#3410 COVID-19 PANDEMIC: STRUCTURAL AND FINANCIAL CHALLENGES AND QUALITY OF TREATMENT IN HEMODIALYSIS CLINICS
Authors: Sloboda Sergio , Sloboda Andre Felipe , Barberes Leonardo , Leite Suzana 
Published: June 2023

Abstract

Background and Aims
In December 2019, Chinese Centers for Disease Control and Prevention was the first to report an outbreak of febrile respiratory disease where a new coronavirus identified, called SARS-CoV-2 that triggered a complex multisystemic disease, Covid-19. It spread rapidly, reaching countries in all five continents. The World Health Organization declared Covid-19 a pandemic in March 2020. The following years were a challenge for humanity and health systems around the world. Studies show that Chronic Kidney Disease (CKD) with glomerular filtration rate &lt;30 ml/min/1.73 m2 is an important risk factor for critical disease. Patients undergoing in-center hemodialysis (HD) are at higher risk for COVID-19, as they stay indoors without renewed air, which is important to control transmission, the same occurring with the professionals involved in the treatment. In our units, in order to mitigate the contamination, in addition to all measures required by health authorities, all SARS-Cov-2 positive patients performed their treatment in a separate room and with an in-center different flow from negative patients.
The aim of this study was to verify whether the significant structural disarrangement that occurred in this period could interfere with the goals of the quality indicators established by the Patient Safety Program (PSP).

Method
We conducted a retrospective cross-sectional study to evaluate the evolution of both operating costs and PSP quality markers during 2019 to 2022. We studied 457 patients undergoing in-center HD, with no distinction by gender, race, age or underlying disease. In the measurement of costs, only materials/medications specifically to HD, as well as the expenses in the remuneration of the constant changes of the care team, the absence due to contracting the disease or the established health standards. The following were analyzed: Conversion of viral hepatitis, with a target of 0%; SpKt/V ≥1.2, target 70%; Healthcare-Related Infections for Arterio-Venous Fistula (HRI-AVF) target &lt;1%. Hospitalization/deaths ratio as an index of the impact of the disease on our population was also calculated. All indexes were measured monthly and annualized using mean (costs), median and standard deviation, as a measure of central trend. Statistical analysis was used ANOVA and Kruskal-Wallis Test.

Results
In 2019, the cost of items corresponded 22.2% SD±1.6 of the value of the dialysis session; 30.4% SD±2.8 in 2020; 32.3% SD±3.0 in 2021 and finally 31.1% SD±3.0 in 2022. Obtaining statistical significance only from 2019 for other periods, p&lt;0.05. We did not observe viral hepatitis conversion at all times, reaching the goal. In the SpKt/V indicator, we observed 78% SD±4 in 2019, 73% SD±4 in 2020, 72% SD±6 in 2021 and 79% SD±6 in 2022, with no statistical significance observed between years. HRI-AVF rate was 1% in 2019, 3%, 2% and 2% in 2020, 2021 and 2022, respectively. No static significance found. The hospitalization/deaths ratio was 13% in 2019, 45% in 2020, 41% and 31% in 2021 and 2022, respectively.

Conclusion
The pressure in health units, a large increase in hospital costs due to the scarcity of materials/medicines and equipment for patient care, and especially the absence of sick professionals and/or increased workload, led to structural and financial disorganization in all health units including HD centres. This destructuring could somehow interfere with the quality of treatment. However, we did not show this relationship, because we found increased costs, and achievement of the goals of Viral Conversion Rates, SpKt/V&gt;1.2 and AVF-related IRAS. The number of hospitalizations was large, as in the whole world, with high lethality. We are in line with the official Brazilian Government: a fall in the prevalence of CKD per 100,000 inhabitants and a fall in deaths due to CKD, leading cause of death from Covid-19, as shown in the graphs below. The implementation of the PSP with a work of solidification of its standards and its objectives, go through continuous work with each patient, and incessant training of all professionals involved. With this, they become a strong barrier of protection to adverse events of the size to those caused by the Covid-19 pandemic.