Understanding dialysis outcome patterns in India through a nationwide study
Findings from a nationwide private haemodialysis network show that there is a variation in the survival of patients receiving haemodialysis in India depending on various factors; and stress on the need to standardise dialysis care across centres
Hockman et al, ‘Centrelevel variation in the survival of patients receiving haemodialysis in India: findings from a nationwide private haemodialysis network’, The Lancet Regional HealthSoutheast Asia, March 13, 2024
The authors attempt to analyse the survival of patients undergoing dialysis at 193 centres in India. The primary outcome was allcause mortality, measured from 90 days after joining a centre, using patientlevel and centrelevel characteristics. The findings indicate the need not only to scale up infrastructure for dialysis across the country, but also to standardise dialysis care and ensure lower mortality by doing so.
India has amongst the highest number of patients receiving chronic dialysis, globally estimated at around 1,75,000 people in 2018. On a daily basis, the number of patients on dialysis has been increasing. The authors notch this up to the launch of the National Dialysis Service in 2016 to improve access, and ongoing efforts to develop affordable dialysis systems, all underlined by the rising incidence of end stage renal disease in the country.
Before this study, there were no large studies examining survival in patients receiving haemodialysis in India, or considering centrelevel effects on survival. As per the authors, the only, and
From the start of the U.S.’s war on Iraq to the release of Bob Dylan’s debut album, March 19 is an important day in world history. A quiz on all things that happened on this date
QUESTION 1
President Woodrow Wilson signed an Act on this day in 1918 defining five time zones and their limits in the U.S. Name the Act and what is it related to?
QUESTION 2
Argentina mobilised troops against the British on this day in 1982 to stake claim to a set of islands in the South Atlantic Sea. The incident would spawn an eponymous war too. What is it called?
QUESTION 3
Name the African country that was suspended from the Commonwealth grouping on this day in 2002 over its government’s human rights abuses, election rigging and undermining of the economy. largest study, conducted in Andhra Pradesh used claims data from a publiclyfunded insurance scheme between 2008 and 2012 to describe outcomes amongst 13,118 beneficiaries, and found that 10.2% of patients died within six months of starting haemodialysis. However, there was limited opportunity in the study to examine whether differences in survival existed between dialysis centres, as has been shown in other countries. As a result, major gaps existed in the full understanding of dialysis outcome patterns in India, limiting efforts to improve care. There is also, as yet, no national benchmark for survival in patients receiving dialysis, they stated.
Measuring differences
The authors measured the differences in the survival rate between dialysis centres across India and evaluated the extent to which these differences are explained by centrebased characteristics. They found that centre and patient level characteristics are associated with survival, but there remains an unexplained variation between centres.
In this study, one of the largest of its nature, over 23,600 patients, undergoing haemodialysis at any centre in the NephroPlus network, for 90 days or more, between April 2014 and June 2019 were chosen. The primary outcome was allcause mortality, measured from 90 days after joining a centre.
The individuallevel variables included sex, smoking status, history of diabetes,
QUESTION 4
Known by the moniker ‘Prophet of the Space Age’, this British science fiction writer, who also cowrote movies such as 2001: A Space Odyssey, died on this day in
QUESTION 5
The leader of this former Soviet Republic announced his resignation on this day in 2019 after ruling over the country from various posts since its Independence in 1991. Name the leader and the country.
QUESTION 6
Founded in 1856, this European investment bank was among the least affected during the global financial crisis of 2008. However, on this day last year, the country’s government had to broker a deal for another firm to buy it to prevent its collapse. Name the bank. history of heart disease or heart failure, history of hypertension, hepatitis B and hepatitis C in patients. Besides this, other categories such as education, monthly household income, dialysis frequency and vascular access were factored in for evaluation. The centrelevel variables included frequency of nephrologist visits, number of beds, number of staff and number of patients.
Mortality rate
After accounting for multilevel factors, the estimated 180day survival ranged between 83% and 97%. The mortality rate in patients attending rural centres was 32% higher than those at urban centres. This latter figure was likely due in part to unmeasured differences in patient characteristics. Nevertheless, it highlights the unique challenges faced by rural centres, the authors aver.
Among the patient characteristics associated with mortality were: catheterbased vascular access which had a higher mortality compared to access via an arteriovenous fistula or graft; also, financial support for dialysis treatment through a government panel scheme or private insurance had a lower mortality compared to outofpocket payment. There was an inverse relationship between mortality and dialysis vintage, with those receiving dialysis for at least a year prior to joining a centre having a 17% lower rate of mortality than those who started dialysis less than 30 days before joining. The presence of diabetes was associated with a higher mortality rate. By
This former head of state survived a controversial shooting incident on this day in 2004 while campaigning on election eve, only to emerge victorious. Who is he?
APincluding centrelevel factors in the analysis; for instance, staffing, processes of care and patient volume, they found it reduced the variability in survival across dialysis centres by 31%.
The way forward
The authors propose this as the first national benchmark for survival amongst dialysis patients in India. As India continues to widen dialysis access, ongoing quality improvement programs will be an important part of ensuring that patients experience the bestpossible outcomes at the point of care. In future, it is clear that the number of patients in need of dialysis will increase.
While overall improvements in health infrastructure and care are essential to keep pace with the demand, the authors of the study underline the need for a collaborative quality improvement system across the country. Alongside establishing national standards for dialysis outcomes in India, it is important to understand the multilevel effects of centre and patientlevel characteristics on these outcomes, the authors add, in the paper. It has been shown, in nephrology and other medical specialities, that clinical practice patterns and patient outcomes vary substantially between centres. Therefore, establishing national benchmarks for dialysis outcomes against which the dialysis centres’ performances and changes over time can be compared is essential to drive this, they say, arguing that their findings present the first step in this voyage.
Questions and Answers to the previous day’s daily quiz:
1. This month of the Islamic calendar is Ramzan. Ans: Ninth Month. It follows ‘Sha’ban’
2. The Holy Koran says that eating and drinking are permissible in Ramzan during this time.
Ans: When the ‘white thread of light becomes distinguishable from the dark thread of night at dawn’
3. Traditionally, the fast is broken by eating this fruit. Ans: Date
4. The name of the festival that marks the end of Ramzan. Ans: Eid al-Fitr
5. The meaning of ‘Ramadan Kareem’.
‘Generous Ramadan’
6. In Ramadan, the reward for every good deed done is multiplied by this number. Ans: 70
7. Name the battle that took place in Ramadan 2 AH (March 624 CE).
Visual: The name of the mosque.
Ans: Ans: Battle of Badr Ans: Sultan Ahmed Mosque (Blue Mosque) in Istanbul Early Birds:
C. Saravanan| Prashant Nain| Rajmohan V| Ashraf Basha