DIALYSIS

2. Chronic Dialysis in India

• India is home to one of the highest numbers of patients undergoing chronic dialysis globally, estimated at approximately 175,000 individuals in 2018. This number continues to rise steadily on a daily basis.
• The authors attribute this trend to the initiation of the National Dialysis Service in 2016, aimed at enhancing accessibility to dialysis, alongside ongoing endeavors to develop cost-effective dialysis systems.
• These initiatives are further accentuated by the increasing incidence of end-stage renal disease across the country.
• Prior to the recent study conducted by Hockman et al., there was a notable absence of large-scale studies examining patient survival rates among individuals undergoing haemodialysis in India.
• Moreover, there was a lack of consideration for center-level effects on survival outcomes. The authors highlight that the only significant study in this domain, conducted in Andhra Pradesh, utilized claims data from a publicly-funded insurance scheme spanning from 2008 to 2012.
• This study, involving 13,118 beneficiaries, revealed that 10.2% of patients succumbed within six months of commencing haemodialysis.
• However, this study had limited scope to explore potential variations in survival rates among different dialysis centers, a phenomenon well-documented in other countries.
• Consequently, critical knowledge gaps persisted in understanding the comprehensive patterns of dialysis outcomes in India, thus hindering efforts to enhance patient care standards.
• Notably, there remains a lack of a national benchmark for survival rates among patients undergoing dialysis in India, underscoring the necessity for further research and standardization in this crucial healthcare domain.

3. Analyzing Survival Rate Variations Across Dialysis Centers

• The authors conducted an in-depth analysis to measure the differences in survival rates among various dialysis centers across India and to determine the extent to which these differences could be attributed to center-based characteristics.
• Their findings revealed that both center-level and patient-level characteristics play a role in determining survival rates, yet there remains a significant unexplained variation between different centers.
• This study, one of the largest of its kind, involved over 23,600 patients undergoing haemodialysis at any center within the NephroPlus network for a duration of 90 days or more, spanning from April 2014 to June 2019.
• The primary focus was on all-cause mortality rates, starting from 90 days after a patient's enrollment at a center.
• The individual-level variables taken into account included sex, smoking status, medical history such as diabetes, heart disease or heart failure, hypertension, hepatitis B and hepatitis C status among patients.
• Additionally, socio-economic factors such as education level, monthly household income, dialysis frequency, and type of vascular access were also considered for evaluation.
• On the other hand, center-level variables encompassed the frequency of nephrologist visits, the number of beds available, staffing levels, and the total number of patients served by each center.
• These variables were crucial in understanding the dynamics influencing survival rates and identifying potential areas for improvement in dialysis care delivery across different centers.

• The authors propose establishing the first national benchmark for survival among dialysis patients in India, marking a crucial step as the country expands dialysis access. They emphasize the necessity of ongoing quality improvement programs to ensure optimal patient outcomes in dialysis care.
• As the demand for dialysis services is expected to rise significantly in the future, there's a clear need for enhanced health infrastructure and care delivery systems.
• While broader improvements in healthcare infrastructure are crucial, the authors stress the importance of implementing a collaborative quality improvement framework nationwide.
• They advocate for setting national standards for dialysis outcomes in India and stress the significance of understanding how center- and patient-level characteristics impact these outcomes.
• Drawing from experiences in nephrology and other medical specialties, where practice patterns and patient outcomes vary widely among centers, establishing national benchmarks for dialysis outcomes becomes imperative.
• These benchmarks will enable comparisons of dialysis centers' performances over time, driving continuous improvement in care quality. The authors consider their study findings as the initial step in this journey towards standardized and improved dialysis care across India.