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The most startling finding of the study is the poor adherence to accepted guidelines for cervical cancer screening and mammography: 55% of patients had not had cervical screening within the previous two years, while 38% of those aged 50 years or over had not had mammography within the same period. These findings are echoed in a recent report on women undergoing haemodialysis in the United States.² The figures compare with contemporary Australian screening adherence rates of 64% for cervical screening (women aged 20-69 years)³ and 54% for mammography (women aged 50-69 years).⁴ Thus, despite intense contact of dialysis patients with the healthcare system, adherence to screening is lower than in the general population. Results from the survey also indicate the need to improve sexual counselling, contraceptive advice, menopausal management and fracture prevention among these women.

Consideration of hormone replacement therapy (HRT) and osteoporosis treatment is difficult in women with ESRD. As the authors outline, HRT carries a potential risk of vascular access thrombosis, and there are currently no evidence-based data on the risk-benefit ratio in this group.⁵ Treating or preventing bone disease in ESRD is complex, and currently limited by lack of efficacy and side effects of the common therapeutic agents and lack of data on agents such as bisphosphonates. Nevertheless, it is surprising that few of the 11 postmenopausal patients with fractures could recall HRT being discussed with them, and only one was taking this therapy.

An important question raised by this survey is "Who should be responsible for general healthcare issues in these patients?". The report does not say how many respondents claimed to have a general practitioner (GP) and, if so, maintained regular contact with this GP. However, a reason usually given by dialysis patients for not attending a GP is that they already spend many hours at the hospital or dialysis centre (usually about four hours, three times a week) and, not unreasonably, expect all their health issues to be dealt with during that contact.

Jang and colleagues conclude from their survey that hospital-based dialysis services should include a service that deals with women's health issues to ensure that this aspect of their routine health management is not neglected. So, why are nephrologists, or indeed other hospital-based specialists, not currently dealing with patients' global health issues? Clearly, specialists are generally aware of guidelines for women's health screening. However, it is not a major daily focus of the already complicated care of their patients and is more likely to be overlooked by a physician focusing on time-consuming, dialysis-related problems. The burgeoning number of dialysis patients combines with limited funding to compound this problem.

In view of these real-life pressures, I suggest an alternative approach that involves patients' GPs, whose daily practice already encompasses women's health screening. Since 1995, the Renal Unit at the Princess Alexandra Hospital, Brisbane, has implemented a "Renal Care and Support Program" to consolidate links between GPs and dialysis and transplant centres. Interaction is via a booklet which contains a summary of the patient's active and past problems, status of their health screening checks (such as those raised by Jang and colleagues), list of medications, information pages and key guidelines for care of the ESRD patient. Advances in information technology continue to enhance these lines of communication.

Many studies have shown that integrated management involving GPs achieves outcomes similar to, and in some instances better than, hospital care.⁶ Our program aims to address the global health issues of patients.⁷ In comparison, the model proposed by Jang seems limited. It would underutilise the skills of primary care physicians in healthcare screening, duplicate services available in general practice, and move these aspects of patient care to a system and staff not resourced to deal with them.

However, if GPs are to be significantly involved in the care of patients with ESRD, we must consider the suitability of applying general principles of care to these patients. This, I believe, can be achieved by providing guidelines in specific areas where approaches differ. For example, it is reasonable to exercise caution in administering HRT to a patient with recurrent vascular-access thrombosis, and some women with ESRD have such a poor prognosis that applying general population guidelines is not appropriate. This issue has not been addressed by Jang and colleagues.

The findings of Jang's study illuminate an increasing problem in our contemporary healthcare system: patients who have frequent contact with subspecialty care may have primary healthcare issues ignored. One way of addressing this issue is a hospital-based service to deal with women's health issues, as proposed by Jang and colleagues, while an alternative is shared care between the specialist service and GPs. Clearly, further consideration and research is required. The issues raised are also likely to translate to subspecialty services other than nephrology.

Carmel M Hawley
Director of Nephrology
Princess Alexandra Hospital, Brisbane, QLD
carmel_hawleyAThealth.qld.gov.au

1. Jang C, Bell RJ, White VS, et al. Women's health issues in haemodialysis patients. Med J Aust 2001; 175: 298-301.
2. Rush H, Neugarten J, Coco M. Women's health issues in a dialysis population. Clin Nephrol 2000; 54: 455-462.
3. Cervical screening in Australia 1997-1998. Canberra: Australian Institute of Health and Welfare, 2000. (AIHW Cat. No. CAN 9.)
4. BreastScreen Australia achievement report 1997 and 1998. Canberra: Australian Institute of Health and Welfare, 2000. (AIHW Cat. No. CAN 8.)
5. Weisinger JR. Role of hormone replacement in the management of osteoporosis in haemodialysis women: perspectives for the future. Nephrol Dial Transplant 2000; 15 Suppl 5: 36-37.
6. Hampson J, Roberts R, Morgan D. Shared care: a review of the literature. Fam Pract 1996; 13: 264-279.
7. Smith R, de Looze F, Kelly B, Rigby R. "Shared care". An integrated model of service delivery for renal and renal transplant patients [abstract]. Abstracts of the 35th Annual Scientific Meeting of the Australian and New Zealand Society of Nephrology; 3-5 Mar, 1999; Brisbane (QLD).

©MJA 2001
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