Use of the ‘Accountability for Reasonableness’ Approach to Improve Fairness in Accessing Dialysis in a Middle-Income Country
Identifieur interne : 002917 ( Pmc/Curation ); précédent : 002916; suivant : 002918Use of the ‘Accountability for Reasonableness’ Approach to Improve Fairness in Accessing Dialysis in a Middle-Income Country
Auteurs : Mohammed Rafique Moosa [Afrique du Sud] ; Jonathan David Maree [Afrique du Sud] ; Maxwell T. Chirehwa [Afrique du Sud] ; Solomon R. Benatar [Afrique du Sud]Source :
- PLoS ONE [ 1932-6203 ] ; 2016.
Abstract
Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the ‘Accountability for Reasonableness’ (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible.
Url:
DOI: 10.1371/journal.pone.0164201
PubMed: 27701466
PubMed Central: 5049822
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Use of the ‘Accountability for Reasonableness’ Approach to Improve Fairness in Accessing Dialysis in a Middle-Income Country</title><author><name sortKey="Moosa, Mohammed Rafique" sort="Moosa, Mohammed Rafique" uniqKey="Moosa M" first="Mohammed Rafique" last="Moosa">Mohammed Rafique Moosa</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa</addr-line></nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town</wicri:regionArea></affiliation><affiliation wicri:level="1"><nlm:aff id="aff002"><addr-line>Renal Unit, Tygerberg Academic Hospital, Cape Town, South Africa</addr-line></nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>Renal Unit, Tygerberg Academic Hospital, Cape Town</wicri:regionArea></affiliation></author><author><name sortKey="Maree, Jonathan David" sort="Maree, Jonathan David" uniqKey="Maree J" first="Jonathan David" last="Maree">Jonathan David Maree</name><affiliation wicri:level="1"><nlm:aff id="aff002"><addr-line>Renal Unit, Tygerberg Academic Hospital, Cape Town, South Africa</addr-line></nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>Renal Unit, Tygerberg Academic Hospital, Cape Town</wicri:regionArea></affiliation></author><author><name sortKey="Chirehwa, Maxwell T" sort="Chirehwa, Maxwell T" uniqKey="Chirehwa M" first="Maxwell T." last="Chirehwa">Maxwell T. 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Chirehwa</name><affiliation wicri:level="1"><nlm:aff id="aff003"><addr-line>Biostatistics Unit, Centre for Evidence-based Health Care, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa</addr-line></nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>Biostatistics Unit, Centre for Evidence-based Health Care, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town</wicri:regionArea></affiliation></author><author><name sortKey="Benatar, Solomon R" sort="Benatar, Solomon R" uniqKey="Benatar S" first="Solomon R." last="Benatar">Solomon R. Benatar</name><affiliation wicri:level="1"><nlm:aff id="aff004"><addr-line>Bioethics Centre, University of Cape Town, Cape Town, South Africa</addr-line></nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>Bioethics Centre, University of Cape Town, Cape Town</wicri:regionArea></affiliation></author></analytic><series><title level="j">PLoS ONE</title><idno type="eISSN">1932-6203</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the ‘Accountability for Reasonableness’ (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="White, Sl" uniqKey="White S">SL White</name></author><author><name sortKey="Chadban, Sj" uniqKey="Chadban S">SJ Chadban</name></author><author><name sortKey="Jan, S" uniqKey="Jan S">S Jan</name></author><author><name sortKey="Chapman, Jr" uniqKey="Chapman J">JR Chapman</name></author><author><name sortKey="Cass, A" uniqKey="Cass A">A Cass</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lysaght, Mj" uniqKey="Lysaght M">MJ Lysaght</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Nugent, Ra" uniqKey="Nugent 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<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS One</journal-id><journal-id journal-id-type="iso-abbrev">PLoS ONE</journal-id><journal-id journal-id-type="publisher-id">plos</journal-id><journal-id journal-id-type="pmc">plosone</journal-id><journal-title-group><journal-title>PLoS ONE</journal-title></journal-title-group><issn pub-type="epub">1932-6203</issn><publisher><publisher-name>Public Library of Science</publisher-name><publisher-loc>San Francisco, CA USA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27701466</article-id><article-id pub-id-type="pmc">5049822</article-id><article-id pub-id-type="doi">10.1371/journal.pone.0164201</article-id><article-id pub-id-type="publisher-id">PONE-D-16-26729</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Nephrology</subject><subj-group><subject>Medical Dialysis</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Surgical and Invasive Medical Procedures</subject><subj-group><subject>Transplantation</subject><subj-group><subject>Organ Transplantation</subject><subj-group><subject>Renal Transplantation</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Surgical and Invasive Medical Procedures</subject><subj-group><subject>Urinary System Procedures</subject><subj-group><subject>Renal Transplantation</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Nephrology</subject><subj-group><subject>Chronic Kidney Disease</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Endocrinology</subject><subj-group><subject>Endocrine Disorders</subject><subj-group><subject>Diabetes Mellitus</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Metabolic Disorders</subject><subj-group><subject>Diabetes Mellitus</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Anatomy</subject><subj-group><subject>Renal System</subject><subj-group><subject>Kidneys</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Anatomy</subject><subj-group><subject>Renal System</subject><subj-group><subject>Kidneys</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and health sciences</subject><subj-group><subject>Infectious diseases</subject><subj-group><subject>Viral diseases</subject><subj-group><subject>HIV infections</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Social Sciences</subject><subj-group><subject>Economics</subject><subj-group><subject>Health Economics</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Health Care</subject><subj-group><subject>Health Economics</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>People and places</subject><subj-group><subject>Geographical locations</subject><subj-group><subject>Africa</subject><subj-group><subject>South Africa</subject></subj-group></subj-group></subj-group></subj-group></article-categories><title-group><article-title>Use of the ‘Accountability for Reasonableness’ Approach to Improve Fairness in Accessing Dialysis in a Middle-Income Country</article-title><alt-title alt-title-type="running-head">'A4R' to Improve Fairness in Dialysis Access Allocation</alt-title></title-group><contrib-group><contrib contrib-type="author"><contrib-id authenticated="true" contrib-id-type="orcid">http://orcid.org/0000-0003-1696-0113</contrib-id><name><surname>Moosa</surname><given-names>Mohammed Rafique</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff002"><sup>2</sup></xref><xref ref-type="corresp" rid="cor001">*</xref></contrib><contrib contrib-type="author"><name><surname>Maree</surname><given-names>Jonathan David</given-names></name><xref ref-type="aff" rid="aff002"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Chirehwa</surname><given-names>Maxwell T.</given-names></name><xref ref-type="aff" rid="aff003"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Benatar</surname><given-names>Solomon R.</given-names></name><xref ref-type="aff" rid="aff004"><sup>4</sup></xref></contrib></contrib-group><aff id="aff001"><label>1</label><addr-line>Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa</addr-line></aff><aff id="aff002"><label>2</label><addr-line>Renal Unit, Tygerberg Academic Hospital, Cape Town, South Africa</addr-line></aff><aff id="aff003"><label>3</label><addr-line>Biostatistics Unit, Centre for Evidence-based Health Care, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa</addr-line></aff><aff id="aff004"><label>4</label><addr-line>Bioethics Centre, University of Cape Town, Cape Town, South Africa</addr-line></aff><contrib-group><contrib contrib-type="editor"><name><surname>Joles</surname><given-names>Jaap A.</given-names></name><role>Editor</role><xref ref-type="aff" rid="edit1"></xref></contrib></contrib-group><aff id="edit1"><addr-line>University Medical Center Utrecht, NETHERLANDS</addr-line></aff><author-notes><fn fn-type="COI-statement" id="coi001"><p><bold>Competing Interests: </bold>The authors have declared that no competing interests exist.</p></fn><fn fn-type="con"><p><list list-type="simple"><list-item><p><bold>Conceptualization:</bold> MRM.</p></list-item><list-item><p><bold>Data curation:</bold> JDM.</p></list-item><list-item><p><bold>Formal analysis:</bold> MRM MC.</p></list-item><list-item><p><bold>Investigation:</bold> MRM JDM.</p></list-item><list-item><p><bold>Methodology:</bold> MRM.</p></list-item><list-item><p><bold>Resources:</bold> MRM JDM.</p></list-item><list-item><p><bold>Writing – original draft:</bold> MRM SB.</p></list-item><list-item><p><bold>Writing – review & editing:</bold> MRM SB.</p></list-item></list></p></fn><corresp id="cor001">* E-mail: <email>rmm@sun.ac.za</email></corresp></author-notes><pub-date pub-type="epub"><day>4</day><month>10</month><year>2016</year></pub-date><pub-date pub-type="collection"><year>2016</year></pub-date><volume>11</volume><issue>10</issue><elocation-id>e0164201</elocation-id><history><date date-type="received"><day>12</day><month>7</month><year>2016</year></date><date date-type="accepted"><day>21</day><month>9</month><year>2016</year></date></history><permissions><copyright-statement>© 2016 Moosa et al</copyright-statement><copyright-year>2016</copyright-year><copyright-holder>Moosa et al</copyright-holder><license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</ext-link>, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p></license></permissions><self-uri content-type="pdf" xlink:href="pone.0164201.pdf"></self-uri><abstract><p>Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the ‘Accountability for Reasonableness’ (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible.</p></abstract><funding-group><funding-statement>The authors received no funding for this work.</funding-statement></funding-group><counts><fig-count count="2"></fig-count><table-count count="3"></table-count><page-count count="16"></page-count></counts><custom-meta-group><custom-meta id="data-availability"><meta-name>Data Availability</meta-name><meta-value>All relevant data are contained within the manuscript and the stable public repository Figshare. Figshare data can be accessed at the following URL and DOI: URL: <ext-link ext-link-type="uri" xlink:href="https://figshare.com/articles/Datasheet_Version_August_2016_xlsx/3808113">https://figshare.com/articles/Datasheet_Version_August_2016_xlsx/3808113</ext-link> DOI: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.6084/m9.figshare.3808113.v1">10.6084/m9.figshare.3808113.v1</ext-link>.</meta-value></custom-meta></custom-meta-group></article-meta><notes><title>Data Availability</title><p>All relevant data are contained within the manuscript and the stable public repository Figshare. Figshare data can be accessed at the following URL and DOI: URL: <ext-link ext-link-type="uri" xlink:href="https://figshare.com/articles/Datasheet_Version_August_2016_xlsx/3808113">https://figshare.com/articles/Datasheet_Version_August_2016_xlsx/3808113</ext-link> DOI: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.6084/m9.figshare.3808113.v1">10.6084/m9.figshare.3808113.v1</ext-link>.</p></notes></front></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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