End-stage kidney disease and rationing of kidney replacement therapy in the free state province, South Africa: a retrospective study

Background End-stage kidney disease (ESKD) and the required kidney replacement therapy (KRT) are significant public health challenges for low-and-middle-income countries. The South African government adopted a KRT rationing policy to balance the growing need for KRT and scarce resources. We aimed to describe the epidemiology and KRT access in patients with ESKD referred to the main public sector hospital in the Free State Province, South Africa. Methods A retrospective study of adult patients with ESKD admitted to Universitas Academic Hospital for KRT, was conducted between 1 January 2016 and 31 December 2018. A review of the KRT committee decisions to offer or deny KRT based on the KRT rationing policy of the Free State was undertaken. Demographic information, KRT committee outcomes, laboratory test results, and clinical details were collected from assessment tools, KRT committee meeting diaries, and electronic hospital records. Results Of 363 patients with ESKD referred for KRT access, 96 with incomplete records were excluded and 267 were included in the analysis. Median patient age was 40 (interquartile range, 33‒49) years, and male patients accounted for 56.2 % (150/267, p = 0.004) of the cohort. The average annual ESKD incidence was 49.9 (95 % confidence interval [CI], 35.8‒64.0) per-million-population. The most prevalent comorbidities were hypertension (42.3 %; 113/267), human immunodeficiency virus (HIV) (28.5 %; 76/267), and diabetes mellitus (19.1 %; 51/267). The KRT access rate was 30.7 % (82/267), with annual KRT incidence rates of 8.05 (95 % CI, 4.98‒11.1), 11.5 (95 % CI, 7.83‒15.1), and 14.1 (95 % CI, 10.3‒18.0) per-million-population in 2016, 2017, and 2018, respectively. Advanced organ dysfunction was the commonest reason recorded for KRT access denial (58.9 %; 109/185). Age (odds ratio [OR], 1.04; 95 % CI, 1.00‒1.07; p = 0.024) and diabetes (OR, 5.04; CI, 1.69‒15.03; p = 0.004) were independent predictors for exclusion from KRT, while hypertension (OR, 1.80; 1.06‒3.04; p = 0.029) independently predicted advanced organ dysfunction resulting in KRT exclusion. Conclusions Non-communicable and communicable diseases, including hypertension, diabetes, and HIV, contributed to ESKD, highlighting the need for improved early prevention strategies to address a growing incidence rate. Two-thirds of ESKD patients were unable to access KRT, with age, diabetes mellitus, and advanced organ dysfunction being significant factors adversely affecting KRT access.

Benefits and Challenges of Policy Options in Rationing the Hospital Radiology Services: A Case Study

Objective: In many countries, limiting the financial and budgetary resources is a challenge in the health system. One of the most costly parts of the health system is undoubtedly the radiology department of hospitals. Therefore, this study aimed to determine the benefits and challenges of the policies proposed for rationing hospital radiology services. Information sources and selected methods for study: In this narrative or literature review study, Persian (SID, Magiran, Barkat Knowledge network system, Irandoc), and Latin (Google Scholar, PubMed, Scopus, ISI web of sciences) databases were searched. The applied keywords were radiology, rationing, distribution, priority setting, resource allocation, and policy brief. In the initial search, 145 articles were studied. Subsequently, after reviewing the titles and abstracts, 65 studies were selected and investigated. Finally, 44 related studies were thoroughly investigated. The inclusion criteria covered the studies in Persian or English. The exclusion criteria included the studies that did not have full texts. Our search included the studies conducted from 1/1/2000 to 1/1/ 2017. Results: The present study examined the benefits and challenges of radiology services rationing. Policy options were presented at 3 levels of provider, organizational, and system. The provider level consisted of training clinical and non-clinical personnel to use and maintain the medical equipment and requiring the physicians to use clinical guidelines. The organization level included reviewing imaging tariffs, entering insurance in controlling supply and demand for radiology services, and assessing equipment by the Institute for Health Technology Assessment. The system level contained assignment of radiological services to the private sector. Conclusion: As health care costs are rising and resources are increasingly constrained by ever-increasing demands, policy makers and officials can use the proposed solutions with regard to contextual conditions to design a rationing model. Services at the macro level of the health system and operationalization of the rationing process reduce the gap between supply and demand of the health services.

The Methodist Church in Poland in reality of liquidation policy. Operation “Moda” (1949-1955)

The aim of the article is to analyze the determinants and other conditions of the religious policy of the Polish state towards the Methodist Church in the Stalinist period. The author took into account conceptual, programmatic, executive and operational activities undertaken by a complex subject of power, formed by three structures: party, administrative and special services. In his opinion, the liquidation direction of religious policy towards the Methodist Church was determined primarily by two factors: 1) the activity of Methodists in Masuria, which was assessed as “harmful activities” because they were competitive to the activity of the Evangelical-Augsburg Church (in which the authorities placed great hopes for effective repolonization of the native population), 2) strong links between the Methodist Church in Poland and the Methodist Church in the West (United States of America, Canada, Great Britain, Sweden). The liquidationa ctivities have been depicted primarily on the basis of solutions included in the action of special services under the codename “Moda”. The author also explains the reasons for the final resignation from the liquidation policy towards Polish Methodism and the inclusion of the Methodist Church in the direction of the rationing policy.