Sunulan Bildiriler
Presented Proceedings
ANALYZING CHRONIC KIDNEY DISEASE(CKD) TREATMENT AT
THE CENTER OF BINGÖL
Bingöl İl Merkezinde Kronik Böbrek Hastalığının Tedavisinin İncelenmesi
Imran Aslan1, Hamide Değer2
Treatment of Chronic Kidney Diseases(CKD) a major problem in Bingöl as in Turkey are analyzed in
Bingöl city/Turkey. Increasing numbers of CKFs cause dissatisfaction and extra load on healthcare staff in
Bingöl city. Two main hospitals in Bingöl giving dialysis services were observed and responsible staff and
patients were interview. Kidney Disease and Quality of Life–Short Form (KDQOL-SF 36) survey used to
measure health related quality of life was applied to 96 patients to compare their performance and find problems
at the beginning of 2015 by descriptive statistics and ANOVA as well as compared with past studies done in
that topic. Patients at private hospital have average 5.06 years Hemodialysis (HD) treatment and patients at
government hospital have average 4.34 years HD treatment until beginning of 2015. The daily water
consumptions of patients at private hospital and government hospital are 1.57 glasses and 5.18 glasses
respectively. About 50% of all patients in both hospitals have diabetes illnesses. Tension with 18 patients at
private hospital and 23 patients at government hospitals is the main cause of CKD. The satisfaction and life
quality of patients at private hospital is better than government hospital in overall.
Key Words: Chronic Kidney Diseases (CKD), KDQOL-SF 36 , Bingöl City
INTRODUCTION
The quality of health services is the core for development of regions to make the region more
attractive and a hub for healthcare tourism. In this study, one of the serious illness named as CKD is
analyzed city wide and how the quality of treatments can be increased is determined based on
analyzing two hospitals and determining the information needs of patients and their main problems.
The private hospital having 40 patients provides high service by transporting patients with its own
cars, providing comfortable beds, and nurses’ services. However, the government hospital has a
dialysis center at the basement of hospital and at where 55 patients are treated. Just HD treatment is
provided at Bingöl city located in the East of Turkey and having about 100 thousands population at
city centre and about 270 thousands population at overall. At the beginning of 2015, almost all patients
were treated at city centre by these two hospitals by free transportation of some patients to hospitals
and almost all treatment costs are supported by governments. Health Green Cards holder can be
treated just by government hospital. However, three districts named Solahan, Genç and Karliova
have about totally 50 CKD patients treated at their new opened HD centers.
According to OECD Health Data 2011, Japan and USA have the highest rate of CKD per
100.000 populations. OECD countries mean is 65.2 and Turkey has 74.7 per 100.000 populations. It
shows that Turkey is in a good position but when it is compared with Iceland, Finland and Netherlands
developed countries, Turkey has too many CKD patients. (OECD, 2011) In Turkey, it is found that
the number of CKDs will increase in the future and it is estimated that 4,484,630,000 $ will be spent
for 2021-2022 years to treat last stage of CKD. (Aslan & Özen, 2013) When there are between 50-79
patients per centre, the cost per séance is 181.6 TL and when the number patients increase, the cost
decreases per CKD. ( Tatar, 2011) There are about patients 186 CKD patients in the Bingöl city with
69 patients from city center. (SB,2014)
1 Assist.Prof., Business Administration,Bingöl University, imranaslan@gmail.com, iaslan@bingol.edu.tr
2 Res. Assistant, Public Management Department, Bingöl University, hedger@bingol.edu.tr
LITERATURE BACKGROUND
Kidneys clean the blood, remove urine, keep minerals in equilibrium, control blood pressure
and produce D vitamin. CKD can be due to diabetes mellitus, high blood pressure and chronic
glomerulonephritis. Moreover, the kidneys remove excess water, and help to control blood pressure
and red blood cell manufacturing and to keep the bones strong and healthy. Good blood control
pressure can delay the further stages of CKD. High blood pressure can cause CKF and vice versa.
Moreover, anaemia and renal bone disease are developed when patients take HD. (Stein &Wild, 2002;
MY, 2003) Each stage of CKD may have some symptoms such as loss of appetite, nausea and/or
vomiting, headaches, fatigue, little or no urine, muscle cramps, changes in skin color, increased skin
pigmentation etc. (KC,2013 ). There are six types of treatments for end stage renal disease (ESRD):
Hemodialysis (HD) - twith three types named as Home Hemodialysis-HHD, Limited Care
Hemodialysis-LCHD, and Full Care Centre Hemodialysis-CHD , Kidney Transplantation (TX), and
Peritoneal Dialysis (PD) with two types Continuous Ambulatory Peritoneal Dialysis—CAPD and
Continuous Cycling Peritoneal Dialysis-CCPD (Ardine et al., 1998). The kidneys of 40% of patients
may be rejected by patients in the first year. Dialysis just provides about 10% of kidney function and
transplantation provides about 50% of original kidney functions. ( Aslan, 2015) Haemodialysis (HD)
patients have a better life span than PD patients providing more flexibility. The expected costs of a
patient are 160,933.04 TL/Life with HD and 142, 730.67 TL/life with PD. ( Aslan, 2015) HD and PD
are compared by Aslan(2015) and PD was found that it is cheaper with flexibility in the life by not
visiting treatment centers, however, HD patients have higher expected living years. Kidney
transplantation(TX) is mainly done from first and second type’s relatives due to high matching
probabilities. There are the risks of rejecting the kidney due to infection, depression etc. (Yatkın,
2009). Markov chains can be used to estimate the changes from HD to PD and TX or vice versa as
done by Aslan İ.& Özen(2013) to estimate more accurate costs. There are not any PD machines in
Bingöl city and just 1-2 patients have got TX recently. (Aslan & Özen, 2013) Nevertheless, It is stated
by at doctor at the private hospital that PD hospitals are mainly coming from HD treatment due to
worsen situations like the need of changes due to complications.
Preventing disease progression, improving patient outcomes, and decreasing costs are the main
aims of screening CKD. Target populations for CKD having diabetes, hypertension, and other main
causes are the main focus of screening by blood and urine tests. Screening data and detecting
individuals with unrecognized or early stages of disease can be used for policy development to
decrease costs and risks. (Obrador et al., 2011) It is found that there is not any city wide screening
policy to prevent CKD.
Information is defined as “tool that is valuable and useful to people in their attempts to cope
with their lives”. Information need is defined as “a recognition that your knowledge is inadequate to
satisfy a goal that you have”. Information related symptoms, risks and complications of treatment,
diet, medication and fluid regimes, social life, family and work, TX,HD,PD, self-care and tests,
psychological impact, and stages of CKF are needed for the treatment of CKF. Individual patient
characteristics, preferences and priorities for information determine the level of information needed
according to circumstances and existing knowledge level. Qualitative versus quantitative methods can
be used to learn types information needs by surveys, interviews etc. Information needs for CKD is
determined by Paula Ormandy (2008) in her PhD thesis. Themes and information needs are shown in
appendix. During the progression of CKD, not much information is needed but cause of CKD,
properties of kidney, what can happen and prognosis information are required.“Getting good treatment
in a comfortable, caring safe environment, delivered in a safe way”, “Having information to make
choices, to feel confident and to feel in control”, and “Being talked to and listened to as an equal;
being treated with honesty and dignity” are three critical factors for effective treatment of CKD.
“Living with Kidney Disease: What you should know” is investigated by Ormandy (2008) to provide
necessary information to patients by books, leaflets, DVDs, videos, formal presentations, and visits to
increase adherence. The priority of information depends on the goals of patient (Ormandy, 2008).
Thurstone Paired-Comparison Scale as shown below is used to determine priorities and preferences of
information needs based on 89 sample size. Minus values of Figure 1 state that they are below 50 % of
the sample. Self-managements, understanding blood results, different tests, and changing diet have the
highest priority as shown below. Furthermore, complications from treatment have the second highest
information priority. Sub groups based on age, sex, current knowledge, co-morbidity etc. can be drawn
for priority of knowledge. The hospital consultant was mostly used to get information about CKD.
Age , modality group , time since diagnosis and current work situation effect the information priority
need whereas gender, time duration on RRT, formal education and co-morbid condition does not
affect the priority of information need (Ormandy, 2008).
Figur 1. Scaling themes for CKF; Ranking Order of the Core Information Needs using Thurstone Case V Scores
(Ormandy, 2008)
According to Thurstone Case V Scores that CKD patients in Bingöl have low level of high
priority information like self-management as they stated in interviews and survey. Main problems are
that patients are not well educated and there are not enough cross-treatment teams for CKD.
METHODOLOGY
By Yıldırım et. All(2007), it was found that the Turkish version of the KDQOL-SF-36 carried
out in randomly selected 82 patients has high reliability with 0.84 Cronbach's Alpha in Istanbul with
End Stage Renal Disease (ESRD). (Yıldırım et al., 2007) In this study, KDQOL-SF-36 form is used
to compare two main hospitals in Bingöl city and determine problems related to CKDs by
observations and interviews. Analysis of Variance(ANOVA) is used to find differences according to
hospitals, gender, education and seeing a psychiatry doctor. 95 patients are surveyed and interviewed
at the beginning of 2015. Cronbach's Alpha was found 0.919 from 35 items.
RESEARCH RESULTS
35 patients(36,8%) and 65 patients(63,2%) are from a private and main government hospital
respectively in Bingöl city. 45 patients( 47,2%) are women and 50 patients(52.6%) are men. Just
three patients had kidney transplantation before with unknown rejection reasons. The mean of age is
60,78 ±12.163 years for all patients. 78,9 % of patients have basic education level mainly five years
and just 2 patients has studied high schoolIn total 87% patients are satisfied with hospitals and almost
all of PH hospital patients having higher survey score are happy with treatment. Well-being and
physical functions of patients are evaluated by scores given to the questionnaire. As seen below, most
of patients do not care about their diet while patients at government hospital care their diet better. 14
patients at private hospital from 34 patients and 15 patients from 49 patients at government hospital do
not do any sport activities in their daily life. Patients do not get regular dietician control by not seeing
a dietician in 8.48±6.8 months and 91.6 % of them have not also seen any psychiatry doctor and just 7
patients visited a psychiatry doctor. Moreover, average 3,5 months and average 4,38 months at
Private Hospital(PH) and Government hospital(GH) respectively, not any dietician has visited or
talked with any patience.
45
40
35
Frequency
30
25
20
15
10
5
0
No
Little
Care
Private Dialysis Center
No
Little
Care
Goverment Hospital Dialysis Centre
Figure 2. Diet care by patients
Before CKD, high tension(HT) and diabetic(DM) are the most greatest cause of ESRD in
Bingöl city with 38% at PH and 35% HT at GH for HT and 14% at PH and 18% at GH for DM.
Kidney related illnesses such as nephritis or kidney injures are the third greatest cause of ESRD in
Bingöl. Moreover, heart related problems are also serious causes of ESRD. After taking HD, tension,
pain, hernia and diabetic are the highest complications at PH and tension, jaundice and tension are the
greatest complications at GH. At PH and GH with 5,88% and 28,57% respectively, patients state that
they need information about their treatment and illnesses. 44 % of them sated that the place of
information is not important and can be everywhere while 33.3 % of patients want to have information
at the dialysis center. 76,47% of PH and 56,25% of GH patients are transferred to hospitals by cars.
PH patients and GH patients take dialysis for 5.06 years and 4.34 years respectively. Moreover, PH
patients drink 1,5 glass water daily while GH patients drink 5.1 glasses water per day. Having high
rate of water drinking can cause hypertension. Moreover, 32,35% and 28,57% of PH and GH patients
have a kind of diabetics respectively. Lassitude with 44% at PH and with 32% at GH and pain with
33% at PH and 19% at GH are two most common side effects of treatment. Tension is the third
greatest side effect with 14 % at PH and 18 % at GH.
Stiff staff, narrow place, not hygienic and being not comfortable are main problems at GH by
asking the open question “why you are not happy at your center”. In both hospital, 13% of 11
patients, 63% of 53 patients, 64% of 22 patients, 26% of 22 patients, 85% of 80 patients are satisfied
with physical conditions, staff, cleanness, transportation and services respectively in second open
question “why are you satisfied with that center” . Personnel satisfaction and cleanness are 54,29%
and 37,14% at PH. For GH, not having good transportation is one of the main reasons of
dissatisfaction. Reasons why patients are not happy are investigated and it is found that patients
feeling bad due to taking TX and not being cured completely at private hospital. Being far, not
comfortable, not enough clean, lack of necessary devices, and not having another alternative hospital
are reasons why they are not satisfied at GH. Opening more dialysis centers, more improved devices,
being closer, helping dialysis patients and wider centers are suggestions done by patients to solve main
problems and increase satisfaction.
For taking breath, stress and unhappiness due to CKF and sexual life, there are significantly
differences between private and government hospital. Private hospital has better scores than
government hospital and there are no significant differences for other questions of SF-36 according to
hospital type as shown below and in appendix section. The GH places at basement are not enough and
patients have to wait for the new hospital to be finished to get a suitable place and better treatment.
Table 1. Differences between PH and GH
I22
I34
I35
Type of
Hospital
Private
Government
Total
Private
Government
Total
Private
Government
N
Mean
34
60
94
35
60
95
34
60
2,18
2,72
2,52
2,37
2,83
2,66
2,41
3,18
Between Groups
Within Groups
Total
Between Groups
Within Groups
Total
Between Groups
Within Groups
Sum of
Squares
6,333
117,125
123,457
4,716
92,505
97,221
12,920
111,219
df
1
92
93
1
93
94
1
92
Mean
Square
6,333
1,273
F-V
P-Value
4,97
0,028
4,716
,995
4,74
0,032
12,920
1,209
10,6
0,002
According to gender, there are no differences in all questions. Some female patients were shy
while answering questions and some of them cannot talk Turkish well. Patients have mainly basic
education level and just five patients have high school education level and just two patients have a
kind of university education.Q2, Q9,Q10, Q13, Q17, Q21-23, Q26-29, Q32,Q33 are not any
statistically significant according to education. Other questions show differences and as the education
level increases, the life quality scores of patients also increase. Q22 and Q34 are significantly different
for seeing a psychiatry doctor or not. About 65% of CKD patients have a kind depression according to
a doctor interview at GH. At private hospital, there is no psychiatry doctor and patients are redirected
to GH, but there is just a psychiatry doctor at GH.
DISSCUSSION AND FURTHER RESEARCH
In this study, KDQOL-SF-36 is used to compare the dialysis services done a main government
hospital and one private dialysis center in Bingöl. The main aim is to compare the success of private
and government hospital and find reasons why healthcare is a problem in Bingöl city for CKDand how
to improve it. Patients at PH have comfortable treatment conditions and satisfaction even there are
more staff and spending at GH. Costs at PH are paid by governments except green health card holders
forcing them to go GH. Not having enough nephrology doctors is another problem at that city;
professional doctors come here to work just two years for their conscription in East of Turkey. After
two years, they mainly go to big cities and patients have to wait for the next nephrology expert.
Government human resource politics in healthcare is the main reason why healthcare is not at the
expected level in Bingöl city. In two years, doctors start to know patients better and patients can have
an improved communication for their treatment. Another government related problem is not finishing
new hospital for years due to political reasons. Patients of CKDs take care at the basement of GH
without enough air transfer and lightning. PH does not not have an dietary expert, an professional
psychiatry doctor and other kind of treatments such as peritonea dialysis, home dialysis etc. Not
having a medicine faculty at Bingöl University prevents to increase the treatment quality at city
especially when the need of professional doctors is considered.
As furher part of this study, KDQOL-SF-36 results will used to determine the quality of
treatments for each patient and then both hospitals will be compared again based on quality of life.
After 2-3 months, another KDQOL-SF-36 survey will be carried out over the same patients to see the
improvements done in their life by also analyzing their lab results. For that aim, a dietician and a
psychiatry consultation are suggested to have at both hospital. There is a just one psychiatry doctor at
GH in the whole city.
CONCLUSION
Taking too much water, staying at a small place, not having a permanent dietician and a
psychiatry doctor, cleanness and lack of professional doctors are main problems at GH. More
comfortable treatment, better staff satisfaction, regular checking, cleanness, good transportation and
consultancy are main advantages of patients at PH. PH hospital has a better overall mean than GH as
shown in Appendix section in a good way and GH has higher scores in just ten questions. Some new
branches have been opened at districts to decrease the workload at city center, however not having
permanent nephrology doctors at districts forces patients to get their treatments at center. Lack of at
meeting information needs is another problem at both hospitals. Some people have low level of
Turkish language knowledge and education to read. As from interviews, it was seen that they do not
know exactly what to do at real life and their illnesses. Patients come economically from low class
families and they obey whatever is told to them. Self-management of their illness score is very low
with about 10-20%. They do not care about their eating habits and do not do any sportive activities.
For years, Bingöl city have depended on neighbor cities such as Elazığ, Diyarbakir or Malatya.
Patients still have to go these cities to get treatment for some situations and some patients die while
going these cities on the way from serious injuries or heart attacks. To improve the treatment quality
of patients at Bingöl city, the city needs some new private hospitals at districts, at least five years
conscription for professional and practitioners doctors to get a better communication with patients and
to know the region. There is one private hospital giving treatments alternative to GH. Some new
private hospitals are to be opened for special operations and serious cases with PD and home HD
options and other dialysis alternatives. Moreover, Bingöl city can be a hub not just for kidney
treatments but healthcare tourism with high potential of thermals and natural beauties for potential
CKD patients at earlier stages.
REFERENCES
Imran Aslan, 2015, “Estimating average lifespan and expected costs for chronic kidney failure (ckf) in
turkey, Research Journal of Business & Management - RJBM (2015), Vol.2(2))
Aslan İ.& Özen Ü. 2013, “Decision Analysis and Markov Chains for Management of Chronic Kidney
Failures in Turkey”, ISS & MLB, p.610-626, Nagoya/Japan, 2013.
Ardine de Wit G., G. Ramsteij P.and Th. de Charro F.,1998, “Economic Evaluation of End Stage Renal
Disease Treatment” , Health Policy, 44, p. 215–232.
Gregorio T. Obrador, Mitra Mahdavi-Mazdehand,Allan J. Collins, 2011, “Establishing the Global
Kidney Disease Prevention Network (KDPN): A Position Statement from the National Kidney Foundation” Am
J Kidney Dis., 57(3), pp.361-370
KC(Kidney Cares), 2013, “Can Stage 3 Chronic Kidney Disease Be Reversed”, 2013. http://www.kidneycares.org/ckd-prognosis/271.html(23.02.2013)
Ormandy P., 2008, Chronic Kidney Disease:Patient Information Need, Preferences and Priorities.
(Degree of Doctor of Philosophy) . University of Salford, School of Nursing,Institute of Health and Social Care
Research, UK,.
OECD,2011, “Health Data 2011”. http://www.oecd-ilibrary.org/sites/health_glance-2011en/04/08/index.html;jsessionid=3sob2sgebnprq.delta?contentType=&itemId=/content/chapter/health_glance2011-36 en&containerItemId=/content/serial/19991312&accessItemIds=/content/book/health_glance-2011en&mimeType=text/html(18.02.2013)
Sağlık Bakanlığı,2014, “Son dönem böbrek yetmezliği – diyaliz”
http://www.tkhk.gov.tr/Dosyalar/7f2369d3481342a495f1fc257f309b0f.pdf(Access Date: 23.06.2015)
Stein &Wild, 2002; MY, 2003
Tatar M., 2012, Özel Hemodiyaliz Merkezleri Maliyet Analizi Çalışması. Hacettepe Üniversitesi,
İktisadi ve İdari Bilimler Fakültesi, Ankara. Retrieved from www.diader.org.tr .
Yatkın I..,2009, “Renal Transplantasyon Hastalarında ve Vericilerde Transplantasyon Öncesi ve
Sonrasında Depresyon, Anksiyete”, Yaşam Kalitesi ve Sosyal DestekHaydarpaşa Numune Eğitim ve Araştırma
Hastanesi Psikiyatri Kliniği, Uzmanlık Tezi, . Istanbul, 2009.
A. Yıldırım, B. Ogutmen, G. Bektas, E. Isci, M. Mete, and H.I. Tolgay, 2007, “Translation, Cultural
Adaptation, Initial Reliability, and Validation of the Kidney Disease and Quality of Life–Short Form (KDQOLSF 1.3) in Turkey”, Transplantation Proceedings, 39, 51–54.
APPENDIX
Table 1 Stage One- Information Need Themes and Sub-themes(Ormandy, 2008)
Table 2: KDQOL-SF-36 results for PH and GH