Non-medical facilitators and barriers towards accessing haemodialysis services: an exploration of ethical challenges

Dynamic measurements of geographical accessibility considering traffic congestion using open data: a cross-sectional assessment for haemodialysis services in Cali, Colombia

Background

Many cities with traffic congestion lack accessibility assessments accounting for traffic congestion and equity considerations but have disaggregated georeferenced municipal-level open data on health services, populations, and travel times big data. We convened a multistakeholder intersectoral collaborative group that developed a digital, web-based platform integrating open and big data to derive dynamic spatial-temporal accessibility measurements (DSTAM) for haemodialysis services. We worked with stakeholders and data scientists and considered people's places of residence, service locations, and travel time to the service with the shortest travel time. Additionally, we predicted the impacts of strategically introducing haemodialysis services where they optimise accessibility.

Methods

Cross-sectional analyses of DSTAM, accounting for traffic congestion, were conducted using a web-based platform. This platform integrated traffic analysis zones, public census and health services datasets, and Google Distance Matrix API travel-time data. Predictive and prescriptive analytics identified optimal locations for new haemodialysis services and estimated improvements. Primary outcomes included the percentage of residents within a 20-min car drive of a haemodialysis service during peak and free-flow traffic congestion. Secondary outcomes focused on optimal locations to maximise accessibility with new services and potential improvements. Findings were disaggregated by sociodemographic characteristics, providing an equity perspective. The study in Cali, Colombia, used geographic and disaggregated sociodemographic data from the adjusted 2018 Colombian census. Predicted travel times were obtained for two weeks in 2020.

Findings

There were substantial traffic variations. Congestion reduced accessibility, especially among marginalised groups. For 6-12 July, free-flow and peak-traffic accessibility rates were 95.2% and 45.0%, respectively. For 23-29 November, free-flow and peak traffic accessibility rates were 89.1% and 69.7%. The locations where new services would optimise accessibility had slight variation and would notably enhance accessibility and health equity.

Interpretation

Establishing haemodialysis services in targeted areas has significant potential benefits. By increasing accessibility, it would enhance urban health and equity.

Funding

No external or institutional funding was received.

Privatization and Oligopolies of the Renal Replacement Therapy Sector on Contemporary Capitalism: A Systematic Review and the Brazilian Scenario

Worldwide the assistance on renal replacement therapy (RRT) is carried out mainly by private for-profit services and in a market with increase in mergers and acquisitions. The aim of this study was to conduct an integrative systematic review on privatization and oligopolies in the RRT sector in the context of contemporary capitalism. The inclusion criteria were scientific articles without language restrictions and that addressed the themes of oligopoly or privatization of RRT market. Studies published before 1990 were excluded. The exploratory search for publications was carried out on February 13, 2024 on the Virtual Health Library Regional Portal (VHL). Using the step-by-step of PRISMA flowchart, 34 articles were retrieved, of which 31 addressed the RRT sector in the United States and 26 compared for-profit dialysis units or those belonging to large organizations with non-profit or public ones. The main effects of privatization and oligopolies, evaluated by the studies, were: mortality, hospitalization, use of peritoneal dialysis and registration for kidney transplantation. When considering these outcomes, 19 (73%) articles showed worse results in private units or those belonging to large organizations, six (23%) studies were in favor of privatization or oligopolies and one study was neutral (4%). In summary, most of the articles included in this systematic review showed deleterious effects of oligopolization and privatization of the RRT sector on the patients served. Possible explanations for this result could be the presence of conflicts of interest in the RRT sector and the lack of incentive to implement the chronic kidney disease care line. The predominance of articles from a single nation may suggest that few countries have transparent mechanisms to monitor the quality of care and outcomes of patients on chronic dialysis.

Defining ethical challenge(s) in healthcare research: a rapid review

BACKGROUND

Despite its ubiquity in academic research, the phrase 'ethical challenge(s)' appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of 'ethical challenge(s)' and closely related terms as used in current healthcare research literature.

METHODS

Rapid review to identify peer-reviewed reports examining 'ethical challenge(s)' in any context, extracting data on definitions of 'ethical challenge(s)' in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher's Index, EMBASE, CINAHL) were searched from April 2016 to April 2021.

RESULTS

393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of 'ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to 'ethical challenge(s)' within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study.

CONCLUSIONS

Only 12/72 studies contained an explicit definition of 'ethical challenge(s)', with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.

The effect of the humanistic care teaching model on nurse patient conflict and nurse turnover intention in a pediatric outpatient department: results of a randomized trial

BACKGROUND

This study was carried out based on the background that sharp nurse-patient conflicts in the pediatric outpatient department lead to a high turnover rate of nurses.

METHODS

A total of 68 nurses working in the pediatric outpatient department of Xiangyang No. 1 People's Hospital were selected as the study subjects, and randomly divided into an experimental group (n=34) and a control group (n=34). Nurses in the control group received a traditional pediatric nursing teaching model, while those in the experimental group received a traditional pediatric nursing teaching model combined with the humanistic care teaching model. The effect of these two nursing teaching models on nurse-patient conflicts in the pediatric outpatient department and the turnover intention of nurses was then compared and analyzed.

RESULTS

There were no significant differences in personal information between the two groups (P>0.05). The strain capacity, operational capacity, nurse-patient communication skills, autonomous learning ability, and teamwork ability of the nurses in the experimental group after training were significantly higher than those in the control group (P<0.05). Both groups after training had significantly higher scores on a professional identity scale than before training, and nurses in the experimental group had significantly higher scores of professional identity than those in the control group (P<0.001). The turnover intention of the nurses in the experimental group were significantly lower than those in the control group (P<0.001). The problem solving ability of nurses in the experimental group was significantly better than that in the control group (P<0.001). Scores in the domains of waiting to see the doctor, the health knowledge education, the ward environment, and nursing quality of nurses in `the experimental group were significantly higher than those in the control group (P<0.001).

CONCLUSIONS

The humanistic care teaching model can significantly improve the professional identity and problem solving ability of nurses in facing different nurse-patient conflicts with significant effect and is worthy of application and popularization in clinical nursing teaching.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100048751.

Renal staffs' understanding of patients' experiences of transition from peritoneal dialysis to in-centre haemodialysis and their views on service improvement: A multi-site qualitative study in England and Australia

INTRODUCTION

Many studies have explored patients' experiences of dialysis and other treatments for kidney failure. This is the first qualitative multi-site international study of how staff perceive the process of a patient's transition from peritoneal dialysis to in-centre haemodialysis. Current literature suggests that transitions are poorly coordinated and may result in increased patient morbidity and mortality. This study aimed to understand staff perspectives of transition and to identify areas where clinical practice could be improved.

METHODS

Sixty-one participants (24 UK and 37 Australia), representing a cross-section of kidney care staff, took part in seven focus groups and sixteen interviews. Data were analysed inductively and findings were synthesised across the two countries.

RESULTS

For staff, good clinical practice included: effective communication with patients, well planned care pathways and continuity of care. However, staff felt that how they communicated with patients about the treatment journey could be improved. Staff worried they inadvertently made patients fear haemodialysis when trying to explain to them why going onto peritoneal dialysis first is a good option. Despite staff efforts to make transitions smooth, good continuity of care between modalities was only reported in some of the Australian hospitals where, unlike the UK, patients kept the same consultant. Timely access to an appropriate service, such as a psychologist or social worker, was not always available when staff felt it would be beneficial for the patient. Staff were aware of a disparity in access to kidney care and other healthcare professional services between some patient groups, especially those living in remote areas. This was often put down to the lack of funding and capacity within each hospital.

CONCLUSIONS

This research found that continuity of care between modalities was valued by staff but did not always happen. It also highlighted a number of areas for consideration when developing ways to improve care and provide appropriate support to patients as they transition from peritoneal dialysis to in-centre haemodialysis.

Ethical Challenges in Dialysis and Transplantation: Perspectives From the Developing World

Renal replacement therapies including dialysis and transplantation for patients with end-stage kidney failure are treatment options beyond the reach of a large segment of the population, particularly in resource-constrained settings. Health care professionals practicing within developing countries face unique ethical issues in the provision of these treatment options despite the existence of free treatment at different centers. Apart from issues of accessibility of dialysis services, initiation of treatment can have disastrous consequences for the entire family unit, which is magnified in collectivist societies. Several cost-cutting measures also may have to be used that raise moral dilemmas for physicians. Although transplantation is considered the most cost-effective solution in developing countries, leading to significantly better quality of life, issues of consent from biologically related living donors and the use of marginal donors may place physicians in a quandary. Policy making in developing countries must consider the socioeconomic implications of treatment choices that extend far beyond the treatment cost.

Impact of virtual reality interventions on haemodialysis patients: A scoping review

BACKGROUND

An understanding of the potential of virtual reality to affect the level of engagement in self-care and health-related quality of life is required for patients receiving haemodialysis.

OBJECTIVE

This scoping review aimed to collate, summarise, and report on related study findings to identify evidence gaps and draw conclusions from the existing literature.

METHODS

The methodological steps outlined in the Arksey and O'Malley framework combined with modifications of Levac and colleagues guided this systematic scoping review. MEDLINEComplete, Embase, CINAHLComplete and PsychINFO databases were searched. Additionally, hand searches of key articles and journals were performed.

RESULTS

From the database searches, 610 studies were identified with 11 meeting the inclusion criteria; another study was added after searching reference lists of included articles, resulting in 12 included articles. The quality, study design and type of virtual reality intervention varied. Only three studies used immersive virtual reality. Several studies demonstrated significant improvement in the physical activity level and a reduction in fatigue in patients during haemodialysis, with no adverse events. Despite the demands of haemodialysis sessions, this study showed that virtual reality interventions may improve the level of haemodialysis patients' adherence and engagement with treatment.

CONCLUSIONS

Findings favour the use of virtual reality to improve physical health and engagement with treatment. However, there is a need for more rigorous study designs within different clinical settings to provide high-quality evidence regarding other ways that virtual reality interventions could improve the quality of life of haemodialysis patients.

Patients' and caregivers' perspectives on access to kidney replacement therapy in rural communities: systematic review of qualitative studies

OBJECTIVE

Patients with chronic kidney disease (CKD) requiring kidney replacement therapy (KRT) in rural communities encounter many barriers in accessing equitable care and have worse outcomes compared with patients in urban areas. This study aims to describe the perspectives of patients and caregivers on access to KRT in rural communities to inform strategies to maximise access to quality care, and thereby reduce disadvantage, inequity and improve health outcomes.

SETTING

18 studies (n=593 participants) conducted across eight countries (Australia, Canada, the UK, New Zealand, Ghana, the USA, Tanzania and India).

RESULTS

We identified five themes: uncertainty in navigating healthcare services (with subthemes of struggling to absorb information, without familiarity and exposure to options, grieving former roles and yearning for cultural safety); fearing separation from family and home (anguish of homesickness, unable to fulfil family roles and preserving sense of belonging in community); intense burden of travel and cost (poverty of time, exposure to risks and hazards, and taking a financial toll); making life-changing sacrifices; guilt and worry in receiving care (shame in taking resources from others, harbouring concerns for living donor, and coping and managing in isolation).

CONCLUSION

Patients with CKD in rural areas face profound and inequitable challenges of displacement, financial burden and separation from family in accessing KRT, which can have severe consequences on their well-being and outcomes. Strategies are needed to improve access and reduce the burden of obtaining appropriate KRT in rural communities.

Developing nephrology services in low income countries: a case of Tanzania

BACKGROUND

The burden of kidney diseases is reported to be higher in lower- and middle-income countries as compared to developed countries, and countries in sub-Saharan Africa are reported to be most affected. Health systems in most sub-Sahara African countries have limited capacity in the form of trained and skilled health care providers, diagnostic support, equipment and policies to provide nephrology services. Several initiatives have been implemented to support establishment of these services.

METHODS

This is a situation analysis to examine the nephrology services in Tanzania. It was conducted by interviewing key personnel in institutions providing nephrology services aiming at describing available services and international collaborators supporting nephrology services.

RESULTS

Tanzania is a low-income country in Sub-Saharan Africa with a population of more than 55 million that has seen remarkable improvement in the provision of nephrology services and these include increase in the number of nephrologists to 14 in 2018 from one in 2006, increase in number of dialysis units from one unit (0.03 unit per million) before 2007 to 28 units (0.5 units per million) in 2018 and improved diagnostic services with introduction of nephropathology services. Government of Tanzania has been providing kidney transplantation services by funding referral of donor and recipients abroad and has now introduced local transplantation services in two hospitals. There have been strong international collaborators who have supported nephrology services and establishment of nephrology training in Tanzania.

CONCLUSION

Tanzania has seen remarkable achievement in provision of nephrology services and provides an interesting model to be used in supporting nephrology services in low income countries.