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The effective management of Chronic Kidney Disease (CKD) in hemodialysis (HD) patients requires specialized treatment as well as a synergy between physician and patient, addressing clinical, social, and psychological concerns in addition to renal issues. In Brazil, the Ministry of Health has centralized the care coordination for individuals with CKD under the Primary Care Physician (PCP). However, from the perspective of HD patients, who coordinates their care and provides primary care? This study aims to answer this question.
This is a quantitative, descriptive, population-based survey conducted through structured interviews. From September 2021 to September 2023, individuals assisted in three dialysis centers located in Paraíba, Brazil, were interviewed. Patients were over 18 years old and had been on dialysis for more than 3 months. Data were organized in Excel, version 2013, with descriptive statistical analysis performed using absolute and relative frequencies for categorical variables, and mean and standard deviation for continuous variables.
A total of 176 individuals were interviewed, with an average age of 51,27 ± 13,74 years and an average time on dialysis of 39,13 ± 38,03 months. 54,5% were male, and 96,6% received HD through the Brazilian Unified Health System (SUS). When asked about the physician responsible for coordinating their pre-HD care, 50% identified the PCP, while only 19,3% identified the nephrologist. After the initiation of HD, 89,7% recognized the nephrologist as the care coordinator. The main factors leading patients to choose the nephrologist as their care coordinator were trust (56,8%), easy access (48,2%), and the need to address CKD/HD-related demands (39%). The nephrologist received a higher or similar rating compared to the PCP regarding skills and knowledge, explanations and communication with the patient, availability, problem-solving ability, meeting CKD/HD-related needs and trust. The PCP was better evaluated in terms of empathy and posture, time spent with the patient, and meeting needs beyond CKD/HD. 39% of the patients do not believe that the PCP is equipped to address issues unrelated to HD. Despite this, patients with care coordinated by the PCP had depressive, anxious, painful, sexual dysfunction, sleep disturbances, gastrointestinal, gynecological, and urological symptoms treated and resolved to a greater extent than those whose care was coordinated by the nephrologist. When asked about the nephrologist’s recommendation for patient referral to primary care, 79% state that the professional is indifferent, while 18% report being encouraged and 1,9% discouraged.
After the initiation of HD, the nephrologist takes over from the PCP as the person responsible for the overall care of the patient. This choice was made due to trust in the professional, easy access, and the need to address CKD/HD-related demands. The PCP was more effective in addressing symptoms unrelated to CKD, although more than a third of patients do not believe that the PCP is qualified for this type of care.