients and their family members on available modes of RRT in the KSA, highlighting pre-emptive transplantation, improving live related organ donation program,  overcoming the obstacles for cadaver donor program among the public including elimination of misconception of organ donation, , motivating health-care workers for cadaver donor program,  popularizing peritoneal dialysis programs among nephrologists  and developing research programs in order to identify susceptible population for CRF so as to implement interventional methods towards prevention  .
To conclude, the demands for HD in Samtah have increased by leaps and bounds. Analysis revealed that young women predominated among those requiring RRT. Registration of Saudis for regular MHD has increased over non-Saudis. Exit from HD center by way of transplantation was little, mortality was low and ESRF patients moving out of this center has become far less. Registration of new ESRF cases, although not constant, has been increasing by two to three per month. All these have contributed to the enormous growth rate of HD population, which exceeded the population growth rate in Samtah region and to the utilization rate, which was above 100% in this center.
| Acknowledgement|| |
The services of previous nephrologists of this hospital viz., doctors D.P. Rathi, Ms. Mona, Ms. N. Thirupurasundari, D.S. Chafekar, Basher, Saibal Rakhit, and K.S.A. Hussain are gratefully acknowledged. Our special thanks go to Ms. Nirmala Velayudham and Noora Ageel Fagughi hemodialysis nurse (for data collection), Mr. Ekanth, Engineering student, Madurai (for graphics) and Mr. Selvaraj, Biostatistitian, Aravind Eye Hospital, Madurai (for statistical aspects). We are grateful to the administrative staff of SGH and Gizan Health Directorate, Gizan, KSA for their timely support.
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P T Subramanian
69, Pasupathy Nagar, Madurai - 625017, India
[Figure - 1]
[Table - 1], [Table - 2], [Table - 3], [Table - 4]