Year : 2005 | Volume
: 16 | Issue : 3 | Page : 306--310
Is There a Need for Establishing a Formal Nephrologist-Directed Primary Care Program in Dialysis Units?
Khaja H. Mujtaba Quadri, Sameer Omar Huraib, Junaid Qureshi, Hammad Raza, Fahad Al Kanhal, Carol Lum, Bella May Loria, Catherine, Powell, Danlami Z Tanimu, Ghormullah Al Ghamdi, Ahmed Al Flaiw, Zuhair M Abunijem
Division of Nephrology and Hypertension, Department of Medicine, King Fahad National Guard Hospital, Riyadh, Saudi Arabia
Khaja H. Mujtaba Quadri
Division of Nephrology and Hypertension, Department of Medicine, King Fahad National Guard Hospital, P.O. Box 22490, Riyadh 11426
We have introduced an annual timetable format for addressing the «DQ»primary care«DQ» needs of the hemodialysis population. For 102 patients enrolled, fourteen interventions adapted for the dialysis population from the US Preventive Services Task Force recommendations were implemented successfully in 65% areas in our pilot year, which include important features like annual history and physical examination, breast examination, mammography, pap smear, lipid profile, adult specific immunization and stool occult blood. Flexible sigmoidoscopy program was unsuccessful in our pilot year.
|How to cite this article:|
Quadri K, Huraib SO, Qureshi J, Raza H, Al Kanhal F, Lum C, Loria BM, Catherine, Powell, Tanimu DZ, Al Ghamdi G, Al Flaiw A, Abunijem ZM. Is There a Need for Establishing a Formal Nephrologist-Directed Primary Care Program in Dialysis Units?.Saudi J Kidney Dis Transpl 2005;16:306-310
|How to cite this URL:|
Quadri K, Huraib SO, Qureshi J, Raza H, Al Kanhal F, Lum C, Loria BM, Catherine, Powell, Tanimu DZ, Al Ghamdi G, Al Flaiw A, Abunijem ZM. Is There a Need for Establishing a Formal Nephrologist-Directed Primary Care Program in Dialysis Units?. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2020 Oct 25 ];16:306-310
Available from: https://www.sjkdt.org/text.asp?2005/16/3/306/32859
Nephrologists have traditionally provided "primary care" to their dialysis patients. One survey of practicing nephrologists revealed that 90% of "responders" provided primary care to their dialysis patients.  Another report concluded that awareness and implementation of routine health maintenance recommendations is essential in the case of female dialysis patients.  A third report pertaining to pediatric dialysis patients concluded that primary care of these patients should include careful compliance with the routine childhood immunization schedule.  A fourth article concluded that, in view of the 15 times greater cardiovascular mortality in dialysis patients relative to the general population, implementation of risk factor reduction strategies earlier in the course of chronic renal disease may prevent cardiovascular disease.  Finally, in a review of issues pertaining to nephrologists as primary care providers, the author points out that "there is little objective information on which to base guidelines and recommendations about nephrologist-directed primary care of patients with end-stage renal disease (ESRD).  The 1994 Clinicians Handbook of Preventive Services adult care timetable summarizes age-specific recommendations for tests, examinations, immunizations and health guidance for the normal adult population.  No similar program exists for dialysis patients.
Advantages of a Formal Program
Patients dialyzed on a standard thrice weekly schedule often seek advice on primary care issues from their treating physician/delegate or nurse. Thus, it appears prudent that a number of primary care interventions can be scheduled in the dialysis unit on dialysis days. Additionally, by having an annual timetable format, specific interventions can be spread over the entire year to accommodate the large dialysis population in certain units.
Moreover, once nurses are familiarized to the structure of such a program, the probability of missing important interventions diminish; for instance, the annual history and physical examination. The thrice a week schedule also helps in implementing certain interventions logistically. They include: immunization, specifically against influenza, pneumococcal vaccination and DT boosters may be given on alternate days in the "immunization week" before the onset of the "flu season". Finally, since most of the "interventions" are pre-requisites of a renal transplant program, patients may automatically get worked up for transplantation, barring specific additional requirements.
Patients may potentially perceive these primary care interventions as an additional "burden" and may not comply with visits "outside" the unit. This may be particularly true if procedures are felt to be cumbersome and long "on dialysis days" and requiring additional transportation/visits on "non-dialysis days".
The King Fahad National Guard Hospital Program for Primary Care of Hemodialysis Patients
This program was conceived in the summer of 2000 and initiated in September 2000 as a pilot program to be re-evaluated in subsequent years.
In the absence of formal primary care guidelines for patients with ESRD, our program aims to introduce a comprehensive, annual time frame for providing routine and dialysis specific primary care services, modified from the US Preventive Services task force recommendations.
After informed consent, all 102 chronic hemodialysis (HD) patients at the King Fahad National Guard Hospital, Riyadh were enrolled in the primary care program in September 2000.  The outline of the "annual time-table" format was approved by the Hospital Administration as well as chairpersons/ divisional heads of all involved departments/ divisions. A comprehensive "in-service" was conducted for the physicians and nurses responsible for routine care of the HD patients. Fourteen age and sex specific appropriately indicated primary care tests, examinations, immunizations and interventions were performed according to our modified annual time-table. [Figure 1].
Dialysis-specific monitoring and multidisciplinary meetings were continued as per our pre-existing standards. Appropriate therapeutic interventions and case-specific referrals were performed. Each area of intervention was deemed to be highly successful (more than 66% or two-thirds compliance), moderately successful (50% to 66% compliance) or unsuccessful (less than 50% compliance).
We were successfully able to implement 9/14 (65%) of our targeted primary care interventions in our HD population in our pilot year. Amongst our unsuccessful interventions 5/14 (35%), the failure of our flexible sigmoidoscopy program may have long-term consequences, when extrapolated to the general population. This may necessitate renewed efforts at patient education in subsequent years. Hence, most of our interventions were accomplished in the dialysis unit, e.g. history and physical exam, breast exams, screening for prostate specific antigen, immunization program, lipid profiling and testing stool for occult blood. Where our success was modest or uninspiring it was in areas where patients had to undergo specific appointments and scheduling in addition to their thrice-weekly dialysis, e.g. pap smear and flexible sigmoidoscopy. Some of the areas, perhaps eye and ENT screening needed to be scheduled on dialysis days, in the absence of which very poor compliance was noted [Table 1].
We, at the King Fahad National Guard Hospital believe that for the HD population, already burdened with a thrice a week dialysis schedule, nephrologist-directed primary care is a multidisciplinary process and needs to be spread over the entire year. Success in implementing this process is largely dependent on working around the dialysis schedule. Hence, most of our interventions were accomplished in the dialysis unit, e.g. history and physical exam, breast exams, PSA screen, immunization program, lipid profiling and stool test for occult blood. Where our success was modest or uninspiring was in areas where patients had to undergo specific appointments and scheduling in addition to their thrice-weekly dialysis, e.g. pap smear and flexible sigmoidoscopy. Some of the areas such as eye and ENT screening needed to be scheduled on dialysis days, in the absence of which very poor compliance was noted.
Our annual "time-table" appears to provide a practical, efficient and administratively acceptable format for providing nephrologist directed primary care to the HD population, hitherto not described in the literature. Future data from this primary care program may yield the longterm effects on morbidity and mortality in our dialysis population.
The long-term impact and costs could be looked at over subsequent years but in general, most interventions implemented are well established cost-effective screening tools.
Junaid Qureshi, Hammad Raza, Fahad Al Kanhal, Carol Lum, Bella May Loria, Catherine Powell, Danlami Z. Tanimu, Ghormullah Al Ghamdi, Ahmed Al Flaiw, Zuhair M. Abunijem and all involved departments and secretarial assistance, particularly Ma. Sofia Claridad.
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|7||Quadri KH, Kanhal F, Qureshi JI, et al. A primary care program for hemodialysis patients. Abstract JASN, A1229 September 2001. Poster presentation at joint ASN/WCN Annual meeting 2001.|