Why in the News? 

Recently, there are some findings from a nationwide private haemodialysis network’, the Lancet Regional Health-Southeast Asia, on the survival of patients receiving haemodialysis in India

Context:

• India has amongst the highest number of patients receiving chronic dialysis, globally estimated at around 1,75,000 people in 2018. Daily, the number of patients on dialysis has been increasing.
• The launch of the National Dialysis Service in 2016 to improve access, and ongoing efforts to develop affordable dialysis systems, are all underlined by the rising incidence of end-stage renal disease in the country.

Key Highlights as per study:

• Survival with Centre- and Patient-Level: The study found that both centre- and patient-level characteristics are associated with survival rates among patients undergoing haemodialysis.
• Unexplained Variation Between Centres: Despite considering various centre-based characteristics, there remained unexplained variations in survival rates between dialysis centres across India. This suggests that factors beyond those accounted for in the study may influence patient outcomes.
• Large Sample Size: The study included a substantial sample size of over 23,600 patients undergoing haemodialysis at any centre in the NephroPlus network between April 2014 and June 2019. This large sample size enhances the robustness of the study’s findings.
• Primary Outcome: The primary outcome of the study was all-cause mortality, measured from 90 days after patients joined a center. This outcome measure provides valuable insights into patient survival rates over time following the initiation of haemodialysis treatment.
• Consideration of Individual-Level Variables: The study accounted for various individual-level variables such as sex, smoking status, medical history (e.g., diabetes, heart disease, hypertension, hepatitis B, hepatitis C), education level, monthly household income, dialysis frequency, and vascular access. These variables offer comprehensive insights into patient characteristics and their impact on survival rates.
• Evaluation of Centre-Level Variables: Centre-level variables, including the frequency of nephrologist visits, number of beds, number of staff, and number of patients, were also considered. These variables help assess the influence of center resources and practices on patient outcomes.

What were the measuring differences?

• Limited Data: The only significant study conducted previously in Andhra Pradesh used claims data from a publicly-funded insurance scheme between 2008 and 2012. It included 13,118 beneficiaries and reported a 10.2% mortality rate within six months of starting hemodialysis.
• Absence of Centre-Level Effects: The previous study did not consider center-level effects on survival, limiting the understanding of differences in survival rates between dialysis centers, as observed in other countries.
• Gaps in Understanding: Major gaps existed in understanding dialysis outcome patterns in India due to the absence of comprehensive studies, hindering efforts to improve patient care.
• Lack of National Benchmark: There was no established national benchmark for survival rates among patients undergoing dialysis in India at the time of the study.
• Need for Further Research: The study highlighted the importance of conducting more extensive research to fill the gaps in knowledge and establish benchmarks for dialysis outcomes in India.

What is the recent issue related to the Mortality rate? 

• • Administrative challenges associated with Mortality:
    • Impact of Centre-Level Factors: Including center-level factors such as staffing, care processes, and patient volume in the analysis reduced the variability in survival rates across dialysis centers by 31%. This suggests that center-level characteristics play a significant role in influencing patient outcomes and survival rates.
    • Survival Range: After adjusting for multi-level factors, the estimated 180-day survival among patients undergoing hemodialysis ranged between 83% and 97%. This variability indicates differences in survival outcomes across dialysis centers in India.
  • Urban-Rural Divide: Patients attending rural dialysis centers experienced a 32% higher mortality rate compared to those at urban centers. This disparity underscores the unique challenges faced by rural healthcare facilities in providing hemodialysis services.

• Patient Characteristics Associated with Mortality:

• • Catheter-Based Vascular Access: Patients using catheter-based vascular access had a higher mortality rate compared to those using arteriovenous fistula or graft access.
  • Financial Support: Patients receiving financial support for dialysis treatment through government panel schemes or private insurance had a lower mortality rate compared to those paying out-of-pocket.
  • Dialysis Vintage: There was an inverse relationship between mortality rate and dialysis vintage, with patients receiving dialysis for at least a year before joining a center experiencing a 17% lower mortality rate than those starting dialysis less than 30 days before joining.
  • Presence of Diabetes: The presence of diabetes was associated with a higher mortality rate among hemodialysis patients.

Way Forward:

• Establishment of National Benchmark: The study proposes the first national benchmark for survival among dialysis patients in India. This benchmark will serve as a reference point for evaluating the quality of care and outcomes across dialysis centres in the country.
• Ongoing Quality Improvement Programs: As dialysis access continues to expand in India, ongoing quality improvement programs are crucial for ensuring that patients receive the best possible care and experience optimal outcomes at the point of care.
• Collaborative Quality Improvement System: The authors emphasize the need for a collaborative quality improvement system across the country to address the increasing demand for dialysis services. This system should involve stakeholders at various levels of healthcare delivery to enhance standards of care and patient outcomes.
• Understanding Multilevel Effects: It is essential to understand the multilevel effects of both centre- and patient-level characteristics on dialysis outcomes. Establishing national standards for dialysis outcomes in India requires comprehensive insights into these factors to drive improvements in care delivery.
• Comparison and Monitoring: Establishing national benchmarks enables comparison and monitoring of dialysis centres’ performances over time. This approach facilitates the identification of variations in practice patterns and outcomes, paving the way for targeted interventions and improvements in healthcare delivery.

Conclusion: The nationwide study on haemodialysis outcomes in India highlights disparities and the need for standardized care. Establishing national benchmarks, ongoing quality improvement, and collaborative efforts are essential for enhancing dialysis care and patient outcomes.

Mains PYQ-

Q- Public health system has limitations in providing universal health coverage. Do you think that private sector can help in bridging the gap? What other viable alternatives do you suggest? (UPSC IAS/2015)

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