DISCUSSION BOARD

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INTRODUCTION

Nephrologists have traditionally provided "primary care" to their dialysis patients. One survey of practising nephrologists revealed that 90 percent of "responders" provided primary care to their dialysis patients.

• 1 Another report concluded that awareness and implementation of routine health maintenance recommendations is essential in the case of female dialysis patients.
• 2 A third re port pertaining to paediatric dialysis patients concluded that primary care of these patients should include careful compliance with the routine childhood immunization schedule.
• 3 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.
• 4 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 ESRD patients.
• "5 The 1994 Clinicians Handbook of Preventive Services adult care timetable summarizes age specific recommendations for tests, exams, immunizations and health guidance for the normal adult population.6 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 time-table 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 diminishes, for instance annual history and physical examination. The thrice a week schedule also helps in implementing certain interventions logistically viz immunization specifically influenza, pneumovax 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.

DISADVANTAGES

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 reevaluated in subsequent years. A preliminary report follows subsequently.

AIMS

In the absence of formal primary care guidelines for patients with end stage renal disease, 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.

METHODS

After informed consent all 102 chronic hemodialysis patients at King Fahad National Guard Hospital, Riyadh were enrolled in the primary care program in September 2000.7 The outline of the "annual time-table" format was approved by Hospital Administration and Chairpersons/ Divisional Heads of all involved departments/ divisions. A comprehensive "inservice" was conducted for the physicians and nurses responsible for routine care of the hemodialysis patients. Fourteen age/sex specific appropriately indicated primary care tests, exams, immunizations and interventions were performed according to our modified annual time-table. Figure (A).

Age

Sept.

Oct.

Nov.

Dec.

Jan.

Feb.

March

April

May

June

July

Aug.

18-34

35-49

Fasting lipid profile (annually)

50-64

Fasting lipid profile (annually) +PSA (annually)

Stool occult blood (annually)

For 60+ (2 yearly) EYE (vision/ glaucoma) ENT (2 yearly)

EYE ENT

Flex sigmoi- doscopy q 3 yearly morning

Flex sig. afternoon

Flex sig. evening

65-79

Fasting lipid profile (annually) +PSA (annually)

Stool occult blood (annually)

EYE ENT (Sat, Mon, Wed) shift

EYE ENT (Sun, Tue, Thurs) shift)

Flex sig. morning (shifts)

Flex sig. afternoon (shifts)

Flex sig. evening (shifts)

18-34

PAP Smear (if married) (yearly x2 then q 3 yrs)

PAP Smear (if married) (yearly x2 then q 3 yrs)

35-49

Fasting lipid profile (annually)

For 40+ Breast exam (annually)

Breast exam

PAP Smear

PAP Smear

50-64

Fasting lipid profile (annually)

Stool occult blood (annually)

For 60+ (2 yearly) EYE (vision/ glaucoma) ENT (2 yearly)

EYE ENT

Breast exam

Breast exam

Mammogram yearly x2 (then q 2 yearly)

PAP Smear (Sat, Mon, Wed) shift

PAP Smear (Sun, Tue, Thurs) shift

Flex sig. morning

Flex sig. afternoon

Flex sig. evening

65-79

Fasting lipid profile (annually)

Stool occult blood (annually)

EYE ENT (Sat, Mon, Wed) shift

EYE ENT (Sun, Tue, Thurs) shift)

Breast exam (Sat, Mon, Wed) shift

Breast exam (Sun, Tue, Thurs) shift

Mammogram yearly x2 (then q 2 yearly)

Flex sig. morning shifts

Flex sig. afternoon shifts

Flex sig. evening shifts

P3, P4, CA++ (ionized), AL, HbAlc, Mg, Fe, TIBC, Ferritin, PTH, pre/post BUN, CBC, HBV profile, HCV Fasting lipid profile (all diabetics)

P3, P4, CA++ (ionized) HbAlc, pre/post BUN, CBC, Vaccination 1. Influenza (annual) 2. Pneumovax (lifetime once) 3. DT (q 10yrs) 4. Hep B status follow-up

P3, P4, CA++ (ionized) HbAlc pre/post BUN, CBC, PRA Arterial Venous BUN Peripheral *EYE clinic for all diabetics (Sat, Mon, Wed)

P3, P4 CA++ (ionized), AL, HbAlc, Mg, Fe, TIBC, Ferritin, PTH, pre/post BUN, CBC, EYE clinic for all diabetics (Sun, Tue, Thurs)

P3, P4, CA++ (ionized) HbAlc pre/post BUN, CBC, History/ Physical Sat/Mon/ Wed shift

P3, P4, CA++ (ionized) HbAlc pre/post BUN, CBC, PRA Arterial Venous BUN Peripheral History/ Physical Sun/Tue/ Thurs shift

P3, P4 CA++ (ionized), AL, HbAlc, Mg, Fe, TIBC, Ferritin, PTH, pre/post BUN, CBC, HBV profile, HCV

P3, P4, CA++ (ionized) HbAlc pre/post BUN, CBC, U/S kidneys (annual) Hand x-rays (q2 yr) (Sat, Mon, Wed) shift

P3, P4, CA++ (ionized) HbAlc pre/post BUN, CBC, PRA Arterial Venous BUN Peripheral U/S kidneys (annual) Hand x-rays (q2 yr) (Sun, Tue, Thurs) shift

P3, P4 CA++ (ionized), AL, HbAlc, Mg, Fe, TIBC, Ferritin, PTH, pre/post BUN, CBC, HBV profile, HCV Dental (yearly) (morning shift)

P3, P4, CA++ (ionized) HbAlc pre/post BUN, CBC, Dental (yearly) (afternoon shift)

P3, P4, CA++ (ionized) HbAlc pre/post BUN, CBC, PRA Arterial Venous BUN PeripheralDental (evening shift)

Dialysis specific monitoring and multi-disciplinary 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).

RESULTS: Tables I and II and Figure B

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Month	Primary intervention	Sex	Age	N	Positive	Negative
April/ May	10. Pap smear (yrly x 2 then q 3 yrs)	F	18-64	24	0 (0%)	13 (54.1%) No show 11 (45.9%)
	11. Ultrasound kidneys (annual)	M/F	12-88	102	Not applicable	Not applicable *unable to schedule in pilot year
	12. Hand x-rays (two yearly)	M/F	12-88	102	39(38.2%) Osteodystrophy 12 Osteopenia 23 Osteoporosis 3 Others 1	19 (18.6%) No show 44(43.2%)
Jun – Aug.	13. Flexible sigmoidoscopy	M	50-79	31	2 (6.4%) (Rectal & sigmoid polyp)	8 (25.8%) No show/refused 21 (67.8%)
		F	50-79	34	1 (2.9%) (rectal polyp)	2 (5.8%) No show/refused 31 (91.3%)
	14. Dental exam	M/F	12-88	102	Not applicable	Not applicable *unable to schedule in pilot year
N.B. Some discrepancy in numbers in various age groups in different months reflect the changes as a result of additional new patients, travel, morbidity/mortality Table I

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CONCLUSIONS

We were successfully able to implement 9/14 (65%) of our targeted primary care interventions in our hemodialysis population in our pilot year. Amongst our unsuccessful interventions 5/14 (35%), only failure of our flexible sigmoidoscopy program may have long-term consequences, when extrapolated to the general population. This may involve renewed efforts at patient education in subsequent years. Our annual "time-table" appears to provide a practical, efficient and administratively acceptable format for providing nephrologist directed primary care to the hemodialysis population, hitherto not described in the literature. Future data from this primary care program may yield the long term effects on morbidity and mortality in our dialysis population.

DISCUSSION

We at KFNGH believe that for the hemodialysis 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 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, perhaps eye and ENT screening needed to be scheduled on dialysis days, in the absence of which very poor compliance was noted. 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.

SUMMARY

We have introduced an annual time-table format for addressing the "primary care" 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 & physical exam, breast exam, mammography, pap smear, lipid profile, adult specific immunization and stool "occult" blood. Flexible sigmoidoscopy program was unsuccessful in our pilot year.

ACKNOWLEDGEMENT TO CO-INVESTIGATORS
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.

REFERENCES

1. Bender FH, Holley JL. Most nephrologists are primary care providers for chronic dialysis patients: results of a national survey. AJKD 28(1):67-71, July 1996)

2. Gipson D, Katz LA, Stehman-Breen C. Principles of dialysis: special issues in women. Seminars in Nephrology 19(2):140-7, March 1999

3. Neu AM, Fivush BA. Immunization for pediatric dialysis patients. Adv. Renal Replacement Therapy, 7(3):239-46, July 2000

4. Sarnak MJ, Levey AS. Cardiovascular disease and chronic renal disease: a new paradigm. AJKD. 35(4 Suppl 1):S117-31, April 2000

5. Holley JL. Nephrologists as primary care providers: a review of the issues. AJKD, 31(4):574-83, April 1998

6. US Public Health Service 1994

7. Quadri KHM, Kanhal F, Qureshi JI, Raza H, Lum C, Loria BM, Powell B, Tanimu DZ, Ghamdi G, Al Flaiw A, Abunijem ZM and Huraib SO. A primary care program for hemodialysis patients. Abstract JASN, A1229 September 2001. Poster presentation at joint ASN/WCN Annual meeting 2001.