Healthcare quality has several dimensions that are all inter-related
“The wish for healing has always been half of health”
– Lucius Annaeus Seneca (4 BC- AD 65)
The quote above by Lucius Annaeus Seneca has made many think about what the other half of health or healing is. The other half could be represented by any number of actions including getting an actual diagnosis and treatment but an important part is the conscious effort on the part of the person desiring health to inform him or herself of their disease and not only to seek help but find “high quality ” help.
To support the quest of those in need for the other half of a health, this discussion on quality and clinical performance measures in kidney disease and dialysis care in Nigeria will start with a brief explanation of the functions of the kidney and kidney disease.
The kidneys are important organs with the important function of removing waste products and toxins from the body. These wastes and toxins are filtered out into the urine. The kidney also is important for the regulation of blood pressure and for creating the signals to the bone to create blood.
Kidney disease is a condition where the functions of the kidneys are lost. Sometimes the loss of function of the kidney is temporary. On other occasions it is permanent or progressive leading eventually to kidney failure requiring dialysis or kidney transplantation to sustain life. It is estimated that some 15-20 million Nigerians to have some form of kidney disease and about 100-500 of every million Nigerians have advanced end stage kidney failure requiring dialysis or kidney transplantation. In some studies, 1 in every 10 hospital admissions have been associated with kidney failure requiring dialysis in Nigeria.(Ref 1-4).
The most common causes of kidney disease in Nigeria are diabetes mellitus, hypertension, infections , glomerulonephritis and toxin exposure from herbal medications or poorly manufactured or expired drugs. (Ref 3). Therefore, if you are over the age of 40, or have a personal history of diabetes or hypertension or a family history of kidney disease, you should ask your doctor to perform simple tests to detect kidney disease early. There are means available to hopefully prevent or delay kidney failure. Your doctor can also help you treat the cause of your kidney disease.
Treatment of kidney disease can be expensive if it is not detected early or managed by competent professionals (Ref 5). Not all healthcare providers or medical centers are equipped to deal with this disease so persons with kidney disease must know what is important in identifying centers that can provide high quality care.
It is therefore the intent of this brief post is to shine light on the issues that are necessary for the delivery of high quality kidney disease and dialysis care in Nigeria. To keep the reader engaged, the post will identify the quality measures, as they should be even in the Nigerian healthcare circumstance so that the information is of most benefit to readers. For the purpose of introduction, a performance measure or quality indicator is a standard of care that implies that healthcare providers are in error if they do not care for patients to the standards of the performance or clinical measure. This post does not intend to cover the more common healthcare service delivery issues such as location, access, respectful and timely service delivery or pricing, as it is probably safe to presume the public, government, payors and healthcare providers have sufficient knowledge and expectations on these front end issues. The strategies to measure quality and clinical performance in this field of healthcare are beyond the scope of this post.
For the purpose of this discussion, kidney disease refers to all severities of the disease before a diagnosis of kidney failure or end stage kidney disease requiring dialysis or transplantation is made. Dialysis care refers to all types of dialysis provided to patients with kidney failure or end stage kidney disease.
An important question for any reader is “how should I look at the information presented in this post?” Well the answer lies in the reason for reading the post in the first place, which in turn defines the position of the reader as a stakeholder. The questions from a patient, their family and friends would and should come from a different stake holder viewpoint than a health policy maker, a payor responsible for paying for kidney disease and dialysis care or the providers that include both the kidney specialists and general practitioners directly or indirectly involved in the provision of the care.
- A patient and their family might focus on quality and clinical performance measures that support a medical centers claim that they will deliver on the promise of preventing death and improving quality of life.
- A policy maker or regulator while also interested in outcomes of death and quality of life would also focus on quality and performance measures that require governmental oversight or incentives.
- A payor may ask questions focusing on a centers process of care that decreases the incidence of poor outcomes and minimizes costs of clinical outcomes of kidney disease such as catheter infections or hospitalizations due to stroke, heart failure and heart attacks. Payors are likely also interested in clear metrics of performance and quality that can be applied across the industry.
- A provider may be interested in knowing the core quality and clinical performance measures necessary to improve patient and payor satisfaction and gain an edge over competitors.
With this in mind, let’s identify what quality and clinical performance measures are important in the delivery of effective kidney disease and dialysis care. These measures are best broken down into three categories based on the structure, process and outcome framework proposed by Donabedian (Ref 6)
The Structure of care refers to the components of the healthcare system
- Adequacy of equipment and resources both for routine and emergency diagnosis and treatment
- Administrative and organizational features of a clinic to efficiently mobilize resources for patient care. For example
- Pre-treatment triage for dialysis patients to determine the best environment for care
- Dialysis machine/water treatment system operation and disinfection protocols to ensure safe and timely delivery of treatment
- Systems to ensure patient education.
- The resources and plans in place to ensure adequate physician, nurse and technician training and oversight
- The resources, plans and administrative plans in place to ensure regulatory compliance.
The Process of care refers to the use of appropriate diagnostic and therapeutic modalities for the individual patient
- Order entry and prescriptions
This includes plans and resources in place to ensure that the assessment of proteinuria, estimating the level of kidney function, prescribing kidney protective medications, correctly identifying threshold and timing of referral to a kidney specialist, evaluating abnormalities of mineral metabolism or evaluation by a surgeon for vascular access for dialysis is done in a timely manner.
- Documentation and health care privacy compliance o Informed consent, patient record safety and privacy
- Patient care including the procedures and protocols in place for routine and emergency care
- Patient education on their disease, treatment options, dialysis access , dialysis adequacy and diet
- Transplantation education and care
The Outcomes of care for kidney disease refer to the consequences of treatment and can represent markers of disease progression, health status or cost.
Examples of key outcomes of care for kidney disease include
- Proportion of patients in a program with adequate blood pressure and anemia control
- Proportion of dialysis patients who started long-term dialysis in an emergency situation
Examples of key outcomes of dialysis care include
- Catheter infection rates
- Rates at which patients get dialysis with a groin catheter.
- The proportion of dialysis patients at a center with a fistula or graft instead of a dialysis catheter,
- Admission/Hospitalization rates for complications of kidney failure such as heart failure
- Death rates
- Dialysis dose goal achievement.
In the Nigerian context, many patients do not come as regularly as 3 times a week for reasons primarily related to out-of-pocket costs of care. Nevertheless, programs should be able to provide patients whenever they come in for treatment with a dialysis dose Kt/V of approximately 1.2 at each treatment. Modern dialysis machines have online monitoring systems that permit the doctor and nurse make adjustments in real-time to achieve this goal.
- Proportion of patients with moderate and severe anemia
- Proportion of patients with adequate blood pressure control
To conclude this discussion, It is important for all stakeholders, especially healthcare providers to realize that clinical practice guidelines while important in improving the quality of care are not quality and clinical performance measures. Guidelines for care are written to suggest diagnostic and treatment approaches for most patients most of the time. They do not however set the standards to which the quality of care and patient outcomes should be measured.
The issue of quality in Nigerian healthcare is a growing topic of interest and discussion. All stakeholders are demanding for more but it is important that they know what to ask for. For additional reading on the greater issue of healthcare quality especially from a patient perspective, the reader is referred to a recent blog post by Dr Uche Ofoma on the Nigeria Health Blog at http://www.healthblogng.com/rating-nigerian-hospitals/#more-671
1. Ulasi I and Ijoma C.K. The enormity of chronic kidney disease in Nigeria: the situation in a teaching hospital in South-East Nigeria
2. Akinsola W, Odesanmi W.O, Ogunniyi J.O, Ladipo G.O. Diseases causing chronic renal failure in Nigerians- a prospective study of 100 cases. African Journal of Medicine and Medical Sciences, 1989. vol 18, no 2, pp 131-137
3. Adetuyibi A, Akinsanya J.B, Onadeko B.O. Analysis of the causes of death on the medical wards of the university college Hospital Ibadan over a 14 year period (1960-1973). Transactions of the Royal Society of tropical Medicine and Hygiene. 1976. Vol 70, no 5-6, pp466-473.
4. Alebiosu C, Ayodele O, Abbas A and Olutoyin A. Chronic renal failure at the Olabisi Onabanjo University teaching hospital, Sagamu Nigeria. Afr Health Sci. 2006 September; 6(3):132-138
5. Ijoma C.K, Ulasi I.I. Cost implications of treatment of end stage renal disease in Nigeria. Journal of the College of medicine. 1998, vol 3, no 2, pp 95-96
6. Donabedian A. Evaluating the Quality of Medical Care. Millbank Memorial Fund Quarterly 1966; 44(suppl):166-206