==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2649770810.5144/0256-4947.2015.288asm-4-288Original ArticleQuality of healthcare for hemodialysis patients in various health sectors in Jeddah, Saudi Arabia Bakarman Marwan A. aAlghamdi Hani A. bAlraddadi Rajaa M. c a Department of Family and Community Medicine, Rabigh Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia b Department of Preventive Medicine, Ministry of Health Primary Health Care, Jeddah, Saudi Arabia c Research Department, Ministry of Health Primary Health Care, Jeddah, Saudi ArabiaCorrespondence: Dr. Marwan A. Bakarman, Department of Family and Community Medicine, Rabigh Faculty of Medicine, King Abdulaziz University, PO Box 80205, Jeddah 21589, Saudi Arabia, T: 966-553370470, F: 966-2-640-000000 loc. 20466, mbakarman@kau.edu.saJul-Aug 2015 35 4 288 292 Copyright © 2015, Annals of Saudi Medicine2015This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.BACKGROUND AND OBJECTIVE We compared the adequacy of the management of hemodialysis patients in different health sectors in a major city in Saudi Arabia. DESIGN AND SETTING Cross-sectional analytic study conducted in three different health sectors in Jeddah, Saudi Arabia. METHODS Data was collected from nine hemodialysis centers, which represent three sectors: Ministry of Health, governmental (but not health ministry) hospitals, and charity centers. A simple random sampling technique was employed for gathering data from the participating centers. Medical records were reviewed and all the relevant data were retrieved using a pre-designed form. RESULTS In the 587 subjects, hypertension, diabetes mellitus and an idiopathic etiology accounted for 85.3% of end-stage renal disease. Only 25.4% of the patients had a hemoglobin level of 110–120 g/L and 12.1% achieved target levels of ferritin and transferrin saturation. The percentage of patients meeting targeted levels of calcium (2.1–2.38 mmol/L), phosphorous (1.13–1.78 mmol/L) and albumin (≥40 g/L) were 54.2%, 38.7% and 23.5%, respectively. The variation between different health sectors was statistically significant (P<.001). Arteriovenous fistula was used for 84% of the patients and catheter for 15.7%. CONCLUSION The quality of healthcare for hemodialysis patients in Jeddah needs improvement to meet the recommendations of the Kidney Disease Outcomes Quality Initiative guidelines. ==== Body Chronic diseases have a huge impact on healthcare systems around the globe. In addition to causing pain, complications and decreased productivity, they affect the patient’s family and the whole community. These diseases are the major cause of death all over the world. Of the 57 million global deaths in 2008, 36 million (63%) were due to chronic diseases. Nearly, 80% of chronic disease deaths occur in low and middle-income countries.1–5 The incidence and prevalence rates of ESRD are increasing on a yearly basis as shown in Table 1.6–8 Around 78% of the total healthcare expenditures in the US are spent on the management of chronic diseases, but still their prevalence is increasing.3 What is the level of the quality of care? This is the most frequently asked question by healthcare decision makers, especially if the cost of the management of these diseases is high and they represent a serious threat to life. Of the many chronic diseases, we chose to study end-stage renal disease (ESRD), which is costly and life threatening. Expenditure on ESRD management is a major financial burden on the health system. For instance, it costs 6.3% of the entire Medicare budget in the US and 21% of the total national health insurance budget in Taiwan.6,9,10 The aim of this study was to compare the quality of care of hemodialysis patients in different healthcare sectors in Jeddah using clinical performance measures, which has not previously been done. We suspected that the quality of care was inadequate. SUBJECTS AND METHODS This was a cross-sectional study conducted on three different health sectors in Jeddah, Saudi Arabia. During the period of the study (1 Jan 2012 to 31 Dec 2012), there were 1681 hemodialysis patients in Jeddah, who represent 14.7% of the total hemodialysis patients of Saudi Arabia. The patients were located in 19 hemodialysis centers in Jeddah run by four different healthcare sectors (35.2% in Ministry Of Health [MOH] sector, 22.8% in governmental (non-MOH) hospitals, 16.6% in charity centers and 25.4% in the private sector). There are two hemodialysis centers in MOH hospitals, 4 centers in governmental (non-MOH) hospitals, 3 charity hemodialysis centers and 10 hemodialysis centers in private hospitals. The majority of hemodialysis patients (74.6%) were receiving healthcare management in the first three sectors,8 because these sectors provide healthcare services free of charge. Therefore, the quality of healthcare in these three sectors is more or less similar and is not affected by the economic status of the patients. Thus, these three sectors were selected to represent the study population. A simple random sampling technique was employed for gathering patient data from all the participating centers, which was done by one of the researchers to avoid selection bias. For each hemodialysis center, an alphabetical list of all adult hemodialysis patients (18 years old or more) was prepared. Patients were then randomly selected from the list (using random numbers generated by MS Excel 2007). The researchers used the In-Center Hemodialysis (HD) Clinical Performance Measures Data Collection Form 2007 as a data collection tool. This form was used by the Medicare Center in the US to collect data for the Clinical Performance Measures Project.9 This form was generated in 1998 by specialized committees sponsored by the Medicare Center. It was tested at 25 hemodialysis centers in the US and is revised on a yearly basis to ensure its validity and to modify it to comply with any update of the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines. 10 The form is used now by more than 3000 dialysis facilities in the US and has proved quite reliable.9 All the contents of the form can be applied in our society except for the section on variables that are specific to US patients. The race variable was not included because it is not applicable in Saudi Arabia. Medical files of all selected patients were accessed in coordination with the medical record departments in the hemodialysis centers, after which relevant data for the study was collected. The sample size of 587 hemodialysis patients was calculated using EpiInfo software version 3.5.3. In the calculation, the expected frequencies of the variables under study were set at 50% to get the largest possible sample size; the desired level of precision was set at 5%; the confidence level was 95% and the power was chosen to be 80%. The total number of hemodialysis patients in chosen centers was 1254 and the sample size was calculated for each center separately to ensure that it was representative for each center and could also be used for comparisons between hemodialysis centers. RESULTS The characteristics of our study group of 587 patients are shown in Table 2. More than two-thirds of the patients were Saudi (70.7%), and most were males (62.5%). Ages ranged widely in all health sectors, from 18 to 95 years old; the mean (SD) age was 50.8 (16) years. The most common causes of ESRD in our community were hypertension alone (30.7%) and hypertension with diabetes mellitus (DM) (30.7%), while 15% were idiopathic. DM alone (8.9%) was followed by systemic lupus erythematosus (4.4%) and the least common cause was glomerulonephritis (3.9%). The majority of patients (95.9%) had hemodialysis sessions three times per week and the mean (SD) duration of hemodialysis session was 208.2 (22.2) minutes, whereas the median was 3 hours and a half (210 minutes). Table 3 shows clinical performance measures for the whole study and for each health sector. The clinical performance measures used in this analysis were based on the KDOQI guidelines. The target level of hemoglobin (Hb) (110–120 g/L) (excluding patients with Hb>120g/L and not prescribed an erythropoietin-stimulating agent) was achieved only in one-fourth of the study groups (25.3%) and this result was almost the same in all health sectors with no statistical significant difference (X2=1.496, df=2 and P=.4733). A serum ferritin concentration ≥100μg/L and transferrin saturation ≥20 were documented only in 12.1% of the patients. However, patients in the MOH and charity health sectors achieved this target, whereas in the governmental (non-MOH) health sector only 29.8% of patients achieved this target (X2=100.1, df=2 and P<.001). About half of the patients (45.3%) had a mean serum calcium level of 2.1–2.38 mmol/L with the highest values in the governmental (non-MOH) sector (56.9%) followed by the charity sector (41.5%). These differences were statistically significant as shown by the chi-squared test (X2=19.55, df=2, P<.001). The mean serum phosphorous level (1.13–1.78mmol/L) was achieved only by 38.7% of the patients. The governmental (non-MOH) was highest (49.3%); the charity sector the lowest (35.9%). Table 3 also shows that about one-fourth (23.5%) of the patients had mean serum level of albumin ≥40 g/L. In the MOH sector, only 5.5% of patients had a mean serum level of albumin ≥40 g/L, whereas in the governmental (non-MOH) sector the percentage reached 48.4%, and only 14.2% in the charity sector. These differences were statistically significant (X2=129.3, df=2, P<.001). Arteriovenous fistula (AVF) appears to be the most common kind of vascular access used for hemodialysis patients (84%) followed by catheter (15.7%), (Table 4). Patients using a catheter ≥90 days represented 13.3% of the study population. DISCUSSION The incidence and prevalence of ESRD is rising alarmingly, not only in Saudi Arabia but also around the globe. In Saudi Arabia, the prevalence of DM and hypertension are increasing and the risk of ESRD is increasing day by day.11 Therefore, studies on the incidence and prevalence of ESRD are important for developing policies to avoid this catastrophic problem among the population of Saudi Arabia. In the present study the majority of the patients in all healthcare sectors were Saudis and were predominately male. Our results are consistent with the local data published by the Saudi Center for Organ Transplantation (SCOT) in 2010 taking into consideration that this study involves only adult hemodialysis patients.8 Moreover, it is also compatible with data published by ERA-EDTA Registry Annual Report (2012).12 Our results show a wide age range of patients from 18 to 95 years and the mean (SD) age of patients was 50.8 (16) years. This wide age range indicates that ESRD may occur at any age and is comparable with the Report of the SCOT in 2010.8 In our study, hypertension and diabetes mellitus were the major causes of ESRD, followed by an idiopathic etiology. This result is in agreement with the data published by SCOT in its Annual Report in 2010.8 Our study shows that only (50.94%) of patients have Hb ≥110 g/L, which means that almost half of the patients were anemic. In the US, most patients have Hb ≥110g/L (84%).9 On the clinical performance measure of anemia, the percentage of patients with an hemoglobin level between 110 and 120 g/L (excluding patients with Hb>120 g/L and not prescribed an erythropoiesis-stimulating agent) was only 25.3% and not statistically different among different health sectors. This figure was less than that recorded in Iran in 2008, which indicated that half of the patients had attained the normal hemoglobin target.13 In addition, this figure was 33% in the US.9 Among anemic patients or patients prescribed an erythropoiesis-stimulating agent with at least one documented ferritin ≥100 μg/L and transferrin saturation ≥20% during the study period), only 29.8% of patients in the governmental (non-MOH) sector achieved this target. In our whole study population only 12.1% patients achieved this target. Our results show fewer patients compared with a US study that reported that 82% of patients achieved this target.9 In the management of mineral metabolism, only 45.3% of patients attained the targeted calcium level. Furthermore, it was found that there was significant variation (P<.001) among the three health sectors: the governmental (non-MOH) sector exhibited the highest score (49.3%) followed by charity centers and the MOH sector. These results differ from a US study that reported 83% of patients achieved the target level of calcium.6 We found that only 38.7% of the patients attained the targeted level of phosphorous while a study in the US documented 52% of the patients.9 The inadequacy of anemia and mineral metabolism management can be related to a lack of written protocols and less availability of laboratory tests as shown in many studies conducted in Saudi Arabia.14–16 In our study, 84% of patients used AVF and 15.7% of patients used a catheter during their last hemodialysis session. These figures achieve the target of KDOQI guidelines for vascular access management, which recommend that AVF should be the primary access for at least 40% of patients undergoing hemodialysis. In comparison to the US, this figure is higher than in the American proportion (45%).9 In our study, 13.3% of patients dialyzed using a catheter for ≥90 days which is near the target in the KDOQI guidelines (≤10%). This figure is also better than the US (22%).9 Vascular access management was consistent with local figures published by SCOT.8 The quality of the care in all healthcare sectors (MOH, non-governmental MOH and charity) is not up to mark. The levels for most parameters are below the normal range, which needs serious attention and action from the concerned authorities. This would help to improve the care provided for several patients and help in saving their precious lives. CONCLUSION Our results indicate that in all three healthcare sectors the majority of patients did not reach the targeted levels for several parameters. The quality of healthcare for hemodialysis patients in Jeddah needs improvements to achieve the targeted levels of hemoglobin, calcium, phophorous and other parameters and to match the recommendations of the KDOQI guidelines. More research is needed to reveal the effect of achieving the targets of these parameters on morbidity, mortality, and quality of life and the cost of the management. A similar annual nationwide study will greatly benefit all hemodialysis centers in comparing their performance with national and regional figures. Table 1 Prevalence and incidence of end-stage renal disease in different countries. Incidence rate (per million population) Prevalence rate (per million population) Country 2006 2010 % change 2006 2010 % change Saudi Arabia 120 133 10.8 462 498 7.8 USA 355 369 3.9 1656 1870 12.9 UK 111 136 22.5 723 1039 43.7 Japan 271 288 6.3 1954 2260 13.5 Table 2 Characteristics of subjects. Characteristics All (n=587) No. (%) MOH (n=256) No. (%) Governmental (non MOH) (n=225) No. (%) Charity (n=106) No. (%) Nationality Saudi 415 (70.7%) 206 (80.5%) 208 (92.4%) 1 (0.9%) Non Saudi 172 (29.3%) 50 (19.5%) 17 (7.6%) 105 (99.1%) Gender Male 367 (62.5%) 173 (67.6%) 119 (52.9%) 75 (70.8%) Female 220 (37.5%) 83 (32.4%) 106 (47.1%) 31 (29.2%) Age in years Mean (SD) 50.8 (16) 46.97 (14.17) 57.09 (16.9) 46.7 (13.9) Median (range) 51 (18–95) 46.5 (18–82) 58 (18–95) 49.5 (18–77) Table 3 Clinical parameters for hemodialysis patients. Serum Level All centers (n=587) No. (%) MOH (n=256) No. (%) Gov. Non-MOH (n=225) No. (%) Charity (n=106) No. (%) P valuec Benchmark to USA Figures (%) Hb≥110g/L Yes 299 (50.9) 114 (44.5) 126 (56) 59 (55.7) .024 84 No 288 (49.1) 142 (55.5) 99 (44) 47 (44.3) Hb level (110–120g/L)a Yes 138 (25.3) 52 (22.7) 60 (27.6) 26 (26.3) .4733 33 No 407 (74.7) 177 (77.3) 157 (72.4) 73 (73.7) Ferritin level ≥100 μg/L& Transferrin Saturation ≥20%b Yes 61 (12.1) 0 (0) 61(29.6) 0 (0) .001 82 No 442 (87.9) 200 (100) 145 (70.4) 97 (100) Calcium (2.1–2.38 mmol/L) Yes 266 (45.3) 94 (36.7) 128 (56.9) 44 (41.5) .001 83 No 218 (54.2) 159 (62.1) 97 (43.1) 62 (58.5) Missing 3 (0.5) 3 (1.2) 0 (0%) 0 (0%) Phosphorus (1.13–1.78 mmol/L) Yes 227 (38.7) 78(30.5) 111 (49.3) 38 (35.9) .001 52 No 347 (59.1) 167 (65.2) 113 (50.2) 67 (63.2) Missing 13 (2.2) 11(4.3) 1 (0.4) 1 (0.9) Albumin ≥40 g/L Yes 138 (23.5) 14 (5.5) 109 (48.4) 15 (14.2) .001 34 No 449 (76.5) 242 (94.5) 116(51.6) 91 (85.8) AVF Yes 495 (84.3) 238 (93) 157 (69.8) 100 (94.3) .001 45 No 92 (15.7) 18 (7) 68 (30.2) 6 (5.7) Catheter used ≥90 days Yes 78 (13.3) 13 (5.1) 62 (27.6) 3 (2.8) .001 22 No 509 (86.7) 243 (94.9) 163 (72.4) 103 (97.2) AVF: arteriovenous fistula, ESA: erythropoietin-stimulating agent; a Excluding patients with Hb> 120g/L and not prescribed ESA (n=545); b Excluding patients with Hb ≥ 110g/L and not prescribed ESA (n=503); c Chi-square test Table 4 Types of vascular access. Types of Vascular Access All Sectors (n=587) No. (%) MOH (n=256) No. (%) Gov. Non-MOH (n=225) No. (%) Charity (n=106) No. (%) AVF 495 (84.3) 238 (93) 157 (69.8) 100 (94.3) Catheter 92 (15.7) 18 (7) 68 (30.2) 6 (5.7) Catheter Used ≥ 90 Days 78 (13.3) 13 (5.1) 62 (27.6) 3 (2.8) AVF should be > 90%, Catheter Used ≥ 90 Days not > 10%. ==== Refs REFERENCES 1 Alwan A Maclean DR Riley LM d’Espaignet ET Mathers CD Stevens GA Monitoring and surveillance of chronic non-communicable diseases: progress and capacity in high-burden countries Lancet 2010 376 9755 1861 8 21074258 2 Alwan A WorldHealth Organization Global status report on noncommunicable diseases 2010 Switzerland World Health Organization 2011 3 Anderson G Horvath J The growing burden of chronic disease in America Public Health Rep 2004 119 3 263 70 15158105 4 Stephen JM Maxine AP Current Medical Diagnosis & Treatment 2007 Forty-sixth ed 2007 5 Yach D Hawkes C Gould CL Hofman KJ The global burden of chronic diseases: overcoming impediments to prevention and control JAMA 2004 291 21 2616 22 15173153 6 Collins AJ Foley RN Chavers B Gilbertson D Herzog C Johansen K United States Renal Data System 2012 Annual Data Report: Atlas of chronic kidney disease & end-stage renal disease in the United States Am J Kidney Dis 2013 59 A7, e1 A7,420 7 Abboud O Incidence, prevalence, and treatment of end-stage renal disease in the Middle East Ethn Dis 2006 16 2 Suppl 2 S2 S4 8 Saudi Center of Organ Transplant Annual Report 2010 Saudi Center of Organ Transplant 2011 9 Centers for Medicare & Medicaid Services 2007 Annual Report, End-stage Renal Disease Clinical Performance Measures Project Department of Health and Human Services, Centers for Medicare & Medicaid Services, Office of Clinical Standards & Quality Baltimore, Maryland 2008 10 National Kidney Foundation K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification Am J Kidney Dis 2002 39 2 Suppl 1 S1 266 11904577 11 Al-Nozha MM Abdullah M Arafah MR Khalil MZ Khan MB Al-Mazrou YY Hypertension in Saudi Arabia Saudi Med J 2007 28 1 77 84 17206295 12 ERA-EDTA Registry ERA-EDTA Registry Annual Report 2010 Amsterdam, The Netherlands Academic MedicalCenter, Department of Medical Informatics 2012 13 Malekmakan L Haghpanah S Pakfetrat M Malekmakan A Alimanesh M Haghpanah A Dialysis adequacy and Kidney Disease Outcomes Quality Initiative goals achievement in an Iranian hemodialysis population Iran J Kidney Dis 2010 4 1 39 43 20081303 14 Souqiyyeh MZ Shaheen FA Attitude of Physicians toward the Use of Erythropoietin in Hemodialysis Patients Saudi J Kidney Dis Transpl 2005 16 3 298 305 17642796 15 Souqiyyeh MZ Shaheen FA Attitude of Physicians toward the iron supplementation in hemodialysis patients treated with erythropoietin Saudi J Kidney Dis Transpl 2003 14 2 134 144 18209438 16 Souqiyyeh MZ Shaheen FA Attitude of Physicians toward the management of Bone Disease Hemodialysis Patients: A Questionnaire Base Survey Saudi J Kidney Dis Transpl 2006 17 1 10 18 17297531