RENAL DATA FROM ASIA–AFRICA
|Year : 2020 | Volume
| Issue : 4 | Page : 840-849
|Hemodialysis at Doorstep - “Hub-and-Spoke” Model of Dialysis in a Developing Country
Manisha Sahay, Kiranmai Ismal, P Sharmas Vali
Department of Nephrology, Osmania Medical College and General Hospital, Hyderabad, Telangana, India
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|Date of Submission||15-Aug-2019|
|Date of Decision||02-Nov-2019|
|Date of Acceptance||04-Nov-2019|
|Date of Web Publication||15-Aug-2020|
| Abstract|| |
End-stage kidney disease has become a huge burden in our country. There has been an increase in dialysis centers across the country. State-funded dialysis has been initiated in many states of India. However, most of the centers are concentrated in the cities. Patients living in the peripheral districts have to travel long distance to reach the dialysis centers. In addition, there is a dearth of nephrology services in the peripheral areas. To address this problem, the hub-and- spoke model of dialysis has been initiated in Telangana state in South India, which has brought dialysis at the doorstep for people residing in remote districts. This study highlights the important features of this model.
|How to cite this article:|
Sahay M, Ismal K, Vali P S. Hemodialysis at Doorstep - “Hub-and-Spoke” Model of Dialysis in a Developing Country. Saudi J Kidney Dis Transpl 2020;31:840-9
|How to cite this URL:|
Sahay M, Ismal K, Vali P S. Hemodialysis at Doorstep - “Hub-and-Spoke” Model of Dialysis in a Developing Country. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2020 Sep 28];31:840-9. Available from: http://www.sjkdt.org/text.asp?2020/31/4/840/292319
| Introduction|| |
Chronic kidney disease (CKD) is increasing all over the country. Diabetes is the most common cause of CKD in India. Out of 1.2 billion Indians, about 80 lakhs develop CKD every year. Out of these patients, about two lakhs progress to end-stage kidney disease (ESKD) per year and need renal replacement therapy (RRT) either in the form of dialysis or trans-plantation. About 55,000 patients are on hemodialysis (HD) in India and approximately 10,000 undergo kidney transplantation in India every year. About 9,000 patients are on peritoneal dialysis. Majority of the end-stage renal disease (ESRD) patients (57%) opt for conservative therapy. Thus, HD is one of the main modalities of RRTs in India. The Government of India has initiated subsidized dialysis across the country under the National Rural Health Mission (NHRM) scheme. In the state of united Andhra Pradesh in South India, public funded dialysis was initiated in 2009. Subsequently, the state of Telangana was formed on June 2, 2014. With lessons learned from the previous model where most of the dialysis centers were located in the capital city and patients had to travel long distance for dialysis, Telangana government initiated the hub-and-spoke model where there are three hub centers located in Hyderabad, which is the capital of Telangana, and each of these hub centers caters to 10–15 spoke centers in the neighboring districts. This article highlights the “hub-and-spoke model” where Osmania hospital is the hub center and caters to spoke centers (peripheral centers) which are located within the Osmania cluster.
Each of these spoke center is attached to an area hospital, and the infrastructure and water is provided by the superintendent of the respective hospitals. Spoke dialysis centers are monitored by physicians, anesthetists, or inten- sivists, who are trained for this purpose. The data from each spoke center are uploaded daily and are supervised by the nephrologist at the hub center on a day-to-day basis. The hub center nephrologist reviews the history, physical examination findings, and investigations for each and every patient from each center and then gives online approval after which the spoke center can initiate dialysis for that patient. The monthly dialysis data for each patient are captured at the spoke center and are uploaded and reviewed by the nephrologist at the hub center every month before approval for the next cycle of dialysis is given. There are regular visits by the hub center nephro- logist to the spoke center. This policy has brought dialysis to the doorstep of most of the patients in Telangana.
| Materials and Methods|| |
In this retrospective observational study, data from all patients undergoing dialysis in the Osmania hub-and-spoke centers were collected. Detailed history was taken including patient demographics and comorbidities. Dialysis vintage was recorded. Details of vascular access were captured. All hematological and biochemical tests were noted. Blood samples were analyzed for seropositivity for hepatitis B (HB) and C and HIV. Details of iron therapy and erythropoietin usage and vaccination were collected. Data on water-processing system parameters were collected. Dialysis outcomes were recorded in the form of death or transplantation or dropouts or conversion to continuous ambulatory peritoneal dialysis (CAPD).
| Statistical Analysis|| |
Variables were presented as mean and standard deviation or as frequencies (percentage). Continuous variables were analyzed using Student’s /-test or ANOVA. Kolmogorov–Smirnov test was used for testing normality. Nonparametric variables were compared using Mann–Whitney U or Kruskal–Wallis tests as appropriate. The Pearson’s χ test or Fisher’s exact test was used for categorical variables. P < 0.05 was considered to indicate a statistically significant difference. The statistical analysis was performed using Epi info ™ Version 7.1, Division of Health informatixs and surveillance, Center for Disease Control, Atlanta, USA.
| Results|| |
There are nine dialysis units (spoke centers or peripheral centers) under the hub center, i.e., Osmania General Hospital. Thus, including one hub center and nine spoke centers, a total of 10 dialysis units in all were analyzed.
There were 18 machines at the time of analysis at the hub center, whereas in all spoke centers put together, the number of machines was 58. All units were performing three to four shifts of dialysis, with the hub center providing five shifts of dialysis per day. Hepatitis B or C patients were dialyzed on separate machines [Table 1]. Each center had a water-processing plant. The number of patients at each center and the number of sessions per month at each center are summarized in [Table 1].
Among patients analyzed, overall 75.7% were male, while 24.2 % were female. Thus, females constituted about one-fourth of the dialysis population at the hub center (24.7%) as well as at peripheral spoke centers (24.0%).
The mean age of the patients was 48.58 ± 13.59 years. The mean age of males was 48.6 ± 13.6 years, whereas the mean age of females was 48.5 ± 13.2 years. Only two patients were below 18 years of age. The patients’ age range was between 16 and 88 years. Nearly 29.9% of the patients had ESRD due to diabetes, and 62.9% had received HB vaccination.
Overall among 705 patients, 568 (80.5%) had arteriovenous fistula as vascular access, while only 21 (2.9%) were on tunneled catheters and 116 (16.4%) were on non-tunneled catheters. The percentage of patients receiving dialysis with permanent access, i.e., tunneled catheter or AV fistula, was lower at the hub center as compared to that of the spoke centers (65.8% vs. 89.6%) (P < 0.05) [Table 2].
All patients were counseled regarding vascular access at the time of first contact with nephrologist. 69.9% were seen by nephro- logist in ESRD and needed urgent start HD. Only 50 patients (7.0%) were initiated on dialysis through AV fistula.
All patients were offered thrice-a-week dialysis. Some patients opted for twice-a-week dialysis. Only those patients with significant residual renal function were permitted twice-a- week dialysis under close supervision.
Out of 705 patients, 266 (50.8%) patients were on thrice-a-week dialysis, whereas 251 (47.9%) were on twice-a-week dialysis and a miniscule percentage (1.2%) underwent once-a- week dialysis. At the hub center, the percentage of patients undergoing thrice-, twice-, and once-a-week dialysis was 123 (67.5%), 58 (31.8%), and 0, respectively, whereas at the spoke centers, 251 (47.9%) were on twice-a- week dialysis, while 266 (50.8%) underwent thrice-a-week dialysis and 6/373 (1.6%) underwent dialysis only once a week [Table 3].
Among 705 patients, 2.1% were seropositive for HB, whereas 14.3% were found to be seropositive for hepatitis C. Nearly 83.5% of the patients were negative for both HB and C, whereas none of the patients were found to be dual positive. Among the hub center the seropositivity for HB and C, respectively, was found in 40 (21.9%) patients and four (2.1%) patients, whereas at the spoke centers, it was seen in 61 (11.6%) and nine (2.1%) patients, respectively [Table 4]. Hepatitis C virus (HCV) positivity was statistically significantly higher at hub centers (P < 0.05). None of the patients were HIV positive as HIV patients were taken for CAPD [Table 3].
Patients with hemoglobin <11 were on erythropoietin mean dose of 4000 units per week and iron injections, i.e., IV iron sucrose 200 mg twice a month.
All the centers reported single-use dialyzer policy with 100% discarding of tubings and dialyzer for both negative and positive patients.
Technician-to-patient ratio was one technician for three dialysis patients at four centers, whereas in others, it was 1:2.
Water quality was tested every month for chemical quality and microbiological titers. All units showed colony-forming units/ milliliter of <100, while endotoxin level was <0.25 EU/mL. All the centers showed water quality as per the AAMI standards.
Supervision of centers
The hub center was monitored by nephro- logists, whereas the spoke centers were monitored locally by trained doctors. Patient data were uploaded by the spoke center which was reviewed by a hub nephrologist. The hub nephrologist visited the spoke center at regular intervals.
The mean distance traveled by the patients from their residence to the dialysis center was 5 km at all the centers.
The hub-and-spoke model was initiated in January 2018 at the Osmania hub center and subsequently at spoke centers. The mean dialysis vintage was nine months (3 months–16 months). During this period, there were 4.9% of deaths. Three patients underwent deceased donor transplantation.
Comparison of various parameters between the hub centers and spoke centers is shown in [Table 5]. The patients were on a standard dialysis prescription of 4 h dialysis per se ssion. KT/v at hub center was 1.28 ± 0.2, whereas that at spoke centers was 1.2 ± 0.11. The mean hemoglobin at hub centers was 9.9 ± 0.9 versus 9.3 ± 1.0 gm/dL at spoke centers. Use of erythropoietin at hub centers and spoke centers was 4000 units per week, which was provided free of cost for the patients. Nearly 8.2% and 10.1% of the patients required hospi- talization at hub-and-spoke centers, respectively. Emergency dialysis was required in 3.7% of patients at hub and 4.2% of patients at spoke centers. Thus, the outcomes between the hub- and-spoke centers were comparable. Shortterm outcomes were similar between those on thrice-a-week dialysis and those on twice-a- week dialysis with significant residual renal function.
| Discussion|| |
HD is an important modality of RRT. The HD facilities show a wide variation between the different Indian states. The Government of Telangana has initiated the hub-and-spoke model which is running in Telangana successfully. This model was started in Osmania in January 2018. This study provides short-term analysis of this model at the hub center of Osmania and its affiliated spoke centers.
The mean age of the patients in our study was 48.58 ± 13.59 years. There was no difference in the age between the two sexes. In a similar study done by Shaikh et al prior to 2012, the mean age of patients was found to be 44 years and approximately half of the patients were between the ages of 40 and 60 years. The mean age at the start of HD was slightly lower for females (42.9 vs. 44.4 years; P < 0.001) in that study. There were only two children on HD in our study. This may be due to the fact that most pediatric patients with ESRD are taken up for peritoneal dialysis (CAPD).
In the present study, the majority of patients were male, i.e., 74%, which is similar to the findings from other Indian studies.,,, This pattern exists in the developed world as well. A similar trend was reflected at the spoke centers as well, with more males availing treatment. Thus, there is a significant gender inequality in patients availing dialysis treatment. This exists irrespective of education status and is not different in urban or rural setting. This may be due to lack of awareness about kidney diseases and illiteracy among women. In addition, women have lesser access to health care compared to men.
The major vascular access in our study was AVF. More patients at spoke centers were on AVF (89.6%) than those at the hub center (65.8%). This was because most of the patients were diagnosed and initiated on dialysis at the hub center and then were subsequently referred to spoke centers after construction of AVF.
Most of the patients presented to the hub centers with advanced CKD. Nearly 90% were initiated on dialysis with nontunneled vascular catheter. Only 10% were initiated on dialysis through the fistula. In a study, Kosa and Lok showed that because of delayed presentation, a large proportion of patients in the developing countries of Asia are started on dialysis with temporary vascular access with femoral and uncuffed internal jugular catheters, thereby incurring an increased risk of catheter-related sepsis, with significant morbidity and morta- lity. This emphasizes the need for spreading awareness among primary care physicians (PCPs) and educating them about timely referral. Furthermore, presentation as ESRD highlights the lost opportunities of prevention of CKD due to absence of screening at the level of PCP, and this could be taken up as well in future government programs.
Awareness programs among PCPs about screening for CKD in diabetics and hypertensives and institution of lifestyle measures, control of hypertension and diabetes, and use of angiotensin-converting enzyme inhibitor and angiotensin receptor blockerss will go a long way toward preventing or retarding CKD.
In our study, HB seropositivity was 2.4%. However, the immunization coverage was not universal, and this may be one area where focus is needed in future to further reduce the incidence and prevalence of HB. In addition, seroconversion was not documented after vaccination due to nonavailability of anti-HBs titers.
HCV seropositivity was seen in 14% of dialysis population in our study. The prevalence of HCV infection in dialysis patients ranged between 0.7% and 18.1% in studies by Prasad and Jha and Johnson et al. Despite global recommendations to the contrary, some Indian experts have suggested the need to dialyze hepatitis C-infected patients in a separate area, as for HB as shown in a study by Agarwal. Similar practice was followed in our study. The prevalence figures for both hepatitis B virus and HCV are likely under- reported in other studies as they have reported positivity on the basis of antibody positivity rather than nucleic acid testing as reported by Potsangbam et al. The high prevalence of HCV in our study may be partly due to the antigen testing done in these patients at the hub center. Frequent referrals from other centers and also blood transfusions may have contributed to the high prevalence of HCV. Though there are separate machines for HCV in our unit, it is likely that infection may have not been diagnosed at the initiation of new patients transferred from other centers.
Nearly 67.5% of the patients at the hub center and 50.8% of the patients at spoke centers were on thrice-a-week dialysis in this study. This is in contrast to previous studies from India by Jha where most patients were on twice-a-week dialysis. This may be due to the increasing awareness among patients about the advantages of thrice-a-week dialysis and government’s support for thrice-a-week dialysis.
Erythropoietin and iron
The mean dose of erythropoietin was 4000 units per week. Iron injections were given twice a month, however the iron profile was not available.
To save costs, dialyzer reuse is practically universal in all the developing countries of Asia as reported by Dhrolia et al and Jha. The reuse practice, however, is not standardized. Untrained personnel perform dialyzer cleaning and reprocessing manually and the efficiency of reuse is not appropriately evaluated by standard measurements, with resultant effects on dialysis adequacy and outcomes.
All (100%) the patients under this scheme were on single-use dialysis. Single-use dialyzer policy was another unique feature of the scheme which may reduce the incidence of new blood-borne infections. It also reduces the workload on the dialysis staff and also prevents the transmission of infections among the workers as well.
In this hub-and-spoke model, the water quality at all centers was as per the AAMI criteria and was tested once in a month. This was supervised by the hub center and record of water analysis reports was maintained. This is in contrast to the previous studies where the quality of water treatment systems was reported as uneven, the quality of feed water was found to be variable, and the treatment systems were not optimized to ensure generation of a consistent supply of water that meets with acceptable quality standards. Testing frequencies were low and documentation was poor as shown in those studies., Water quality is especially important in countries where periodic rains and flooding lead to erosion of soil and variable contamination of surface water, which is the usual source for dialysis water. The Indian Society of Nephrology has developed guidelines to improve HD practices with emphasis on water quality.
Monitoring of center
Insufficient number and uneven distribution of trained medical and paramedical professionals, properly equipped facilities, and lack of guideline-driven treatment impact all aspects of kidney care in the region according to a study by Jha et al. There are 2000 nephro- logists in India, however the number of ESKD patients per year is two lakhs. Thus, there is a huge disparity between the supply and demand. To make the situation worse, most of the nephrologists are concentrated in the cities. In a study by Osman et al, it has been reported that there is a low nephrologist density in India [1.04 per million population (PMP)]. In the South Asian ISN region, all countries reported trainee densities below the global average. India reported very low density of nephrology trainees (0.24 PMP). The shortage can be attributed to many factors, such as immigration of skilled workers to developed countries for better payment and extended work hours in nephrology training. This study by Osman et al thus highlighted the dearth of qualified nephrology workforce in developing countries.
The hub-and-spoke model initiated by the Government of Telangana is one of the ways to solve the gap between the number of patients and inadequate number of nephro- logists. As described in our article, the hub- and-spoke model utilizes the services of non- nephrology specialists. All the peripheral centers were monitored by physicians, anesthetists, or intensivists local to those areas. These physicians underwent initial training at the hub center to make them competent in handling dialysis-related problems. These physicians work in close collaboration and under the supervision of the hub nephrologist. All critical patients were referred to the hub center for stabilization. Regular dialysis for stable patients was done at the spoke center itself. Once the patient was stabilized at the hub center, he/she was referred back to the spoke center. Thus, utilization of services of local physicians in the hub-and-spoke model bridges the gap between supply and demand to a large extent by utilizing the available resources.
The average distance traveled by the patient was 5 km in our study. Before the initiation of the hub-and-spoke model for dialysis, the patients had to travel from all over the state to the capital city of Hyderabad (i.e., > 100 km). Some patients were forced to travel 200 km to avail dialysis facility, and this was a major cause of dropouts from dialysis as this meant loss of daily wages in addition to the stress of travel. This problem has been addressed to a large extent by the hub-and-spoke model of dialysis, and this is one of the major advantages of this model. Similar models exist in developed countries. In the USA, 77% of rural counties lack dialysis facilities. Thakar from the University of Cincinnati developed a tele- nephrology program under which they were able to administer dialysis treatments at rural level and 67% of patients were successfully treated and discharged from a rural hospital. Most renal units in the UK adopt a hub-and-spoke model to deliver HD to patients close to home. Patients travel to the main unit only for treatment of acute medical problems and hospitalization.
In a study by Shaikh et al from India, survival on HD was poor, and there was a high dropout rate, with only 53% of patients continuing dialysis for > 6 months. In an African study, only approximately 10% of African adults with incident ESKD continued dialysis for > 3 months, with patients stopping dialysis after a mean of 6.5 sessions only. However, in our study, there were 79.4% of patients who were on dialysis for > 6 months. The reported 1-year survival rates were 70% in Myanmar and about 90% in the Philippines in a study by Naramura et al. Data from the Taiwan registry by Wu et al showed a 1st-year mortality of 15%. In the USA, as per the United States Renal Data System Report, the expected remaining lifespan on dialysis was approximately 10.5 years for dialysis patients aged 40–44 years and approximately 5.5 years for those aged 60–64 years. In our study, 95% of the patients were alive after a mean period of nine months. However, longer follow-up will throw better light on patients’ survival. The reason for improving survival in our study may be delivery of dialysis at the doorstep, increasing patient awareness about dialysis, and providing emphasis on thrice-a- week dialysis.
| Conclusion|| |
The hub-and-spoke model of dialysis can provide a solution in the Indian context by bringing dialysis to the doorstep of all patients irrespective of their place of residence. It may help improve dialysis outcomes as these centers are monitored locally by trained physicians and are under the direct supervision of nephrologists. This helps in effective utilization of the available workforce in resource- limited settings. This model may serve as the first step toward improving the quality of dialysis in addition to providing dialysis at point of care.
Conflict of interest: None declared.
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Department of Nephrology, Osmania General Hospital, Hyderabad 500012, Telangana
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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