MEETING FUTURE MANPOWER NEEDS IN NEPHROLOGY- STRATEGIES AND ...

MEETING FUTURE MANPOWER

NEEDS IN NEPHROLOGY-

STRATEGIES AND SOLUTIONS

Dr Zaki Morad

International Medical University

Nephrology in Malaysia

When did Nephrology begin?

• Nephrology as recognised presently started in the early 1970s and there were only three physicians trained in nephrology. There was no long term dialysis program, no renal transplantation until 1975, no renal pathologists or renal trained nurses

• Renal diseases as with all other “medical” diseases were managed by general physicians prior to the 1960s

Nephrology in Malaysia

The present state:

• About 15,000 patients on dialysis

• About 1,700 patients with functioning

transplants

• 70 adult and Pediatric nephrologists

• ~2,000 renal trained nurses

Table 1.01: Stock and Flow of RRT, Malaysia 1997 –

2006

Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

New dialysis pts 1136 1252 1544 1840 2085 2348 2597 2858 3054 3152

New Transplants 126 104 127 143 161 168 160 189 161 126Dialysing at 31st

December 3698 4539 5538 6691 7839 9114 10429 11855 13337 14647Functioning

transplant 1083 1111 1176 1248 1330 1425 1502 1590 1683 1725

No

. o

f p

ati

ents

Year

0

500

1000

1500

2000

2500

3000

3500New Dialysis

1997 1999 2001 2003 2005

Year

0

2000

4000

6000

8000

10000

12000

14000

16000Dialysing at 31st December

1997 1999 2001 2003 2005

Table 1.02: New Dialysis Acceptance Rate and New

Transplant Rate per million population 1997 – 2006

Acceptance rate 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Dialysis 52 56 68 78 87 96 104 112 117 118Transplant 6 5 6 6 7 7 6 7 6 5

Rat

e, p

er m

illi

on p

opula

tion

Year0

20

40

60

80

100

120

Dialysis

1997 1999 2001 2003 2005

Rate

, p

er m

illi

on

po

pu

lati

on

Year

0

2

4

6

8Transplant

1997 1999 2001 2003 2005

Table 1.03: RRT Prevalence Rate per million population 1997 –

2006

Prevalence rate 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Dialysis 171 205 244 285 326 372 416 463 510 550

Transplant 50 50 52 53 55 58 60 62 64 65

Rat

e, p

er m

illi

on p

opula

tion

Year0

100

200

300

400

500

600Dialysis

1997 1999 2001 2003 2005

Rat

e, p

er m

illi

on p

opula

tion

Year0

10

20

30

40

50

60

70Transplant

1997 1999 2001 2003 2005

Primary Renal Disease 1997 – 2006

Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

% Unknown

cause

33 32 29 28 30 30 28 28 26 27

% Diabetes

Mellitus

36 41 41 45 46 50 53 54 55 57

% GN 13 10 10 9 6 6 5 4 5 3

% SLE 1 1 2 2 1 1 1 1 1 1

%

Obstructive

Nephropathy

5 5 4 3 3 3 3 2 2 2

%

Hypertensio

n

9 8 11 12 9 7 7 7 7 6

International

comparison:

Incidence of ESRD

2004

Source: USRDS 2006

376

MalaysiaMalaysia

Nephrology in Malaysia

Meeting future manpower needs

• Estimating manpower needs is a complex process and not quite an exact science

• USA, UK and few other countries have formulated specialists manpower requirements based on certain principles and job description modeled in Full time equivalent units (FTE).

• No such exercise has been done in Malaysia

How do we estimate the future manpower

needs for Nephrology in the country?

Need to determine:

• The scope of work of nephrologists

• The RRT burden

• The role of general physicians/ general

practitioners in nephrology especially in

management of Dialysis patients

• Health care financing system

• Research committments

Scope of work of nephrologists

The nephrologists may have to do more in the future:

• Clinical work – general nephrology, Dialysis and Transplantation

• “Preventive” nephrology – early detection and management of CKD ( in conjunction with Primary care physicians)

• Training – training of nephrologists is increasingly becoming more structured and organised. This requires greater commitment on the part of the supervising consultant.

• Management

The RRT burden

• The prevalence of dialysis patients is increasing

at close to 10%

• There is more elderly and diabetic patients both

of whom require greater care

• Successfully transplanted patients require less

care than dialysis patients after the first few

months. With “stagnating” transplantation rates

more patients will be on dialysis thus increasing

the workload of the nephrologist.

Role of general physicians in Nephrology

• General physicians and GPs have played

important roles in the care of RRT

patients.

• This has enabled the dialysis population to

grow rapidly over the last decade.

• The future manpower needs in nephrology

will be affected to some extent whether

they will continue to play this role

Health care financing

• The government has indicated that it will be

introducing a form of healthcare financing in the

near future

• There is little information on the form of financing

and reimbursement for chronic diseases

requiring long term treatment such as dialysis

• New forms of financing will affect dialysis

provision and hence manpower requirements

Meeting future manpower needs

The present number of Nephrologists is about 3 per million population which meets the target set by the Ministry of Health.

The plan is now to have about 6 per million within the next 10 years which calls for producing about 10 nephrologists per year ( taking into account retirements)

We are now producing 4-6 nephrologists per year

Meeting future manpower needs

Strategies :

• Make nephrology more interesting

- Have more procedures and interventions

within the domain of nephrology practice

- clinical epidemiology

- clinical economics

Meeting future manpower needs

Strategies:

• Improve training programs

- improvements in general specialty training (ensuring physicians start training early and finish training at an earlier age)

- a more structured training program with greater supervision

- training in management issues like cost containment, cost effectiveness, general management

- attitudes and values

Meeting future manpower needs

Clinical research

• More clinical research are being done in

Asia Pacific

• Nephrologists should be involved in

research

• The manpower planning should take into

account involvement in research

Meeting future manpower needs

• Improving conditions in the public sector

service to attract and retain nephrologists

- remuneration

- working enviroment

Meeting future manpower needs

Nurses/Medical Assistants

Dietitians

Medical Social workers

Pharmacists

Technical support staff

Meeting future manpower needs

Nurses/Medical assistants

• There is still a lack of trained renal/dialysis nurses to meet the minimal requirements set by the Private Healthcare Facilities Act

• Dialysing the elderly and the diabetic ESRD patients calls for skilled nurses

• Role for nurses in early CKD detection and management

Meeting future manpower needs

Dietitians

• The RCP/RA of UK recommended in 1991 that a renal unit of 200 dialysis patients would require two dietitians

• There is still a major shortage of dietitians in the country and few of the dialysis patients are attended to by dietitians

• A major need to increase the number of dietitians and train them in renal dietetics

CONCLUSION

• The number or incident and prevailing patients on RRT continues to increase. There will be more patients who are older and have more comorbid conditions posing greater demands on the renal service

• Nephrologists have also to take greater interests in early detection and management of CKD

CONCLUSION

• The future calls for more nephrologists,

nurses and other allied staff

• Training has to include the skills to

manage not just the clinical problems but

management issues of cost containment,

manpower development, epidemiology etc

THANK YOU