Selecting patients when resources are limited: a study of US medical directors of kidney dialysis and transplantation facilities

This study reports and discusses responses of 453 medical directors of renal dialysis and transplantation facilities to detailed patient selection questionnaires. The questionnaires examine selection criteria being used today as well as those which would be employed were resources to remain or become scarce relative to need. Selection criteria examined (and the number of directors supporting them when resources are limited) are: qualitative prognosis, psychological stability, likelihood of medical benefit, quantitative prognosis, medical benefit (virtually all); willingness, age (very large majority); unique moral duties, disproportionate resources, environment, progress of science, social value (majority); ability to pay, random selection, constituency (very large minority); sex (virtually none). Qualitative prognosis, quantitative prognosis, medical benefit, ability to pay, and especially age are the criteria employed today whose influence would increase if resources are further limited. Some of the ethical implications of various criteria are discussed.

A simulation model for planning services for renal patients in Europe

A discrete-event simulation model is being developed to provide information for national and regional health planners about the effect of different treatment policies and practices on the increasing numbers of patients with irreversible kidney failure. The simulation program, written in Pascal using Pascal-SIM, describes the activities of individual patients whose progress through treatment depends on their characteristics and treatment history, as well as on treatments availability. Programming techniques have been developed to cope with the multiple scheduling of patient entities and the resultant queue-management problems. In order to provide simulation runs on request, for any population group, appropriate data is selected from the European Dialysis and Transplant Association Registry data base for use in the simulation program. Results are shown on a computer screen while the simulation is running, and are saved for further analysis to provide feedback to the requesting organization.

An assessment of models of a health system

A variety of stochastic and deterministic non-optimizing techniques have been used both predictively and for comparing policy options for patient treatment. Models of the system of the treatment of kidney patients are reviewed and are shown to be based on too small a subsystem to be useful for planning and budgeting. Other drawbacks include poor user-credibility and lack of robustness. Discrete-event simulation is shown to be the most appropriate technique which does not limit the type of distribution functions that may be used and can model patient attributes, resource use and constraints.

How available are evening dialysis services?

The availability of evening dialysis is considered important if the patient with renal failure is to return to work. Dialysis units are categorized by location and whether or not dialysis services are offered in the evening. The location of dialysis patients is compared with these estimates to determine the percentage of patients having access to evening dialysis either in their own dialysis units or in a unit in their market area. A very large proportion of patients in the working age groups are likely to have access to evening dialysis both in their own market area and in their own dialysis unit.

Deaths from chronic renal failure under the age of 50. Medical Services Study Group of the Royal College of Physicians

From a survey of the West Midlands and Mersey Regions and the Grampian Health Board, we found that in 1978 and 1979 some 122 patients with chronic renal failure died in hospital under the age of 50. Of these, 69 had been given dialysis or transplantation, or both, while for many reasons the remainder had been considered unsuitable. While the criteria varied, the reasons given for non-acceptance of cases seemed sound, and in no instance during this particular period was a patient denied dialysis because of a shortage of machines. We think that the public should be aware of these findings and not led to think that if only enough dialysis machines were available death from renal failure would be a rarity.

St. Francis Hospital, Honolulu. Comprehensive renal disease program crosses geographic boundaries

Six satellite facilities affiliated with one hospital enable distant residents and visitors to receive dialysis treatment. Patients may opt for self-care, assisted care, or transplantation, and receive psychological, pastoral, nutrition, and rehabilitation services.

Maintenance dialysis and renal transplantation facilities in South Africa--1977

A survey undertaken in July 1977 revealed that 27 hospital centres were treating 307 patients with chronic renal failure by maintenance haemodialysis and 22 patients by chronic peritoneal dialysis. An additional 28 patients were receiving home dialysis. Seven of the centres had transplantation programmes and were treating 271 survivors with functioning renal homografts.

Distribution of nephrological services for adults in Great Britain. Report of the Executive Committee of the Renal Association

A survey was performed to find out how many doctors in Great Britain were providing nephrological services. The number of such doctors in each region correlated closely with the size of population, but the relation between the numbers of sessions they provided and the size of population, though significant, was not nearly so close. The number of sessions provided correlated strongly with both the number of patients on dialysis and the number of outpatients seen each week. These findings indicated that nephrological services were unevenly distributed throughout the country, while patients with renal diseases are probably evenly distributed. Even in the regions providing the most sessions demand still exceeds supply. In Britain only 62-0 patients per million population were being treated for terminal renal failure at 31 December 1975, whereas over twice that number were being treated in Switzerland (136-1 per million) and Denmark (132-4 per million). Despite the deficiencies in the service, doctors attempt to see all patients with a renal disorder at least once and to treat acute renal failure, though many patients cannot be followed up.

[A fourth possibility treating chronical uremic patients: the satellite dialysis station (author's transl)]

It is possible to reduce the lack of dialysis places by establishing so-called satellite-dialysis-stations. Carrying out the normal dialysis treatment the satellite-station shows certain advantages in comparison to the dialysis center. There are presented the results of 21 patients in a satellite-dialysis-station. On average the systolic blood pressure before dialysis was 132,1 +/- 17,7 mm Hg, the diastolic blood pressure 83,5 +/- 14,9 mm Hg, serum creatinin 9,9 +/- 1,5 mg/100ml, hemoglobin 12,4 +/- 3,2 g/100 ml and the hematocrit 34,4 +/- 5,3%. 16 patients are still working. During the first 12 months of treatment in the satellite-dialysis-station the hematocrit of the patiens was raised on average by 6,4%. Concerning the results of the therapeutic and psychic situation of the patients the satellite-dialysis-station is comparable to the home dialysis treatment.

Long-term intermittent haemodialysis in Egypt

The pattern of mortalities from genitourinary diseases in Egypt was analysed from recent official figures. On the basis of certain assumptions concerning etiology, age, and geographical distribution, it was estimated that 37.7 per million of the general population would benefit from regular dialysis treatment, though the facilities available will permit only 5% of these subjects to receive treatment in 1975. As other diseases and conditions are much more prevalent, no great relative increase in dialysis facilities in Egypt is anticipated in the near future. A computer-controlled plan is suggested for organizing regular dialysis treatment at the national level to ensure an appropriate choice of medically suitable subjects of highest value to the community. Means of reducing the need for dialysis by minimizing the incidence of terminal chronic renal failure and of making best use of the available facilities are discussed.