PHYSICIAN BURNOUT IN NEPHROLOGY

V WIJERATNE1, SJ MAY1
1Tamworth Hospital, North Tamworth, Australia

Background: Burnout amongst health care workers and physicians is an increasingly recognised issue. It has impacts on clinicians personal and job satisfaction, health and stress levels as well as healthcare delivery to patients.
Aim: To determine the prevalence of physician burnout amongst nephrologists and nephrology trainees.
Methods: The standardised and validated burnout measurement tool through the Maslach Burnout Inventory – Human Services Survey for Medical Personnel (MBI-HSS MP) was used to determine the rates of emotional exhaustion, depersonalisation and personal accomplishment amongst nephrologists and nephrology trainees in Australia. Demographic information was collected and participants were invited to complete the online survey via email.
Results: Forty-six nephrologists and nephrology trainees responded to the survey. 87% of respondents were nephrologists with 54% of respondents in metropolitan, 9% in outer metropolitan and 37% in regional locations. High levels of emotional exhaustion and depersonalisation were reported in 26% and 28% of participants respectively. Low levels of personal accomplishment were reported in 20% of respondents. The overall level of burnout in the participants was 21%. Trainees reported higher levels of burnout at 33%. Burnout was more prevalent in outer metropolitan practice at 50% compared to metropolitan (20%) and regional practice (17%). Male respondents also reported higher rates of burnout at 30% compared to female practitioners at 6%. Younger nephrologists and trainees reported higher rates of burnout.
Conclusion: Physician burnout remains a prevalent issue, particularly amongst younger nephrologists, trainees and practitioners in outer metropolitan settings. The rates of burnout reported remain similar to levels amongst other physicians in the literature. Addressing the factors affecting burnout in the groups at risk will be vital in reducing its impact in the future.


Biography:
Dr Viduranga Wijeratne is a Renal Advanced Trainee in Tamworth Rural Referral Hospital. He completed his BMed MD at UNSW and his basic physicians training at Concord Repatriation General Hospital.

THE END OF THE CKD JOURNEY- RRT OR DEATH WITHOUT RRT: THE CKD.QLD EXPERIENCE

WE HOY1,2, J ZHANG1,2, Z WANG1,2, A CAMERON1,2, HG HEALY1,3, S VENUTHURUPALLI1,3, K-S TAN3, S GOVINDARAJULU3, A ROLFE3, M MANTHA3, T TITUS3, R CHERIAN3,  P WU3,  C  BANNEY3, C  MUTATIRI3, K MADHAN3, D RANGANATHAN3, G KAN3, T HAN3, S HOSSAIN3, A KARK3, S COLEMAN3, B TAYLOR3, A MALLETT3
1NHMRC CKD.CRE and CKD.QLD , Brisbane , Australia, 2Faculty of Medicine, University Of Queensland , Brisbane, Australia, 3Queensland Health , Brisbane, Australia

Aim: To examine the fate of patients with CKD in selected public renal specialty clinics in Queensland and compare those who started RRT with those who died without RRT.
Background. An AIHW study suggests that, in Australia, the number of persons who start RRT is equalled or exceeded by those who die of end stage kidney failure (ESKF) without receiving RRT.
Methods: 6,371 patients in CKD.QLD (54% males, mostly CKD stages 3b, 4 and 5, were followed from consent date until the start of RRT, death, or a censor date of June 30, 2016. Outcomes and causes of death were ascertained from Queensland Health records, through a data linkage collaboration. Follow up ranged from 0 to 5.4 years, median (IQR) of 2.8 (3) years, or a total of 15,714 person years.
Results: By the censor date, 605 (9.5%) patients had started RRT, at a median (IQR) age of 63 (20) and 837 (13.1%) had died without RRT, at median (IQR) age 78 (14). Rates of both were higher in males than females, with RRT incidences of 3.8 vs 2.7, p=0.001, and death rates of 5.8 vs 4.8, p=0.001. Among deaths without RRT, 377 (45.5%) mentioned terminal ESKF or chronic renal failure, 193 (23.3%) mentioned CKD, an additional 57 (6.9%) mentioned AKI, with no gender difference in terms of the causes.
Discussion. More of these CKD patients died without RRT than started RRT. Average ESKF-free survival was 15 years longer for patients who did not start RRT (78 vs 63 years). About half the deaths without RRT were ESKF deaths, while another 30% mentioned a renal diagnosis. Ascertainment of CKD in death certificates was very good.


Biography:
Dr Wendy Hoy was awarded an Officer of the Order of Australia [2010] for service to medical research in the field of chronic disease, particularly renal disease, through her promotion of health service delivery reform and advocacy for Indigenous health in Australia and the USA. Also recognised internationally for her multidisciplinary research and leadership in CKDu in Sri Lanka, PAHO and WHO projects, she was elected as a Fellow of the Australian Academy of Science [2015]. Based at The University of Queensland, she leads the Centre for Chronic Disease, the NHMRC CKD Centre for Research Excellence, and the CKD.QLD Collaborative.

CKD.QLD: PROFILE AND LONG-TERM OUTCOMES OF ABORIGINAL & TORRES STRAIT ISLANDER (A&TSI) PEOPLE WITH CHRONIC KIDNEY DISEASE (CKD) FROM DARLING DOWNS, QUEENSLAND

SK VENUTHURUPALLI1,2,3, A GUPTA1, A LEE1, U MAHMOOD1, S GOVINDARAJULU1,2, HG HEALY2,3,4, R FASSETT2,5,6,  A CAMERON2,3,4, WE HOY2,3
1Renal Services (TBH), Darling Downs Hospital And Health Service, Toowoomba, Australia, 2NHMRC CKD.CRE and CKD.QLD, The University of Queensland, Brisbane, Australia, 3 School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Brisbane, Australia, 4Kidney Health Service (RBWH), Metro North Hospital and Health Service, Brisbane, Australia, 5School of Human Movement Studies, The University of Queensland, Brisbane, Australia, 6Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia

Aim: To overview A&TSI people with CKD and their outcomes from the Darling Downs (DD) renal service. The DD is a very large area (90,000 km2), with distance a barrier to equitable health service delivery.
Background: A&TSI people have higher rates of CKD and worse outcomes than the general CKD population. More accessible and integrated healthcare delivery should improve this situation.
Methods: Included are patients with preterminal CKD enrolled in CKD.QLD in the DD renal service, age ≥18 years, who identified as A&TSI. Patients who lived ≥50 Km from Toowoomba were offered telenephrology services, and a CKD Nurse Practitioner service was established in the A&TSI community of Cherbourg.
Results: 126 patients identified as A&TSI, constituting 9.3% of patients with CKD seen in renal service. Mean age was 56.4± 12.9 years, with equal gender distribution compared with 64.6 ± 15.3 years and 55.4% males and 44.6% females in non-A&TSI patients. 46.4% were seen via tele-nephrology. Most had hypertension (93.6%), diabetes (75.2%), obesity (69.6%; BMI>30) and were current or past smokers (76.6%). Diabetic nephropathy (60%) was the leading cause of CKD, followed by GN (12.8%) and unknown (8.8%). Major comorbidities included CVD (47.2%), GORD (23.2%), depression/mental illness (23.2%), arthritis (20%) and COPD (20%). During follow-up of up to 7 years, 24 patients (19.2%) started dialysis (20 HD and 4 PD) and 20 patients died (16%) without dialysis. 5 more died after starting dialysis.
Conclusions: A&TSI people with CKD from the Darling Downs were younger, with equal gender distribution and had multiple comorbidities. High rates of modifiable health and CKD risk factors were identified. Institution of tele-nephrology and a Nurse Practitioner role improved equity of health service access.


Biography:
Dr. Venuthurupalli is a consultant within Queensland Health, based at Toowoomba Hospital and a senior lecturer with Faculty of Medicine, UQ. He is completing his PhD in Chronic Kidney Disease under the mentorship of Professor Wendy Hoy, University of Queensland. He has more than 20 years experience in the field of Nephrology. He has with major publications in reputed journals. He has successfully established telenephrology as a model of care (MOC) for management of CKD patients in Darling Downs Hospital and Health Service (DDHHS) called “Reduce Miles-Spread Smiles” which was awarded Queensland Health Excellence award in December 2017.

COST-EFFECTIVENESS IN KIDNEY MEDICINE: IS CINACALCET SUPERIOR TO PARATHYROIDECTOMY?

K HEGERTY1,2, S JONES1, C SCUDERI1,2, J EGLINGTON1, T BROADBENT1, H ZHANG1, AJ MALLETT1,2
1Kidney Health Service, Royal Brisbane And Women’s Hospital, Herston, Australia, 2Faculty of Medicine, The University of Queensland, Herston, Australia

Aim: To compare parathyroidectomy costs to those of cinacalcet therapy for the treatment of SHPT in CKD patients.
Background: Cinacalcet for treatment of secondary hyperparathyroidism (SHPT) in chronic kidney disease (CKD) has been less available to patients since Australian Pharmaceutical Benefits Scheme funding was withdrawn in August 2016.
Methods: A retrospective audit of CKD patients with SHPT at a tertiary Australian centre who underwent parathyroidectomy from January 2012 to July 2017 (n=34) was undertaken (HREC/17/QRBW/231). ANZDATA reports a median wait time to renal transplant in Australia of 2.4years (range 1.3-4.1years). The centre-specific total cost of 2.4years of cinacalcet therapy 60mg daily was calculated and compared to the total cost of parathyroidectomy based on hospital electronic record data for fractional length of stay (FLOS) and peri-operative complications. A literature review was concurrently undertaken.
Results: The average cost of cinacalcet ($13,149/patient) was found to be more cost-effective than the average total cost of surgery ($23,062/patient) (range $11,375 to $53,279/patient). The median postoperative length of stay was 7.51days (range 3.47-35.74days).
The literature reviewed appeared divided on the issue of cost-effectiveness. Belozeroff et al. assessed 181 patients 6 months post parathyroidectomy and found that the combined cost of treatment for hypocalcaemia, re-admission rates and an increase in physician encounters led to a lower overall cost with cinacalcet therapy.  In contrast, Narayan et al. found that parathyroidectomy was more cost effective by 7.6 months post-operatively.
Conclusion: This emphasizes the importance of assessing the cost-effectiveness of therapies in clinical medicine, especially nephrology. In this cohort at a single Australian tertiary centre we identified cinacalcet to be more cost-effective than parathyroidectomy as a treatment approach in CKD patients with SHPT.


Biography:
Advanced Trainee in Nephrology at the Royal Brisbane and Women’s Hospital

ECONOMIC ANALYSIS OF REGULAR HEMODIALYSIS TREATMENT IN END-STAGE KIDNEY DISEASE

M RAMA PUTRA1, G RAKA WIDIANA1
1Division of Nephrology and Hypertension Department of Internal Medicine School of Medicine Udayana University/Sanglah Central Public Hospital Denpasar Bali, Denpasar, Indonesia

Background: Hemodialysis (HD) treatment is a high volume, high cost, and high risk of medical services. Most of HD treatment in Indonesia and it is universally covered by National Health Insurance.
Methods: This economic analysis is aimed to calculate HD costs and its components, and  outcomes.
Results:We conducted economic analysis of hemodialysis (HD) treatment among ESRD at Sanglah Hospital Denpasar Bali. We calculated direct, indirect and intangible cost during 5 years in 30 HD patients which were randomly selected from medical records. We found  mean total direct cost 437,093,800 IDR  (31,452.39 USD) including   double lumen catheter insertion 4,180,526 IDR  (300.82 USD); AV-fistula 5,537,683 IDR  (398.48 USD); HD treatment  351,00.000 IDR  (25,257.25 USD); medicines 59,852,000 IDR  (4,306.82 USD), including EPO, intravenous iron and oral medicines; lab tests and radiology examination 15,665,000 IDR  (1,127.22USD); mean indirect cost 41,981,333  IDR (300,20.89 USD),consists of transportation expenses and meals; mean intangible cost (loss of job opportunities) 44,546,666 IDR  (3,205.49 USD) calculated from patient’s salary or provincial minimum wages, leading to total cost 522,763,210 IDR (37,616.98 USD) for 5 years of HD treatment. We also found that among 223 patients mean KDQOL was 56.75 ±21.00. During one  years of followed up, among 222 patients evaluated, 18 patients died, leading to 91.9 % of one year survival, with mean survival time 358 days (95%CI: 354 -362 days).
Conclusion: Five years total cost of HD is 37,616.98 USD with 358 days one year mean survival and 56.75 KDQOL
Key words: Regular hemodialysis, end-stage kidney disease, cost, QOL, survival


Biography:
I Made Rama Putra, born in Tabanan, Bali, Indonesia on October 14th, 1971. Graduated as medical doctor in 1997, and internist 2011. Work for district hospital bangli, rural area. Trainee nephrology since July 2016. Attending budapest nephrology school on august 2017. Write paper for pernefri meeting in 2015, 2016 and 2017

ASSESSING THE RISK AND SEVERITY OF HOSPITALISATIONS ACCORDING TO LEVEL OF KIDNEY FUNCTION: AN EXTEND45 ANALYSIS

M JUN1, L SUKKAR1,2, B NEUEN1, C FOOTE3,  K ROGERS1,  A KANG1, A SCARIA1, A CASS4,  C POLLOCK5,  D SULLIVAN6,  J KNIGHT1,  M GALLAGHER1, M JARDINE1
1The George Institute For Global Health, Newtown, Australia, 2University of Sydney, Camperdown, Australia, 3Concord Repatriation General Hospital, Concord, Australia, 4Menzies School of Health Research, Darwin, Australia, 5Kolling Institute for Medical Research, St Leonards, Australia, 6NHMRC Clinical Trials Centre, Camperdown, Australia

Aim: To determine the risk and severity of all-cause and cardiovascular hospitalisations by kidney function level in a community-based cohort study of NSW adults aged ≥45 years.
Background: Contemporary assessments of the relationship between chronic kidney disease (CKD) and health services use by level of kidney function have been limited. Prior studies typically used diagnosis codes to identify CKD which have relatively low sensitivity for ascertaining earlier stages of CKD.
Methods: Based on data from the EXTEND45 study (the 45 and Up Study linked to hospital and community pathology datasets by the Centre for Health Record and Linkage [CHeReL]), we identified a population-based cohort (2006-2014) of 41,099 people aged ≥45 who had a measure of kidney function (estimated glomerular filtration rate [eGFR]). The risk and severity of hospitalisations (defined by the hospitalisation length of stay [HLOS]) were assessed by eGFR category (≥90 [reference], 60-89, 45-59, 30-44 and <30ml/min/1.73m2) using multivariable Cox regression.
Results: Of 41,099 participants, 80.2% experienced ≥1 hospitalisation event over a mean follow-up of 5.8 years. All-cause hospitalisation risk increased as eGFR declined (HR 0.99[95% CI:0.97-1.03]; 1.05[1.00-1.09]; 1.17[1.10-1.24] and 1.57[1.43-1.72] for eGFR 60-89, 45-59, 30-44, and <30ml/min/1.73m2, respectively; p-trend<0.001) even after adjustment for age and sex. Cardiovascular events rose even more steeply than all-cause hospitalisations (HR 1.23[1.08-1.39]; 1.49[1.28-1.73]; 1.73[1.45-2.07] and 2.24[1.80-2.79], respectively). Mean HLOS also increased as eGFR declined (all-cause hospitalisation [2.3, 2.8, 3.9, 5.1 and 5.7days, respectively]; cardiovascular hospitalisations [3.7, 3.8, 5.7, 5.9 and 8.3days, respectively).
Conclusions: In contemporary NSW, declining kidney function is associated with higher illness burden, particularly cardiovascular burden. The increased mean HLOS suggests that discrete medical events are more severe as kidney function declines.


Biography:

Min Jun is a Senior Research Fellow at the George Institute for Global Health and Scientia Fellow at UNSW Sydney.He holds a PhD(2012) and MScMed(ClinEpi) in clinical epidemiology from the University of Sydney and has completed a 3.5-year international postdoctoral fellowship at the University of Calgary, Canada.Min’s research interests include the use of large trial and real-world, population-based data sources to better understand current and potential management strategies in kidney disease as well as exploring the associations between various risk factors and clinically important outcomes among individuals with chronic disease.

HEALTH-RELATED QUALITY OF LIFE IN PEOPLE OVER 75 YEARS OF AGE WITH END-STAGE KIDNEY DISEASE MANAGED WITH COMPREHENSIVE CONSERVATIVE CARE OR DIALYSIS

K SHAH1, F MURTAGH2, K MCGEECHAN3, S CRAIL4,  A BURNS5,  A TRAN1,  RL MORTON1
1NHMRC Clinical Trials Centre, University of Sydney, Camperdown, Australia, 2Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom, 3School of Public Health, University of Sydney, Camperdown, Australia, 4Royal Adelaide Hospital, Adelaide, Australia, 5Royal Free Hospital, London NHS Foundation Trust, Hampstead, United Kingdom

Aim: To compare health-related quality of life (HR-QOL) in those over 75-years managed with comprehensive conservative care or dialysis; and evaluate associations between HR-QOL and socio-demographic characteristics.
Background: Older people with end-stage kidney disease (ESKD) and their clinicians need information about likely HR-QOL with comprehensive conservative care or dialysis to inform treatment decisions.
Methods: Prospective cross-sectional study of HR-QOL in older people treated at Australian and UK renal units offering comprehensive conservative care and dialysis programs. HR-QOL was measured with the ShortForm-12 (SF-12) questionnaire and transformed into quality-adjusted survival (QALY) weights, known as utilities, using the SF-6D algorithm. Mean utilities on a 0-1 scale (0=death, 1=full health) and standard deviations were estimated using Australian and UK population values. Determinants of increased/decreased utility were investigated using univariate and multivariate linear regression models.
Results: Of 129 patients from 3 renal units, mean age 82 years [IQR 78-85], 65% males, 46 (36%) were managed with comprehensive conservative care and 83 (64%) managed with dialysis. The mean utility for 123 patients with complete data was 0.651 (SD=0.151) for comprehensive conservative care and 0.605 (SD 0.132) for dialysis. In multivariate analysis, utility was 0.084 lower for females compared with males (p=0.001); 0.060 lower for those without private health insurance compared to those with private health insurance (p=0.04) and 0.058 lower for those in the dialysis group versus comprehensive conservative care group (p=0.029). In each treatment group, the ‘social’ and ‘vitality’ domains of HR-QOL incurred the greatest decrement.
Conclusions: HR-QOL in this population of older people is estimated at around 60% to 65% of full health. For people over 75-years, comprehensive conservative care may offer quality of life benefits over dialysis.


Biography:
Karan Shah is a Health Economist at NHMRC Clinical Trials Centre, University of Sydney. Prior to his full-time role as a Health Economist, he pursued Masters of Science in Health Economics at Heidelberg University in Germany. He has research interest in methodological development in estimating quality of life, within trial health economic models, quantitative research methods: systematic reviews, meta-analysis, statistical analysis, assessment of test evaluation and monitoring.

FACTORS THAT INFLUENCE HOSPITALISATIONS IN PATIENTS WITH CHRONIC KIDNEY DISEASE

A JEYARUBAN1,2,3, WE HOY1,2,  A CAMERON1,2,  HG HEALY1,2,3, J ZHANG1,2, A MALLETT1,2,3
1CKD.QLD and NHMRC CKD.CRE, Brisbane, Australia, 2Faculty of Medicine, The University of Queensland, Herston, Australia, 3Kidney Health Service, Royal Brisbane and Women’s Hospital, Herston, Australia

Aim: To explore factors that increase hospitalisation rates in patients diagnosed with CKD.
Background: Chronic kidney disease (CKD) is characterised by high hospitalisation and readmission rates.
Methods: A retrospective cohort study involved 1,123 RBWH patients enrolled in the CKD.QLD registry from January 2011 to August 2017 with a minimum of 2 years follow-up. Patients with renal replacement therapy prior to 2011 and patients with less than 2 years of biochemical data were excluded. Hospitalisation data and co-morbidities were extracted from clinical records. CKD stage and delta eGFR (CKD-EPI; stratified by quartiles) were deduced.
Results: 1,123 patients were identified with mean age 66.71 +/-16.2 years. Comorbidities included diabetes (46.8%), ischaemic heart disease (IHD; 29.5%), heart failure (7.6%), cerebrovascular events (CVD;10.6%), peripheral vascular disease (14%) and hypertension (74.2%). 19.6% of patients experienced an incident cardiovascular event (CVE).
CKD patients with CVE had a significant increase in hospitalisations compared to patients without CVE (mean:4.3(4.9) vs 8(6.8), p<0.05). Hospitalisations were significantly higher with advancing CKD stages with means; stage 1: 2.6(4.8), stage 2: 4.2(5.8), stage 3: 5(5.3), stage 4: 6(5.4), stage 5: 6(6), p<0.05. Patients in the fourth quartile delta eGFR(mL/min/1.73m²/yr) had significantly more hospitalisations than those in the first quartile of delta eGFR with means:5.5(5.5) vs 4.2(4.6) respectively (p=0.01). Moreover, patients with diabetes (6.0vs 4.2), IHD (6.8vs 4.3), heart failure (6.6vs 4.9) and CVD (6.2vs 4.9) also had significant increase (p<0.05) in hospitalisations. However multivariate analysis adjusting for age only showed a significant association between hospitalisations with CVE (p<0.05).
Conclusion: Many factors seem to be associated with increased hospitalisations in the CKD population. Identifying these factors, such as CVE, offers opportunities to decrease morbidity and health care costs.


Biography:
Andrew Jeyaruban is currently a medical registrar with a keen interest in renal medicine. He graduated from James Cook University with Honours in 2014. Andrew then completed his residency at the Royal Brisbane and Women’s Hospital Brisbane, Australia. He is currently a basic physician trainee at the Liverpool Hospital, Sydney.

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