Under the epidemic situation, "dialysis difficulties" have been repeatedly found, where is the community hemodialysis card?

Community hemodialysis has become a trend overseas, especially in developed countries in Europe and the United States, but various domestic reasons are superimposed, and private dialysis institutions are faltering. (Visual China/Photo)

Hemodialysis 3 times a week for 4 hours each time can be said to be the most relaxed and comfortable time for dialysis patients.

Breathless, the skin is not itchy, the body is not puffy, the face is not gray, the end-stage kidney disease patients in the needle dialysis, to complete the body's most basic metabolism, to maintain the most basic dignity of life. It is conceivable that once the regular treatment is interrupted, what kind of survival anxiety will be brought to the dialysis family.

This kind of survival anxiety is no stranger. Wuhan at the beginning of 2020, Xi'an at the end of 2021, Shanghai, Jilin and Changchun in March and April 2022. Every time the COVID-19 pandemic is severe or requires large-scale closure management, the problem of treating hemodialysis patients surfaces.

"Why is the epidemic often a hot search for dialysis patients? Because this group is so special! Zhi An, founder of the kidney disease patient mutual assistance platform "Kidney Like People", told the Southern Weekend reporter. According to the National Blood Purification Case Information Registration System (CNRDS), there are about 693,000 hemodialysis patients nationwide in 2020.

Compared with ordinary patients, hemodialysis patients are smaller in scale, have more complications, have frequent treatments, and need medical professional care, "coupled with the relative saturation of dialysis medical resources, once the hospital for regular treatment is temporarily closed or requisitioned as a designated hospital, this balance will be broken, and patients will fall into a difficult situation."

Late on the night of March 31, 2022, Hao Deming, executive vice president of the China Association of Non-public Medical Institutions, received a call for help – the other party was the Shanghai Pudong New Area Epidemic Prevention and Control Command, which needed more than 100 hemodialysis medical support. After the recruitment notice was issued the next day, more than 700 people signed up, and the first and second batch of nearly 200 volunteers rushed to Shanghai, and the third batch was also recruiting.

It is not the first time that non-public and public medical care have joined hands to fight the epidemic, but the repeated epidemics in various places have also reflected the embarrassment of private dialysis institutions: on the one hand, the epidemic is full of tests, patients expect timely and convenient medical treatment, and the resources of public dialysis institutions are saturated, on the other hand, the development of private dialysis institutions is blocked, and it is difficult to play a market role to truly enter the community and play a convenient role.

It is worth noting that hemodialysis has always been the exclusive business of public medical institutions, and it was not until 2011 that the policy floodgates began to loosen. Loose floodgates do not mean unimpeded. For various reasons, 11 years later, community hemodialysis is still not paid enough attention to, and the development is slow.

Special "Retrograde"

"My dialysis patients are closely connected, can I open the window for ventilation?" "The dialysis equipment in the hospital is a model that I was not familiar with before, and I am afraid of dragging my legs to the team, what should I do if the psychological pressure is high?" ......

On the evening of April 12, 2022, a special online training was held from more than 7 o'clock to more than 10 o'clock, and the trainees were the hemodialysis medical care in Shanghai, and some doctors who failed to catch up with the training were still working night shifts in major dialysis rooms in Shanghai, taking care of patients and closed-loop transfers.

Of these more than 170 special "retrogrades", the youngest is only 21 years old. They hold a license to practice and a hemodialysis induction certificate, and they are the most urgently needed dialysis doctors in Shanghai. These people come from private dialysis centers in provinces and cities outside Shanghai, and some of them are even "veterans" who participated in the fight against the epidemic in Wuhan in 2020.

Dialysis patients are undoubtedly susceptible people with low immunity, when the patient has not dialysis for a long time, he will have chest tightness, wheezing, coughing, sputum and vomiting. "The hole in the tip of the needle leaks out of the big wind, and at the scene (of the dialysis room), anyone can become a source of infection." Professor Wu Anhua, one of the trainers and chief expert of the Infection Control Center of Xiangya Hospital of Central South University, said that he was also supporting the fight against the epidemic in Jilin at this time.

If medical care is supported in designated hospitals for the treatment of positive infected people, it is necessary to face the new crown virus with strong transmission ability, and Wu Anhua deliberately emphasized several times the precautions such as wearing and taking off protective clothing and "hand hygiene".

Two years ago, in Wuhan and other cities in Hubei, people could also find "retrogrades" from non-public medical institutions. According to the statistics of the China Association of Non-public Medical Institutions, more than 5,000 medical staff from 319 medical teams have gone to 246 medical institutions or isolation points and rehabilitation stations to participate in epidemic prevention and control and treatment.

"Participating in epidemic prevention and control, disaster relief and assistance is the duty and duty of doctors, and these have nothing to do with public or non-public." In mid-to-late February 2020, Hao Deming said in an interview with the media.

"As soon as I saw shanghai recruiting hemodialysis volunteers, I signed up." Ying Chen is a dialysis doctor at the Fifth Hospital of Dongxin in Shangrao, Jiangxi, and the captain of the Jiangxi team of the first batch of "Shanghai Hemodialysis Medical Team". Since April 3, he has been supporting seven hemodialysis nurses from Jiangxi at Zhoupu Hospital in Shanghai's Pudong New Area.

Ying Chen told the Southern Weekend reporter that at that time, there was also the director of the dialysis room of the private third-class hospital where he worked, "Our department has more than 300 hemodialysis patients to take care of on weekdays, and the dialysis manpower is already tight, so I came and the director stayed behind."

"The family is not thick", or to rush to help

"Most of the non-public medical institutions are small in scale and have limited manpower, so it is not easy to send a medical team into an established system." Wang Jiusheng, executive vice chairman of the Kidney Disease Dialysis Professional Committee of the China Association of Non-public Medical Institutions, told Southern Weekend that although the "family foundation is not thick", everyone still insists on rushing to help.

What few people know is that dialysis medical care not only has high professional skills requirements and a large risk of occupational exposure, but also bears the responsibilities of technicians, clerks, cleaners, patient education and other responsibilities in daily work, and overload work is easy to cause physical and mental injuries such as burnout.

In 2019, the National Health Commission revised the standard operating procedures for blood purification (2020 edition), and the draft for comments requires that each independent hemodialysis center must have at least one deputy senior professional title leader of kidney disease who has been practicing for 5 years. Engaging in this difficult and high-risk job in private medical institutions, and without the iron rice bowl and golden sign endorsement of public hospitals, talent recruitment has become a huge test.

"There's no way, we have to train ourselves." Chen Shaobo, chairman of Dakang Medical, a national chain dialysis enterprise, admitted to the Southern Weekend reporter, "So far, more than 90% of Dakang Medical's dialysis institutions have taken root in the county, and in the county, you simply can't recruit a few suitable." ”

If in large cities, private hemodialysis institutions are also at risk of job hopping and loss. "Fortunately, the flow of personnel in the county is relatively small, the competitive environment is not so fierce, we have trained a lot of people with our hearts, and now the situation of personnel is not so tense." Chen Shaobo said.

Recalling the rush to Wuhan in February 2020, Chen Shaobo admitted that it was a kind of tragic grandeur that "the wind is cold and the water is cold, and the heroes will not return once they are gone", because no one knows what kind of "enemy" they will face, and even "be prepared for sacrifice".

"This time, everyone's mood in Shanghai is different, we know more about the new crown virus, and we know what we can do and what to do." This time, Chen Shaobo served as the deputy general leader of the non-public aid Shanghai medical team, and Dakang Medical also sent a 16-person medical team, which is one of the non-public institutions with the largest number of drawn people.

Rooted in the county, rooted in the community

Around March 31, it was the most urgent and tense stage of Hemodialysis in Shanghai.

On the evening of the 31st, an incomplete statistics of the "Science and Technology Innovation Board Daily" of the Shanghai Poster Group confirmed this: of the 36 local hospitals that provided dialysis treatment, only half of them were still in operation, and only three of all the hospitals were non-public.

To some extent, this reflects the current situation of the dialysis industry in first-tier cities: the city is very large, the population is very concentrated, the medical resources are very rich, the top three hospitals are piled up, and the excellent dialysis talents are also concentrated. For independent hemodialysis institutions with heavy assets, large investment and slow returns, the first-tier cities are unattainable, and the number of private enterprises that can take root is very limited.

"So in the beginning we went to the county." Chen Shaobo said bluntly that their survey found that in more than 2800 counties across the country, a large part of them could not do dialysis, and patients were running and working hard, "we will focus on solving the medical needs of this part of the population." Most of the medical aid in Shanghai came from the district and county dialysis institutions.

In 2011, the former Ministry of Health approved the pilot of the Independent Hemodialysis Center in Shandong province with the approval of the Weigao Group and the Bethune Fund Management Committee, and Dakang Medical undertook the pilot work of the Bethune Foundation at that time. In the past ten years, Dakang Medical has opened more than 100 independent blood purification centers and nephrology specialist hospitals, mainly serving dialysis patients from more than ten provinces such as Jiangxi, Guangxi and Guizhou.

Yu Xiang, a dialysis doctor who transferred from a military hospital, is obsessed with the significance of community dialysis in the city. In his view, large public hospitals have the ability to do a good job in the treatment of difficult and critically ill patients, and the maintenance dialysis treatment of ordinary patients can be precipitated to small independent institutions, "(community hemodialysis institutions) to serve patients well around patients."

In fact, community hemodialysis has become a trend overseas, especially in developed countries in Europe and the United States. A 2017 study by experts in the Department of Nephrology at West China Hospital of Sichuan University pointed out that in the United States, the three major chain dialysis companies have established more than 4,000 hemodialysis centers (accounting for 68%) to treat 71% of patients, while the hemodialysis centers affiliated with public hospitals are mainly responsible for short-term hemodialysis of emergency, critical and hospitalized patients.

In 2020, Yu Xiang founded an independent dialysis agency in Xi'an, and has now installed 60 machines in batches and has invested about 11 million yuan. During the epidemic in Xi'an at the end of 2021, the dialysis center has undertaken more than 80 dialysis patients diverted from public hospitals, solving the urgent need.

"I know that Xi'an public medical care is strong, and it is difficult for independent dialysis centers to reach saturation, but I have always believed that community-based dialysis services are the best and most convenient." Yu Xiang has participated in the fight against the epidemic in Wuhan and Xi'an, and when interviewed by Southern Weekend reporters, he also supported dialysis at the Pudong New Area People's Hospital in Shanghai.

Medicare reimbursement and quality of care

For patients and their families, the medical quality of private dialysis institutions and medical insurance reimbursement are two major practical factors that must be considered.

To help her 74-year-old father solve the problem of dialysis, Ms. Zhou of Jilin City asked for help on Weibo for the third time on April 11. Zhou's father was close to blindness in both eyes, and he had underlying diseases such as hypertension and diabetes, and his heart was not good.

Ms. Zhou told the Southern Weekend reporter that there are few dialysis institutions in Jilin City, and her father has been dialysis in Jilin People's Hospital before, only three or four kilometers away from home, where the medical care is more familiar with the physical condition of the elderly.

"My father's medical insurance fixed point is also there, the proportion of medical insurance plus commercial insurance reimbursement can reach 80%, and the one-month dialysis and various drug costs are less than 2,000 yuan; if you go to a private institution that cannot be reimbursed, it may be tens of thousands per month." Ms. Zhou said.

In 2012, China included end-stage renal disease in the scope of medical insurance for major diseases, and the proportion of hospitalization reimbursement increased to 70%, and in 2014, the reimbursement ratio was increased to 90%, which greatly alleviated the treatment burden of uremia patients. However, private hemodialysis centers cannot easily obtain medical insurance qualifications such as the new rural cooperative.

"In public hospitals or private institutions that can implement medical insurance reimbursement, dialysis patients do a good job of strict self-management as long as they have no other diseases, and the cost per time is actually not high." Before the kidney transplant, Zhi'an was also a patient who needed regular dialysis, and he clearly remembered that each dialysis after medical insurance reimbursement only cost 24 yuan per dialysis.

For Zhi'an, he values the relatively complete public hospitals, especially when dialysis patients need emergency treatment and hospitalization, the public hospital can immediately carry out rescue, and conduct comprehensive examination and multidisciplinary consultation. "In contrast, most private institutions lack such facilities and teams."

According to the study of "Chinese Perydialysis Chronic Disease Nephropathy Management Code", the incidence of low calciumemia in Chinese hemodialysis patients is 35.9%, hyperphosphatemia is 58.6%, and high iPTH (full-stage parathyroid hormone) is 45.4%.

"Dialysis requires medical care to educate patients about kidney disease, especially diet." Zhi'an lamented, "Patients who do not manage their bodies will be hospitalized more each year. ”

"I understand, but 'no'"

Dark red blood, complex diseases, non-stop instruments, patients coming in and out, these concepts are entangled to form a "heart wall" - panic.

"Once there is pollution, the consequences are unimaginable!" "Oppose the construction of the Hemodialysis Center in the community!" In October 2020, Southern Weekend reported that the Harbin Dragon Hemodialysis Center was boycotted by surrounding residents. In an interview with a reporter from Southern Weekend, an owner said that he also understood the difficulties of hemodialysis patients, but still thought that he should stay away from residential areas.

This "I understand, but 'no'" behavior is typical of the neighbor-avoidance effect. Many private dialysis institutions in Tianjin, Wuhan, Hefei, Shenyang and other places have entered the community plan, all of which are "braking" due to social conditions and public opinion. In addition to worrying about contagion, opponents are also worried about civil doctor-patient disputes, accidents, and the impact on the preservation and appreciation of surrounding real estate.

Similar panics are not out of thin air. In 2013, Xinhua Hospital in Huainan City, Anhui Province, Zhen'an County Hospital in Shaanxi Province in 2016, and Dongtai People's Hospital in Jiangsu Province in 2019, a number of nosocomial infections of hemodialysis patients infected with hepatitis occurred. Of the three hospitals involved, the first is a private institution and the last two are public hospitals.

Mei Changlin, a tenured professor at Shanghai Changzheng Hospital and vice chairman of the Nephrology Branch of the Chinese Medical Association, told the Southern Weekend reporter that if dialysis institutions accept ordinary dialysis patients for maintenance treatment, the sewage discharged is mainly urine, do not worry; if there are PATIENTS with blood-borne infectious diseases such as AIDS and hepatitis B, they can do a good job in partition isolation and special aircraft disposal in strict accordance with relevant regulations, and can also do a good job in hospital infection control.

"As long as private dialysis institutions can be established with practice permits, it is (like public hospitals) under the strict supervision of the government, and the sewage and health conditions are also up to standard." Mei Changlin believes that dialysis agencies and regulatory authorities should do their part and take patients as the center.

In the past 11 years, private dialysis institutions have faltered, only in 2016, the former National Health and Family Planning Commission issued Document No. 67 to encourage the chain development of hemodialysis centers to usher in a short spring, and in recent years, capital has been in the wait-and-see stage.

According to public survey data, as of 2019, there are 6393 hemodialysis rooms (centers) across the country, and according to the statistics of the Kidney Disease Dialysis Committee of the Chinese Non-public Medical Association, only 11.6% of these institutions are independent hemodialysis centers, far lower than the United States, Germany and Japan.

A recent research report by Huaan Securities pointed out that the downstream of the hemodialysis market is dominated by public hospitals, and the service institutions of independent hemodialysis centers and medical-enterprise joint venture hemodialysis centers still have a large gap in the service side and still have a large space for development.

"Respecting the current patient is respecting the future self"

When the outbreak suddenly broke out, the round-trip travel significantly increased the risk of infection for patients and caregivers. "The new crown virus has put forward a prevention and control problem for all dialysis agencies in the world." Mei Changlin sighed.

In the past, patients with such highly contagious respiratory tract diseases were often transferred to specialized infectious disease hospitals or public health centers for dialysis. Nowadays, how dialysis centers deal with highly contagious respiratory infectious diseases, how to open up emergency dialysis areas to adapt to the latest prevention and control situations, how to allocate dialysis resources, mutual recognition of mutual inspection and test results, etc., deserve the attention and experience of every medical and health personnel.

According to the requirements of Shanghai Municipality, the negative patients in the hospital where Ying Chen worked have been diverted to other hospitals, leaving behind the positive patients of the hospital and the positive patients who were transferred to the hospital. Ying Chen and his colleagues have two points and one line of "hotel-hospital" every day, four shifts are rotated in reverse, and more than 30 dialysis instruments in the hospital have all increased the frequency of shifts, so that more dialysis patients can be treated.

"An important principle of dialysis is proximity to the patient, and the longer the distance between the patient and the dialysis point, the higher the risk of death." Mei Changlin feels that many rooted unknowns and misunderstandings need to be broken, and people should have more respect and goodwill when dialysis institutions enter the community, "Dialysis patients have all kinds of difficulties, respect for current patients, is to respect the future self."

On April 13, Mei Changlin said in an interview with Southern Weekend reporters that with the parallel measures of Shanghai to clarify the diversion medical treatment plan, strengthen the protection of dialysis patients, and alleviate the shortage of dialysis resources by foreign medical care, "the most difficult period for hemodialysis patients has basically passed."

Southern Weekend reporter Huang Sizhuo Southern Weekend intern Chen Shi Zhong Caifen