Scientific Justification of Organizational Measures for Improving Dialysis Care for the Population

The dissertation is devoted to the problem of improving the organization of dialysis care for the population at the level of administrative-territorial entities. The research is based on a comprehensive socio-hygienic analysis of the state of the renal replacement therapy service, within the framework of which the factors influencing the functioning and development of hemodialysis services, as well as the morbidity dynamics of chronic kidney disease, were studied. The work was carried out on the materials of the hemodialysis department of City Clinical Hospital No. 1 in Tolyatti.

During the research, an analysis of the dialysis center's work for 2001–2003 was conducted, the treatment outcomes of patients with terminal renal failure by hemodialysis were evaluated, and the economic aspects of the renal replacement therapy service, including the cost of the hemodialysis procedure, were determined. It was established that the population's access to dialysis therapy in the Russian Federation is significantly below the average world level, and the structure of diseases leading to chronic kidney disease in the Samara Oblast differs from the generally accepted global practice. Based on the obtained data, a system of organizational measures for improving dialysis care for patients was developed and an optimal model of a dialysis center was created.

Relevance of the Topic. At present, there is a universal increase in the morbidity of the population. This entails an increase in disability and mortality, which in turn affects the growth of expenditures on medical and social needs and enormous economic losses due to the reduction of the labor potential of society. The prevalence of diseases of the genitourinary system among disease classes in the Russian Federation amounts to 12%. At the same time, a high rate of disability among patients is noted, with 95% of them being of working age [7, 15].

One of the most prevalent pathologies of the genitourinary system is chronic kidney disease. At its terminal stage, patients require renal replacement therapy, of which up to 90% is hemodialysis [11, 40, 75, 93, 110, 130, 141, 142, 143, 144, 147, 151, 153].

The problem of ensuring the population's access to renal replacement therapy is one of the key issues in the modern healthcare system. The resolution of this issue determines the quality of medical care as a whole. Positive trends can be observed in the activities of the domestic renal replacement therapy service in recent years; however, these changes are clearly insufficient for adequate coverage of the population's needs [16, 20, 21, 23, 27, 28, 31, 32].

The growth of hemodialysis care significantly lags behind the growth of the population's need for renal replacement therapy. The main reasons for this include both underfunding of the renal replacement therapy service at the national level and the irrational expenditure of allocated funds, due to the absence of a unified program for calculating the cost of specific types of renal replacement therapy and, in particular, hemodialysis care [12, 15, 26, 28].

Despite an increase in the number of hemodialysis positions in recent years, the population's access to renal replacement therapy has improved only marginally [32]. The overall increase in population morbidity and, consequently, the growth in the number of individuals with kidney diseases leads to an increase in the number of patients with terminal-stage chronic kidney disease who require renal replacement therapy [16, 20, 21, 23, 27, 28, 31, 32].

The actual access to such treatment, according to data from the Russian Dialysis Society (1998), is 38.3 per 1 million inhabitants. Meanwhile, the average world indicator of population access to dialysis is 175 per 1 million inhabitants. At the same time, an annual increase of 7–9% in the number of individuals requiring replacement therapy is reported [74, 83, 87, 94, 114, 132, 139, 141, 142, 143, 144, 145, 152, 153].

In the Russian Federation and, in particular, in the Samara Oblast, the composition of hemodialysis patients differs significantly from the global practice regarding the primary nosology leading to chronic kidney disease. According to data from national registers of economically developed countries in Europe, the United States, Australia, and Japan, up to 50% of patients with terminal-stage chronic kidney disease are patients with diabetes mellitus [70, 76, 91, 112, 120, 124, 153, 154, 155]. In the Samara Oblast, hemodialysis patients with diabetes mellitus constitute less than 10% of the total population of such patients.

All of this attests to the relevance of the scientific investigation of the problem of dialysis care for the population, primarily at the level of administrative-territorial entities. The necessity of such an approach is dictated by the socio-economic characteristics of the region, the population size, and the established level of disease prevalence.

Research Objective. Based on a comprehensive socio-hygienic investigation, to develop and scientifically substantiate a system of organizational measures for improving hemodialysis care for the population.

To achieve this objective, the following tasks were set:

1. To study and evaluate the factors influencing the state, functioning, and development of the renal replacement therapy service.

2. To study the dynamics of the number of patients and the structure of diseases leading to the development of chronic kidney disease.

3. To conduct an analysis of the dialysis center's work for 2001–2003.

4. To determine the main economic aspects of the renal replacement therapy service.

5. To develop a system of organizational measures for improving dialysis care for patients.

The object of the research is the hemodialysis department of City Clinical Hospital No. 1 in Tolyatti, as part of the overall renal replacement therapy system within the healthcare structure, concentrating all major problems of recent years. The subject of the research is the organization of the renal replacement therapy service in the hemodialysis department of City Clinical Hospital No. 1 in Tolyatti. In addition, regulatory documents of the Government of the Russian Federation, the Ministry of Health of the Russian Federation, and reporting statistical materials of medical and preventive institutions of the Samara Oblast were studied. The following methods were used in the research: historical, logical, cybernetic, sociological, and economic-mathematical.

Scientific novelty of the research lies in the fact that for the first time:

— a comprehensive analysis of the state of the renal replacement therapy service was conducted and factors influencing its state and development were evaluated;

— a patient registration system for those potentially requiring renal replacement therapy was developed;

— the cost and full cost of dialysis service for a patient with chronic kidney disease over the full course of treatment, calculated per calendar year, was determined;

— a comprehensive system of organizational measures for improving dialysis care for patients was proposed.

— an optimal model of a dialysis center for serving the population of an administrative-territorial entity was created.

Practical significance of the research and implementation of the results. The results of the dissertation work were used in the development of the "Program for the Development of Hemodialysis Care for the Population of Tolyatti for 2001–2003," considered by the Tolyatti Department of Health in 2001. By decision of the City Department of Health, the emergency medical service was entrusted with the responsibility of transporting hemodialysis patients and, if necessary, their accompanying persons from home to dialysis and back. On the basis of the analysis of sociological research materials, additional rooms and equipment were allocated to enhance the comfort and safety of receiving hemodialysis therapy. A medical psychologist was introduced into the staff of employees. The department was computerized.

The research materials are used in the educational process of the Department of Public Health and Healthcare of the Samara State Medical University and the Department of Public Health and Healthcare of the Institute of Advanced Education of the Samara State Medical University.

Provisions for defense:

1. The main patterns of the disease structure in the dialysis patient population with terminal-stage chronic kidney disease.

2. The methodology for calculating the cost of a hemodialysis service.

3. A system of comprehensive measures for improving hemodialysis care for patients.

Author's personal contribution to the conducted research.

The author independently collected the necessary research material and determined the methods required for its processing; conducted an analytical review of foreign and domestic literature on the studied problem (personal participation share 100%).

Jointly with the medical psychologist of the hemodialysis department, a sociological questionnaire was developed to study the problem of hemodialysis care, and a sociological investigation was conducted with subsequent processing of the obtained information (personal participation share 90%).

The dynamics of the number of patients and the structure of diseases leading to the development of chronic kidney disease were studied. An analysis of the hemodialysis center's work over time was conducted; the unit cost and full cost of the comprehensive dialysis care service for patients, and the cost and full cost of dialysis service for a patient with chronic kidney disease over the full course of treatment, calculated per calendar year, were determined.

Presentation of the research results.

The main provisions of the dissertation were reported at: the collegium of the Tolyatti Department of Health (2001); annual All-Russian nephrology conferences in Saint Petersburg (2001–2004); annual international conferences "Nephrology and Hemodialysis" in Moscow (2001–2004); the All-Russian Scientific and Practical Conference in Novosibirsk (2002); the jubilee scientific and practical conference dedicated to the 25th anniversary of the neurological department of City Clinical Hospital No. 1 in Tolyatti in Tolyatti (2002); the Fourth International Scientific and Practical Conference "Health and Education in the 21st Century" in Moscow (2003); the scientific and practical conference dedicated to the 40th anniversary of the urological service of Tolyatti (2003); the jubilee scientific and practical conference of May 20–21, 2004, in Tolyatti (2004).

Publications: The main provisions of the dissertation work are presented in 9 printed works.

Structure and volume of the work: The dissertation is set out on 198 pages of typescript and consists of an introduction, 6 chapters, a conclusion, findings, practical recommendations, 14 appendices, a list of references including 38 domestic and 163 foreign sources. The work is illustrated with 12 tables and 4 figures.