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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 3  |  Page : 355-364
Survey of the Attitude of Physicians towards Establishing and Maintaining a Peritoneal Dialysis Program


Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia

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   Abstract 

In an attempt to evaluate the attitude of physicians towards establishing and maintaining a peritoneal dialysis (PD) program in the Kingdom of Saudi Arabia (KSA), we sent a questionnaire to 160 physicians; the heads of the 148 active dialysis centers in the KSA and 12 other consultants working in these centers. This covered decision makers in 109 centers (73.6%) in the Ministry of Health (MOH), 18 (12.2%) in Governmental-non-MOH centers, and 21 (14.2 %) in private hospitals that, together, care for a population of more than 7300 patients on chronic hemodialysis (HD) and 559 on PD. The study was performed between September and December 2005. A total of 145 of the 160 physicians (90.6%) from 141 dialysis centers (95.2%) answered the questionnaire. There were 81 respondents (56.3%) who believed that follow-up of the PD patients should be available in all the dialysis centers, 80 (55.2%) would like to have a PD clinic at their centers, and only 20 (13.8%) had PD clinics in their centers. However, 93 (66.4%) respondents did not request from the administration of their hospitals to open a PD clinic and 62 (44.6%) admitted to having no expertise in managing the patients on PD, while 53 (38.1%) claimed that they did not have enough space in their dialysis centers to start a PD program. Regarding training and expertise, 57 (40.7%), 58 (43.3%), 48 (35.6%) and 72 (52.9%) physicians had training in continuous ambulatory PD (CAPD), intermittent peritoneal dialysis (IPD), automated peritoneal dialysis (APD) or continuous cyclic peritoneal dialysis (CCPD), and acute PD, respectively. The comparisons between the health sectors in the KSA showed that MOH had significantly less active PD programs, and this reflected tremendously on the knowledge of the staff. Our survey indicates that the current practices concerning the PD programs in the KSA are modest, and that a new strategy is required to spread this modality of therapy horizontally in all the dialysis centers, and vertically by introducing the latest technologies in the field of PD, such as automated PD machines and connectology. There is also a need to increase the awareness of physicians about the benefits and applicability of PD. National guidelines and training are indispensable and cannot be overemphasized to improve this service, especially in the MOH hospitals.

How to cite this article:
Souqiyyeh MZ, Shaheen FA. Survey of the Attitude of Physicians towards Establishing and Maintaining a Peritoneal Dialysis Program. Saudi J Kidney Dis Transpl 2006;17:355-64

How to cite this URL:
Souqiyyeh MZ, Shaheen FA. Survey of the Attitude of Physicians towards Establishing and Maintaining a Peritoneal Dialysis Program. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2021 Mar 4];17:355-64. Available from: https://www.sjkdt.org/text.asp?2006/17/3/355/35768

   Introduction Top


Surveys of the attitudes of physicians toward their practices in the dialysis units are one of the tools used to evaluate the quality of care provided to the patients on regular dialysis.[1],[2],[3]

Peritoneal dialysis (PD) has been established as a modality of renal replacement therapy (RRT) for patients with end-stage renal disease (ESRD) worldwide which provides great advantages in the quality of life and outcome. The use of PD has been outlined in the guide­lines that have been laid down by the American Society of Transplantation and European Renal Association (European Best Practice of Trans­plantation). [4],[5] The goals and means of therapy are defined according to the best evidence available from the medical literature. The practices of the physicians can be improved according to these guidelines in order to augment the patients' care.

The expansion of use of PD in the Kingdom of Saudi Arabia (KSA) has been slow over the years. The lack of PD services in many dialysis centers in the KSA is worth exploring in order to know the factors that hinder the establishment of PD clinics, as well as the availability and expertise of the personnel in managing PD patients. This may help in organizing proper strategies in terms of starting the clinics and training the personnel, besides enhancing the communications between physicians in this field The aim of this study is to survey the attitude of the heads of dialysis units in the KSA towards establishing and main­taining PD Programs. The evaluation includes the physicians' perception of the to the signi­ficance of the factors involved in the establish­ment of the PD program, their expertise, and their preferences and beliefs about the advantages and advances in the field of PD.


   Materials and Methods Top


We sent a questionnaire to 160 physicians; this group consisted of the heads of the 148 active dialysis centers in the KSA and 12 other consultants working in these centers. This selection covered decision makers in 109 (73.6 %) centers in the Ministry of Health (MOH), 18 (12.2%) centers in Governmental­non-MOH, and 21 (14.2 %) in private hospitals that, together, care for a population of more than 7300 chronic HD and 559 PD patients. The questionnaire was mailed to the targeted physicians during September 2005 and the responses were received at the Saudi Center for Organ Transplantation (SCOT), Riyadh, KSA during November and December of 2005.

The questionnaire was intended to evaluate the following aspects in the practice of physicians who take care of the CRF patients in the KSA:

a. The current status and the obstacles for the establishment of a PD program in Saudi Arabia.

b. The physicians' beliefs and attitudes towards the benefits and applicability of PD.

c. The physicians' beliefs and attitudes towards the means of training of dialysis staff about PD.

In addition, we compared the responses according to the affiliation of the dialysis center (MOH, non-MOH, private) and according to the presence or absence of a PD clinic

We considered the best answers as those in accordance with the common denominator of the established guidelines and practices in the United States of America (USA) [4] and Europe [5] , which include:

a) A recommendation to consider PD as an established modality of renal replacement therapy.

b) A recommendation to integrate a PD clinic in every dialysis center with appropriate staffing and to consider a dialysis center without PD clinic as a paralyzed center.

c) A recommendation that every ESRD patient should be given the option of PD with a full explanation of the benefits and side effects.

d) Protocols of PD procedure policies should be available to all the dialysis units.

e) Means of training should be explored and organized for the staff of the dialysis centers.


   Statistical methods Top


Data was entered in a Microsoft Excel file. However, the description of data and analysis were done by using the statistical program, SPSS.

The Pearson Chi-Square test was used through­out the analysis to test the significance of differences between groups and sub-groups. Significance was set at P< 0.05.


   Results Top


A total of 145 out of 160 physicians (90.6%) answered the questionnaire from 141 dialysis centers (95.2%) that, together, cater to 7620 (98.2%) dialysis patients in the KSA; there were 108 respondents (98.1%) from the MOH centers, 19 (65.5 %) from the non­MOH centers, and 17 (80.9%) from the private centers.

[Table - 1] shows the answers related to the current status and obstacles for the establish­ment of PD programs in Saudi Arabia. There were 81 respondents (56.3%) who believed that facilities for the follow-up of PD patients should be available in all the dialysis centers, 80 (55.2%) would like to have a PD clinic at their centers, and only 20 (13.8%) already had PD clinics in their centers. However, 93 respondents (66.4%) had not requested from the administration of their hospitals to open a PD clinic and 62 (44.6%) admitted to having no expertise in managing the patients on PD. Fifty-three respondents (38.1%) claimed not having enough space in their dialysis centers as the obstacle to starting a PD program. The query about the training which the staff had received pre­viously showed that 57 (40.7%), 58 (43.3%), 48 (35.6%), and 72 (52.9%) physicians had prior training on handling continuous ambu­latory PD (CAPD), intermittent peritoneal dialysis (IPD), Automated peritoneal dialysis (APD) or continuous cyclic peritoneal dialysis (CCPD), and acute PD, respectively.

[Table - 2] shows the issues related to the beliefs of the respondents about the benefits and applicability of PD. There were 62 respondents (44.3%) who believed that PD should be offered to all new ESRD patients. Also, 110 respondents (75.9%) believed that the PD patients have less infection with viruses and better anemia control than HD, 100 (69.0%) believed that the advances of connecting tubing, such as the Y-shape tubes and double bags, had made the incidence of peritonitis so low as to warrant PD as a real option for dialysis in ESRD patients, and 96 (67.1%) believed that automated PD should be available in all the PD centers as an option for PD treatment, besides CAPD.

[Table - 3] shows the physicians' beliefs about the means of training of dialysis staff on PD. Of the 20 dialysis centers that have active PD clinics, 17 (85%) were willing to participate in any training program on the modes of PD, while seven (43%) would do it through co­ordination with SCOT. Of all the respondents, 123 (85.4%) welcomed the availability of Saudi guidelines for the establishment of PD dialysis programs and 129 (89%) believed that there should be an annual meeting for PD at SCOT.

[Table - 4] shows the differences of the responses of the study participants according to their affiliation. In comparison to non-MOH and private dialysis centers, there was a significantly lower percentage of MOH centers in the following groups: a) those that request their respective administrations to start PD programs, b) for their physicians to have formal training on the modes of PD, and c) and those that hold the belief that automated PD should be available in all the PD centers as an option for PD treatment. In comparison to MOH and private dialysis centers, the non­MOH dialysis centers had a significantly higher percentage of PD programs, nurses with expertise on PD, and a higher belief that PD should be offered to all new ESRD patients. Furthermore, the non-MOH dialysis centers had a significantly higher percentage of physi­cians with certain beliefs about the appli­cability of PD and its benefits, such as a lower incidence of peritonitis with the new connecting system, less viral infections, and better control of anemia. Finally, the availability of expertise with various forms of PD, as well as knowledge about the advances in the connecting systems that resulted in a lower incidence of peritonitis, was less among the physicians in the MOH centers.

[Table - 5] shows the differences in the responses of the respondents based on the presence or absence of a PD clinic in their respective centers. In comparison with those with PD clinics, the centers with no PD clinics had significantly less expertise in the modes of PD, both among physicians and nurses, and lesser availability of skilled surgeons for the insertion of PD catheters. Furthermore, the physicians in the centers that lacked the PD clinics had significantly less knowledge about the benefits, advances, and applicability of PD.


   Discussion Top


The current study attempted to detect the attitude of the physicians in charge of the HD centers in the KSA towards the establishment of PD programs in their respective centers.

The results showed that PD is lagging tremendously behind HD as a modality of RRT for the ESRD patients in Saudi Arabia. Less than 15% of the dialysis centers have a PD program, which reflects on the total number of patients treated on PD. The need for making this method of RRT available in every dialysis center has been emphasized by many authors. [6],[7],[8],[9],[10],[11],[12],[13] Many respondents in our study believed that PD should be available only in the larger dialysis centers, and they were even not willing to have PD in their centers. The majority of respondents in our study admitted that a lack of expertise was the main reason for not requesting for the esta­blishment of a PD program in their respective centers. There was a lack of expertise in many modes of PD, even acute PD.

Numerous reports emphasize that all patients with CRF, prior to starting dialysis, should receive an elaborate description of and en­ couragement to use PD. [14],[15],[16],[17],[18],[19],[20] The majority of the respondents in our study believed wrongly that PD should be offered only to those patients in whom HD and/or transplantation was not feasible. There was a lack of knowledge among many respondents as to the recent advances in the connecting systems (conne­ctology) that has reduced the incidence of PD-related peritonitis, [21],[22],[23],[24],[25],[26] as well as automated PD, which has facilitated the life style of PD patients. [27],[28] Furthermore, many respondents in our study did not have any idea about the maximum duration a patient can be on PD, which is more than four years in many patients.[29],[30],[31],[32],[33],[34],[35],[36] On the other hand, many respondents believed that PD was advantageous in having less viral infection and better anemia control than HD, which is compatible with many reports and guidelines.[4],[5],[37],[38],[39] However, despite this knowledge about the benefits of PD present in the overwhelming majority of the respondents, it was still unpopular to many of them.

Almost all the centers with active PD programs were willing to train the staff of the other centers about the various modes of PD through either direct contact, or through the auspices of SCOT. Almost all the respondents in our study believed that guidelines and regular meetings about PD should be available and implemented. Such activities have been emphasized.[40]

In our study, we found differences among the health sectors with regard to the activities of PD. The MOH, which is the biggest sector in Saudi Arabia, lagged significantly behind in the number of centers with active PD programs and in staff having adequate expertise and training in PD modes, in comparison with the other governmental centers. In addition, the staff in the centers with active PD programs had a significantly greater awareness about the benefits and applicability of PD in RRT than those in the centers that lacked this service. We believe that more effort is needed to increase the awareness on PD among the dialysis centers in the MOH sector, in addition to a solid strategy to increase the availability of PD in more centers than the present meager six percent.

Finally, the use of a protocol to guide both the establishment of PD programs and management of patients on PD in Saudi Arabia may impose a significant positive impact on the practice. The overwhelming majority of the respondents, mostly from the MOH centers, welcomed such a protocol. We believe it is the responsibility of SCOT to provide such guidelines for the KSA.

We conclude that the current practices concerning the PD programs in the KSA are modest, and that a new strategy is required to spread this modality of therapy. There is also a need to increase the awareness among physicians about the benefits and applicability of PD, particularly in those centers that lack this service. National guidelines and training are indispensable to improve this service, especially in the MOH hospitals.


   Acknowledgement Top


We would like to thank Baxter pharma­ceuticals in Saudi Arabia for their grant that made this study possible.

 
   References Top

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Correspondence Address:
Muhammad Ziad Souqiyyeh
Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
Saudi Arabia
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