This is an abbreviated version of a full blog post on the KidneySolutions blog page.
For a detailed review of the topic go to http://kidneysolutions./2013/12/16/quality-and-clinical-performance-measures-in-kidney-disease-and-dialysis-care-in-nigeria/
For more information on Kidney disease, you can also visit the KidneySolutions website at http://www.kidney-solutions.com/ or the KidneySolutions YouTube page for lots of educational information. You can also send email to- [email]info@kidney-solutions.com[/email]

Summary: There is a growing epidemic of kidney disease and kidney failure happening in Nigeria. Lots of lives and resources are being spent by individuals to get the best care they need but many are taking advantage of the difficult circumstances of patients and offering care that is far below standards. What should patients, doctors, health insurance providers and the government expect from providers of such care? This post tries to provide some insights.


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.

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. 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. 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 very important to know that most cases of kidney disease can be prevented with much less cost impact if efforts are made to regularly visit a doctor at least once a year to improve abnormalities such as high blood sugar, high blood pressure - the most common causes of kidney failure in Nigeria.

An important question for any reader of this post 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 health insurance provider 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.

For example

- 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 or government while also interested in outcomes of death and quality of life would also focus on quality and performance standards that require governmental oversight or incentives.
- A health insurance provider 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. Health insurance providers 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.

Let us 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.

The Structure of kidney care services refers to the components of the healthcare system. It is important that any kidney care center has the proper structures in place to deliver high quality care. Aspects of the structure of care for a kidney disease center should include-

- Adequacy of equipment and resources both for routine and emergency diagnosis and treatment of kidney diseases
- Administrative and organizational features of a clinic to efficiently mobilize resources for patient care. For example
What is the pre-treatment triage for dialysis patients to determine the best environment for care. Some dialysis patients who are critically ill are best cared for in an intensive care unit, while others who are more stable can be cared for in an outpatient center. Care in an intensive care unit is more expensive but only because more complicated cases are dealt with there.
- Dialysis machine/water treatment system operation and disinfection protocols to ensure safe and timely delivery of treatment. This is probably one of the most important issues because many patients have compounded problems when they are exposed to hundreds of liters of water for dialysis that is not ultra-pure.
- Systems to ensure patient education. Patients should be educated on what to do at the earliest signs of kidney disease when kidney disease is easier and cheaper to deal with and not ignored till it is too late and requires more expensive treatment such a dialysis or transplantation.
- 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. In this regard, national bodies such as the Medical and dental council of Nigeria with recommendations from the Nigerian Association of Nephrology should ensure that every registered kidney disease and dialysis center meets standards for quality. Professionals that know something about kidney disease and dialysis care should be on monitoring and approval teams to ensure that mediocre centers are not permitted to operate.

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 or 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, blood glucose and anemia control. All patients should be able to ask their doctor about the quality of control of these parameters. Health insurance providers should also have confidence that centers are keeping these parameters under 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. Many patients need to know that at every treatment, they need to achieve a urea reduction ratio (URR) of at least 65% or what is called a Kt/V of 1.2. 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, centers 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 dialysis nurse to make adjustments in real-time to achieve this goal with every treatment.

- 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. As Nigerian we should demand highest quality of care and encourage those who provide such and punish centers that provide poor quality care. 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

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