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Dialysis outcomes in India: a pilot study.1 Vivekanand Jha Executive Director, The George Institute for Global Health, India James Martin Fellow, The George Institute for Global Health, University of Oxford Oommen John Senior Research Fellow, The George Institute for Global Health, India Rohina Joshi Senior Research Fellow, The George Institute for Global Health, Australia Senior Lecturer, The University of Sydney, Australia Sradha Kotwal Research Fellow, The George Institute for Global Health, Australia Beverley Essue Research Fellow, The George Institute for Global Health, Australia Stephen Jan Professor of Health Economics, The George Institute for Global Health, Australia Martin Gallagher
Senior Director, Renal & Metabolic Division, The George Institute for Global Health, Australia
Associate Professor of Medicine, University of Sydney, Australia. John Knight Professorial Fellow, The George Institute for Global Health, Australia Adjunct Professor of Medicine, University of Sydney, Australia
CORRESPONDING AUTHOR Dr John Knight, Professorial Fellow, The George Institute for Global Health, Level 10, King George V Building, Royal Prince Alfred Hospital, NSW, Australia
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/nep.12404
1 This article is protected by copyright. All rights reserved.
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Missenden Rd Camperdown NSW 2050 Australia Tel:+61 2 9657 0300
Fax:+61 2 9657 0301
email: [email protected]
ABSTRACT Long term prospective studies of health outcomes for dialysis patients are common in many parts of the world, but have been rare in India. As renal replacement therapy becomes more widespread and more affordable, the measurement of patient outcomes and comparison with national and international benchmarks will be a valuable tool in planning health services and demonstrating effective use of resources. To this end we describe a pilot study of dialysis outcomes in India which could form the basis of a comprehensive national program of data collection Methods. 100 incident patients commencing chronic haemodialysis in two north Indian nephrology centres will be followed prospectively for 12 months. Clinical outcome data will be collected comparable to that used by established dialysis registries in other countries. The economic impact of dialysis upon patients is central to the use of this treatment, so data will be collected on the direct and indirect costs of the treatment and the economic impact of dialysis on the patient and their family. Value of project. This prospective cohort study of dialysis outcomes in northern India is a pilot for the collection of similar comparative data in dialysis centres in different states across the country with a view to the development of a national dialysis registry. The information on the economic impact of dialysis on patients and their families will provide one of the first detailed insights into this critical aspect of dialysis services.
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INTRODUCTION
The development of maintenance dialysis as a treatment for end stage kidney disease (ESKD) in the early nineteen sixties was a landmark in human therapeutics. From the earliest days, nephrologists have recorded the health outcomes of patients undergoing this life saving treatment in prospective cohort studies. Over the subsequent decades these national and international renal clinical registries have provided invaluable information on disease burden
estimates, treatment practices, risk factors, survival, and impact of disease prevention programs.
Data repositories such as the United States Renal Data Service1 and the European Dialysis and Transplant Registry2 have prospectively tracked the steady improvement in health
outcomes for dialysis patients over the ensuing 50 years. Special mention should be made in this context of the Australian and New Zealand Dialysis and Transplant Registry3, one of the
oldest and best exemplars in the world, which boasts a complete collection of health outcomes data for patients with treated ESKD in these two countries since 1963.
The many hundreds of scientific publications from these renal registries over the decades since their formation have been central to the dramatic improvement in patient outcomes and the subsequent expansion of dialysis treatment . They set the standards for what can be expected by way of health outcomes from dialysis treatment, and are widely used for this purpose by patients, clinicians, hospitals and funding agencies to benchmark the quality of care. Registries have also informed policy for early detection of kidney disease: the
inexorable rise in ESRD in Taiwan and Cuba prompted policymakers to focus on new strategies for disease prevention4,5. More recently, since 1996, the international Dialysis Outcomes and Practice Patterns Study (DOPPS)6 has benchmarked the results of
haemodialysis in 20 countries around the world, using a carefully designed random sampling 3 This article is protected by copyright. All rights reserved.
Accepted Article
method. DOPPS data, published in over 170 articles in the medical literature, provide a vivid snapshot of the success story of dialysis treatment in participating countries.
DIALYSIS IN INDIA
Projections of worldwide population changes suggest that ESKD is becoming more common, and that there will be a disproportionate rise in the number of cases of ESKD in countries like India as the numbers of elderly people and those with hypertension and diabetes grows7. This increase in incidence is being accompanied by an increase in demand for effective treatments.
For India, a landmark inflexion point was reached around 2001. In that year a national government health survey recorded that deaths from the non-communicable diseases - heart disease, diabetes, stroke, kidney failure - had overtaken deaths from communicable diseases malnutrition, infectious diseases, perinatal mortality - as the leading causes of mortality in national health statistics 8,9 In 2012, India launched a National Prevention & Control of Non
Communicable Diseases, which includes chronic kidney disease.
As a natural consequence, members of the burgeoning middle and upper classes of Indian society have come to expect that their elderly relatives will have access to renal replacement therapies as their kidneys fail, just as their Western counterparts do. This change in healthcare seeking behaviour of families with rising incomes and increased access to on line information has led to a dramatic increase in demand for RRT, reflected in the rapid growth in number of dialysis units10.
The annual unadjusted annual incidence of ESKD in India has been estimated at around 150 per million population11. Currently in India there are reported to be around 1500 dialysis centres run by around 1000 nephrologists, dialysing 50,000 patients12. Some of the dialysis services are in public hospitals and offer limited free or subsidised dialysis. There are some 4 This article is protected by copyright. All rights reserved.
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small-scale philanthropic programs which provide dialysis to the needy. Many state funded insurance schemes now fund dialysis. There are also some for-profit dialysis centres, which offer dialysis and renal transplantation to patients on a full cost recovery basis. There have been some innovative models of dialysis centres under Public Private Partnership, where dialysis units are set up by the private players within a public delivery system that provides dialysis services at an agreed cost subsidised by the government, however these models are yet to be pragmatically evaluated. This clinical capacity should be viewed in light of the estimated 180,000 new patients entering ESKD each year. Demand for dialysis services in India is said to be growing at the rate of 31% per annum, and the size of the dialysis market is said to have increased in value from $100 million in 2007 to $150 million in 201212.
The time for the introduction of standardised systems for measuring dialysis outcomes in India is now. There have been a number of single centre case series reported13,14, but there is
currently no systematic prospective national renal data collection system in India. To complicate matters, in the absence of a systematic referral system for ESRD patients, following up patients is difficult as they often change dialysis units. This is one of the reasons there are no long term studies on dialysis patients. As the numbers of people requiring and gaining access to dialysis increases, prospective data on their baseline characteristics and outcomes will be essential for measuring service quality.
THE COST OF DIALYSIS TREATMENT
ESKD is a significant cause of morbidity and mortality in both developed and developing countries15. In wealthy countries treatment of ESKD with renal replacement therapy (RRT) in the form of dialysis or renal transplantation is considered best practice, even in elderly patients. Access to these therapies is constrained by cost considerations and capacity in developing countries such as India with limited health budgets 16. 5 This article is protected by copyright. All rights reserved.
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Fewer than 10% of Indian patients who develop ESKD currently receive RRT, with up to 70% of those that start dialysis dying or stopping treatment within the first 3 months, often for reasons of cost17. These treatment initiation and survival rates compare unfavourably with those seen in dialysis services in wealthy countries. In Japan, for example, 91% of patients commencing dialysis at one unit under the age of 70 were still alive after 12 months of treatment18.
Dialysis is expensive, and ESKD creates a significant financial burden on families, even in
affluent countries where the actual dialysis treatment is provided free by the state19. The direct costs of this treatment are a major consideration in India. Total health expenditure in
India in 2011 stood at just 3.9% of GDP or US$7 per capita per annum with only 0.65 physicians and 0.9 hospital beds per thousand population20. Many competing health priorities have made a greater call on the public purse than chronic dialysis, even though dialysis costs are relatively modest in India. A recent analysis estimated that a single haemodialysis session
cost around US$30 in a public hospital, so that dialysis twice a week for a year would cost around US$300016. This is ten to twentyfold less than the cost of dialysis treatment in many
wealthy countries. However the unadjusted gross national income (GNI) per capita in India is US$1040, and two thirds of the population of 1.2 billion live on less than US$2 a day20. Without financial support from family, philanthropy or the government, dialysis is beyond the financial reach of the majority of Indian patients with ESKD. Dialysis is therefore most often seen as a short term bridging treatment to kidney transplantation, most commonly from a living donor.
The availability of funding can have a significant impact on health outcomes for individual patients because India presently has no national health insurance system or governmentfunded program to meet the cost of the treatment of ESKD. Even a successful kidney transplant often leads to catastrophic out-of-pocket healthcare expenditure, pushing families 6
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further into poverty21. For this reason our study will also collect health economic information
on the direct and indirect costs of dialysis treatment, sources of funding, and the economic impact of dialysis on patients and their families.
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PROTOCOL
This protocol describes a twelve month prospective pilot cohort study of dialysis outcomes in 100 patients in two clinics in Northern India. It is intended that this project, along with other similar studies in other parts of India, could be a forerunner of the establishment of a national Indian ESKD treatment registry, with the support of the Indian Society of Nephrology, of commercial dialysis providers, and of state and national health authorities.
The methodology for this prospective cohort study is modeled on the recommendations for observational studies of the World Health Organisation, which combine simplicity with rigour and offer an approach which we consider will work well in a resource constrained environment22. We have also considered the standards of practice for observational research set out in the STROBE statement23,24 . As it is a pilot study, we have taken note of the advice of Thabane et al on the role of pilot studies in determining the feasibility of future research25.
Methodologies for the collection and analysis of ESKD treatment data are mature and relatively well defined through decades of experience in the large, longstanding renal registries. The protocol makes use of some of the same data fields and analytic approaches as ANZDATA3, drawing on Australia's long experience of collecting and analysing this kind of information.
This protocol has been approved by the Institutional Ethics Committees at the study hospital sites in Chandigarh and Delhi in northern India and registered with the Clinical Trials Registry–India maintained by the National Institute of Medical Statistics of the Indian Council of Medical Research (CTRI/2014/12/005283)26.
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METHODS Study objectives and design. This pilot study is intended as a proof of concept feasibility study to enable the planning of a more comprehensive national survey. The aims are to 1. Enrol a cohort of ESKD patients in Indian tertiary referral nephrology services in two northern cities (Chandigarh and Delhi),
2. Characterise the demographic and clinical characteristics of patients starting dialysis, including their age, gender, and socio-economic status,
3. Document the cause of ESKD in patients starting dialysis and capture their presentation, recent history, comorbidities, and state of health at the time of commencing dialysis,
4. Record the type of dialysis provided, access, regimen and the associated direct costs of care,
5. Measure the economic impact on the patient and their family of the decision to commence dialysis, including health care related transport and accommodation costs, any loss of livelihood for the patient and family members, and costs associated with sale of assets or borrowing to pay for treatment.
6. Follow up the cohort prospectively and record major health events such as hospitalisation, renal transplantation, cardiovascular events and death,
7. Explore the reasons for ceasing dialysis and examine cause of death via verbal autopsy,
8. Construct a Kaplan Meier life table for survival on dialysis for the first 12 months of treatment, with interim analyses at 3 months and six months.
9. Demonstrate that it is feasible to undertake a prospective cohort study of this type in dialysis patients in India
10. Provide preliminary data to be used in a grant application to support a larger national study with adequate statistical power to address these questions in more depth. 9
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Study sites. The criteria for unit selection will be willingness to enter the study and capacity to undertake clinical research, including an ethical approval apparatus, clinical trial trained nursing and medical staff and access to appropriate IT support.
The pilot study will be conducted at Medanta Hospital (private) in New Delhi and at Post Graduate Institute (PGI) (public) in Chandigarh. Each hospital will provide a study coordinator and hardware.
Subjects. 50 patients in each units = 100 subjects in total in the pilot. These numbers have been determined pragmatically with a view to early implementation of the pilot study.
Inclusion criteria. Patients 18 years or older without life threatening comorbidities commencing either haemodialysis or peritoneal dialysis for the treatment of ESKD.
Exclusion criteria. Start of dialysis in ICU or dialysis initiation for acute kidney injury.
Study process and procedures. One full time local research fellow will be responsible for
the day-to-day conduct of the study. Clinical and demographic data (Table 1) will be recorded at entry to the study. The subjects’ clinical status and current dialysis treatment and any adverse events believed to be related to the study conduct will be recorded at entry (Table 1) then at 1 month, 3 months, 6 months and one year, together with significant clinical events (Table 2). Interim analyses of outcome data will be performed at 3 months, 6 months and 12 months. If patients transfer between dialysis units every effort will be made to continue prospective follow up at the new centre. A dedicated study phone number will be shared with the participants to report any major events while enrolled in study. This service will also function as an informal patient tracking mechanism.
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Informed consent. Patients will provide written informed consent for inclusion in the study. A patient information leaflet and informed consent form have been created in English and Hindi. Patients will be able to withdraw consent if they choose at anytime. The data provided to the research team will not contain any identifiable information. Identifiable information will be retained at the sites.
Confidentiality and privacy. The risk to privacy of participants from the misuse of personal information is low. Staff at the sites involved as well as The George Institute sign a confidentiality agreement at the commencement of employment and receive regular privacy & confidentiality training. All participants will be assigned a study number and only deidentified clinical data will be stored in the computerised data collection system. Access to the clinical data will be via a computer and requires two passwords. Password protected screensavers will be used when information is unattended. The researchers will store study data on a secure network, protected by a firewall. All digital files will be password protected. Any paper documents generated from this project will be scanned and stored electronically on a secure network and, if not scanned, will be stored in a locked cabinet in the research office of The George Institute for Global Health, India. All data will be reported in aggregated form and there is no potential for reports or presentations to publically identify any individual or organization.
Data storage and record retention. Data will be stored as outlined above. Researchers will be provided with de-identified data and this dataset will be retained by the researchers for 7 years following the conclusion of the study to ensure it is available for academic queries regarding the results or methodology.
Outcome measures. Primary outcome measure. Survival on ESKD therapy. 11
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Secondary outcome measures. ESKD treatment modality chosen (PD, HD, transplant), modality survival (changes from one treatment modality to another), transplantation events (source of donor, time to transplantation, immunosuppression regimen), transplantation outcomes (patient survival, graft survival), voluntary withdrawal from treatment and reasons for withdrawal, direct and indirect costs, economic impact on the patient and their family.
Assessment of safety. This is a prospective observational cohort study with no interventions. The likelihood of a study participant suffering harm from participation in this research is thought to be remote. The risks to patient privacy and confidentiality are considered to be minimal as no patient identifying data will leave study sites and the researchers will not have access to identifiable data. All data will be reported in aggregated form with a minimum cell size of 5 to reduce the potential for reports or presentations to identify any individual or organization. Any adverse events thought to be related specifically to the conduct of the study will be reported to the study Steering Committee to then to the supervising Ethics Committee(s) .
Statistics. A descriptive statistical analysis of all study participants will be presented. Survival profile of patient will be provided by means of Kaplan-Meier survival curves stratified by some baseline characteristics such as gender, socio-economic status and type of dialysis treatment. Log rank test will be used to test any significance difference in survival
between groups. All time-to-event secondary endpoints will be analysed using the same principles. The other type of outcomes will be described, mean and standard deviation for continuous outcomes with frequency / ratio for binary outcomes. Quantified differences in
patients’ characteristics will be assessed by means of hazard ratio for time-to-event outcomes, mean difference for continuous outcomes and relative risk for binary outcomes.
Data collection, management and quality assurance. Consideration will be given to the practicality of using direct data entry into a web-based online data collection system rather 12
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than paper clinical record forms. Access to the data collection system will be restricted to approved study personnel and will require a username and password. All patient identifiers, demographics, and health information will be stored securely on computer servers with password protection in a locked room of a secure building with onsite security personnel and card access at the coordinating centre. Access to the data will require a username/password combination with study staff only having access to data appropriate to their role in the study.
The researchers will store study data on a secure network, protected by a firewall with no files containing any names or addresses of individual participants. All digital files will be password protected. Any paper documents generated from this project will be scanned and stored electronically on a secure network and, if not scanned, will be stored in a locked cabinet in the research office of The George Institute, India.
All data generated from this project will be stored for 7 year after cessation of the study to ensure availability in the event of academic queries about the methods or results. After this time period, source information will be disposed securely i.e. paper documents will be shredded and computerised data will be permanently erased and back-ups physically destroyed.
Expected outcomes of the study. 1. Feasibility analysis for larger multicentre nationwide study 2. Estimates of survival on dialysis 3. Better understanding of reasons for stopping dialysis 4. Up to date analysis of dialysis costs and funding sources
Ethical considerations and trial registration. Ethical approval has been obtained from the institutional ethics committee at each centre. The study will be performed in accordance with the ethical standards of the Declaration of Helsinki and Declaration of Istanbul.
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Costs. Full funding for this pilot study will be provided by the George Institute for Global Health.
CONCLUSION This pilot study will be the first multicentre prospective study of health outcomes in Indian dialysis patients, and the first to collect detailed information on the economics of dialysis in India and its impact upon patients and their families. This study will inform planning for dialysis services in India and provide feasibility data to support the development of a national registry of dialysis outcomes in Indian patients.
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REFERENCES 1.
US Renal Data Service. http://usrds.org.
2.
European Dialysis and Transplant Registry. http://era-edta-reg.org
3.
Australian New Zealand Dialysis and Transplant Registry. http://anzdata.org.
4.
Hwang SJ, Tsai JC CH. Epidemiology, impact and preventive care of chronic kidney
disease in Taiwan. Nephrology (Carlton). 2010;15(suppl 2):3–9.
5.
Almaguer M, Herrera R, Alfonso J, Magrans C, Manalich R, Martinez A. Primary
health care strategies for the prevention of end-stage renal disease in Cuba. Kidney Int. 2005;68:S4-S10. doi:10.1111/j.1523-1755.2005.09701.x.
6.
Dialysis Outcomes and Practice Patterns Study. http://dopps.org.
7.
Jha V, Garcia-Garcia G, Iseki K, et al. Chronic kidney disease: Global dimension and
perspectives. Lancet. 2013;382:260-272. doi:10.1016/S0140-6736(13)60687-X.
8.
Registrar-General of India. Summary Statistics of Causes of Death India. New Delhi,
Ministry of Home Affairs 2008.
9.
Joshi R, Cardona M, Iyengar S, et al. Chronic diseases now a leading cause of death in
rural India--mortality data from the Andhra Pradesh Rural Health Initiative. Int J Epidemiol. 2006;35:1522-1529. doi:10.1093/ije/dyl168.
10.
Jha V. Current status of end-stage renal disease care in India and Pakistan. Kidney Int
Suppl. 2013;3(2):157-160. doi:10.1038/kisup.2013.3.
11.
Modi GK, Jha V. The incidence of end-stage renal disease in India: a population-based
study. Kidney Int. 2006;70(12):2131-3. doi:10.1038/sj.ki.5001958.
15 This article is protected by copyright. All rights reserved.
Gross A. India’s dialysis market. Published July 10th 2013 in Medical Device Daily by
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12.
Pacific Bridge Medical. http://www.pacificbridgemedical.com/publications/high-ratesof-chronic-kidney-disease-lead-to-medtech-opportunities-in-india/. Accessed 18th
May 2014.
13.
Rao M, Juneja R, Shirly RBM, Jacob CK. Haemodialysis for end-stage renal disease
in Southern India — a perspective from a tertiary referral care centre. Nephrol Dial Transplant. 1998;13:2494-2500.
14.
Chandrashekar A, Ramakrishnan S, Rangarajan D. Survival analysis of patients on
maintenance haemodialysis. Indian J Nephrol. 2014;24:206-213.
15.
Eckardt KU, Coresh J, Devuyst O, et al. Evolving importance of kidney disease: From
subspecialty to global health burden. Lancet. 2013;382:158-169. doi:10.1016/S01406736(13)60439-0.
16.
Khanna U. The economics of dialysis in India. Indian J Nephrol. 2009;19:1-4.
17.
Sakhuja V, Sud K. End-stage renal disease in India and Pakistan: burden of disease
and management issues. Kidney Int Suppl. 2003;63(83):S115-8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12864888.
18.
Masakane I. High-quality dialysis: a lesson from the Japanese experience: Effects of
membrane material on nutritional status and dialysis-related symptoms. Clin Kidney J. 2010;3(suppl 1):i28-i35. doi:10.1093/ndtplus/sfq034.
19.
Essue BM, Wong G, Chapman J, Li Q, Jan S. How are patients managing with the
costs of care for chronic kidney disease in Australia? A cross-sectional study. BMC Nephrol. 2013;14(1):5. doi:10.1186/1471-2369-14-5.
20.
South Asia: India. CIA Factbook 2014. https://www.cia.gov/library/publications/the-
world-factbook/geos/in.html. Accessed 18th May 2014. 16 This article is protected by copyright. All rights reserved.
Ramachandran R, Jha V. Kidney transplantation is associated with catastrophic out of
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21.
pocket expenditure in India. PLoS One. 2013;8(7):e67812.
doi:10.1371/journal.pone.0067812.
22.
WHO template for protocols for observational studies.
http://www.who.int/rpc/research_ethics/format_rp/en/. Accessed 18th May 2014.
23.
The STROBE Statement. http://strobe-statement.org.
24.
Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The
Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies. Int J Surg. 2014;4(10):1623-1627. doi:10.1016/j.ijsu.2014.07.013.
25.
Thabane L, Ma J, Chu R, et al. A tutorial on pilot studies: the what, why and how.
BMC Med Res Methodol. 2010;10:1. doi:10.1186/1471-2288-10-1.
26.
Clinical Trials Registry - India. http://www.ctri.nic.in.
17 This article is protected by copyright. All rights reserved.
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TABLES Table 1. Data collection at entry to study Demographics and economic status
Medical history
Name (first, last +/- alias) DOB
Sex
Address
Primary Phone
Secondary Phone
Household composition
Employment status
Annual household income bracket
Health insurance status
Out of pocket expenses
Travel cost
Cost of treatment
Income/support
Social supports
Socioeconomic measures
Cause of ESKD
Diabetes
Hypertension
Coronary artery disease
Ischaemic heart disease
Cerebrovascular disease
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Initial Dialysis history
Laboratory results at entry to dialysis
Drug treatment at entry to dialysis
Dialysis Facility
Peripheral vascular disease
Chronic lung disease
TB
Cancer
Smoking
Pre-ESKD care
Other health conditions
Date of first dialysis
Type of dialysis
Prescription (Duration/number of sessions)
Access type
Potassium
Creatinine
Urea
Haemoglobin
Erythropoetin
Phosphate binders
Herbal medicines
Quality of life
Number of chairs
Sessions offered
Staffing: nurses/technicians
Staff:patient ratio
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Table 2. Data collection at intervals 1 month, 3 months, 6 months, 1 year Economic outcomes
Major clinical events
Current dialysis history
Employment Status
Current Out of pocket expenses
Travel cost
Cost of treatment
Current income bracket
Social supports
Socioeconomic measures
Source of funds for ESKD treatment
Still alive? Yes/No
Cause of death if deceased. Verbal autopsy
Change in modality of ESKD
Nature of change
Reason for change
Renal transplant?
Source of kidney
Graft still working
If no, reason for loss
Unplanned hospitalisation
Cardiovascular events
Cancer
AE related to study
Date of first dialysis
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Most recent lab data
Current drugs
Quality of life
Current Type of dialysis
Prescription (Duration/number of sessions)
Access type
Potassium
Creatinine
Urea
Haemoglobin level
Erythropoietin
Phosphate binders
Herbal medicines
21 This article is protected by copyright. All rights reserved.
Dialysis outcomes in India: a pilot study.1 Vivekanand Jha Executive Director, The George Institute for Global Health, India James Martin Fellow, The George Institute for Global Health, University of Oxford Oommen John Senior Research Fellow, The George Institute for Global Health, India Rohina Joshi Senior Research Fellow, The George Institute for Global Health, Australia Senior Lecturer, The University of Sydney, Australia Sradha Kotwal Research Fellow, The George Institute for Global Health, Australia Beverley Essue Research Fellow, The George Institute for Global Health, Australia Stephen Jan Professor of Health Economics, The George Institute for Global Health, Australia Martin Gallagher
Senior Director, Renal & Metabolic Division, The George Institute for Global Health, Australia
Associate Professor of Medicine, University of Sydney, Australia. John Knight Professorial Fellow, The George Institute for Global Health, Australia Adjunct Professor of Medicine, University of Sydney, Australia
CORRESPONDING AUTHOR Dr John Knight, Professorial Fellow, The George Institute for Global Health, Level 10, King George V Building, Royal Prince Alfred Hospital, NSW, Australia
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/nep.12404
1 This article is protected by copyright. All rights reserved.
Accepted Article
Missenden Rd Camperdown NSW 2050 Australia Tel:+61 2 9657 0300
Fax:+61 2 9657 0301
email: [email protected]
ABSTRACT Long term prospective studies of health outcomes for dialysis patients are common in many parts of the world, but have been rare in India. As renal replacement therapy becomes more widespread and more affordable, the measurement of patient outcomes and comparison with national and international benchmarks will be a valuable tool in planning health services and demonstrating effective use of resources. To this end we describe a pilot study of dialysis outcomes in India which could form the basis of a comprehensive national program of data collection Methods. 100 incident patients commencing chronic haemodialysis in two north Indian nephrology centres will be followed prospectively for 12 months. Clinical outcome data will be collected comparable to that used by established dialysis registries in other countries. The economic impact of dialysis upon patients is central to the use of this treatment, so data will be collected on the direct and indirect costs of the treatment and the economic impact of dialysis on the patient and their family. Value of project. This prospective cohort study of dialysis outcomes in northern India is a pilot for the collection of similar comparative data in dialysis centres in different states across the country with a view to the development of a national dialysis registry. The information on the economic impact of dialysis on patients and their families will provide one of the first detailed insights into this critical aspect of dialysis services.
2 This article is protected by copyright. All rights reserved.
Accepted Article
INTRODUCTION
The development of maintenance dialysis as a treatment for end stage kidney disease (ESKD) in the early nineteen sixties was a landmark in human therapeutics. From the earliest days, nephrologists have recorded the health outcomes of patients undergoing this life saving treatment in prospective cohort studies. Over the subsequent decades these national and international renal clinical registries have provided invaluable information on disease burden
estimates, treatment practices, risk factors, survival, and impact of disease prevention programs.
Data repositories such as the United States Renal Data Service1 and the European Dialysis and Transplant Registry2 have prospectively tracked the steady improvement in health
outcomes for dialysis patients over the ensuing 50 years. Special mention should be made in this context of the Australian and New Zealand Dialysis and Transplant Registry3, one of the
oldest and best exemplars in the world, which boasts a complete collection of health outcomes data for patients with treated ESKD in these two countries since 1963.
The many hundreds of scientific publications from these renal registries over the decades since their formation have been central to the dramatic improvement in patient outcomes and the subsequent expansion of dialysis treatment . They set the standards for what can be expected by way of health outcomes from dialysis treatment, and are widely used for this purpose by patients, clinicians, hospitals and funding agencies to benchmark the quality of care. Registries have also informed policy for early detection of kidney disease: the
inexorable rise in ESRD in Taiwan and Cuba prompted policymakers to focus on new strategies for disease prevention4,5. More recently, since 1996, the international Dialysis Outcomes and Practice Patterns Study (DOPPS)6 has benchmarked the results of
haemodialysis in 20 countries around the world, using a carefully designed random sampling 3 This article is protected by copyright. All rights reserved.
Accepted Article
method. DOPPS data, published in over 170 articles in the medical literature, provide a vivid snapshot of the success story of dialysis treatment in participating countries.
DIALYSIS IN INDIA
Projections of worldwide population changes suggest that ESKD is becoming more common, and that there will be a disproportionate rise in the number of cases of ESKD in countries like India as the numbers of elderly people and those with hypertension and diabetes grows7. This increase in incidence is being accompanied by an increase in demand for effective treatments.
For India, a landmark inflexion point was reached around 2001. In that year a national government health survey recorded that deaths from the non-communicable diseases - heart disease, diabetes, stroke, kidney failure - had overtaken deaths from communicable diseases malnutrition, infectious diseases, perinatal mortality - as the leading causes of mortality in national health statistics 8,9 In 2012, India launched a National Prevention & Control of Non
Communicable Diseases, which includes chronic kidney disease.
As a natural consequence, members of the burgeoning middle and upper classes of Indian society have come to expect that their elderly relatives will have access to renal replacement therapies as their kidneys fail, just as their Western counterparts do. This change in healthcare seeking behaviour of families with rising incomes and increased access to on line information has led to a dramatic increase in demand for RRT, reflected in the rapid growth in number of dialysis units10.
The annual unadjusted annual incidence of ESKD in India has been estimated at around 150 per million population11. Currently in India there are reported to be around 1500 dialysis centres run by around 1000 nephrologists, dialysing 50,000 patients12. Some of the dialysis services are in public hospitals and offer limited free or subsidised dialysis. There are some 4 This article is protected by copyright. All rights reserved.
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small-scale philanthropic programs which provide dialysis to the needy. Many state funded insurance schemes now fund dialysis. There are also some for-profit dialysis centres, which offer dialysis and renal transplantation to patients on a full cost recovery basis. There have been some innovative models of dialysis centres under Public Private Partnership, where dialysis units are set up by the private players within a public delivery system that provides dialysis services at an agreed cost subsidised by the government, however these models are yet to be pragmatically evaluated. This clinical capacity should be viewed in light of the estimated 180,000 new patients entering ESKD each year. Demand for dialysis services in India is said to be growing at the rate of 31% per annum, and the size of the dialysis market is said to have increased in value from $100 million in 2007 to $150 million in 201212.
The time for the introduction of standardised systems for measuring dialysis outcomes in India is now. There have been a number of single centre case series reported13,14, but there is
currently no systematic prospective national renal data collection system in India. To complicate matters, in the absence of a systematic referral system for ESRD patients, following up patients is difficult as they often change dialysis units. This is one of the reasons there are no long term studies on dialysis patients. As the numbers of people requiring and gaining access to dialysis increases, prospective data on their baseline characteristics and outcomes will be essential for measuring service quality.
THE COST OF DIALYSIS TREATMENT
ESKD is a significant cause of morbidity and mortality in both developed and developing countries15. In wealthy countries treatment of ESKD with renal replacement therapy (RRT) in the form of dialysis or renal transplantation is considered best practice, even in elderly patients. Access to these therapies is constrained by cost considerations and capacity in developing countries such as India with limited health budgets 16. 5 This article is protected by copyright. All rights reserved.
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Fewer than 10% of Indian patients who develop ESKD currently receive RRT, with up to 70% of those that start dialysis dying or stopping treatment within the first 3 months, often for reasons of cost17. These treatment initiation and survival rates compare unfavourably with those seen in dialysis services in wealthy countries. In Japan, for example, 91% of patients commencing dialysis at one unit under the age of 70 were still alive after 12 months of treatment18.
Dialysis is expensive, and ESKD creates a significant financial burden on families, even in
affluent countries where the actual dialysis treatment is provided free by the state19. The direct costs of this treatment are a major consideration in India. Total health expenditure in
India in 2011 stood at just 3.9% of GDP or US$7 per capita per annum with only 0.65 physicians and 0.9 hospital beds per thousand population20. Many competing health priorities have made a greater call on the public purse than chronic dialysis, even though dialysis costs are relatively modest in India. A recent analysis estimated that a single haemodialysis session
cost around US$30 in a public hospital, so that dialysis twice a week for a year would cost around US$300016. This is ten to twentyfold less than the cost of dialysis treatment in many
wealthy countries. However the unadjusted gross national income (GNI) per capita in India is US$1040, and two thirds of the population of 1.2 billion live on less than US$2 a day20. Without financial support from family, philanthropy or the government, dialysis is beyond the financial reach of the majority of Indian patients with ESKD. Dialysis is therefore most often seen as a short term bridging treatment to kidney transplantation, most commonly from a living donor.
The availability of funding can have a significant impact on health outcomes for individual patients because India presently has no national health insurance system or governmentfunded program to meet the cost of the treatment of ESKD. Even a successful kidney transplant often leads to catastrophic out-of-pocket healthcare expenditure, pushing families 6
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further into poverty21. For this reason our study will also collect health economic information
on the direct and indirect costs of dialysis treatment, sources of funding, and the economic impact of dialysis on patients and their families.
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PROTOCOL
This protocol describes a twelve month prospective pilot cohort study of dialysis outcomes in 100 patients in two clinics in Northern India. It is intended that this project, along with other similar studies in other parts of India, could be a forerunner of the establishment of a national Indian ESKD treatment registry, with the support of the Indian Society of Nephrology, of commercial dialysis providers, and of state and national health authorities.
The methodology for this prospective cohort study is modeled on the recommendations for observational studies of the World Health Organisation, which combine simplicity with rigour and offer an approach which we consider will work well in a resource constrained environment22. We have also considered the standards of practice for observational research set out in the STROBE statement23,24 . As it is a pilot study, we have taken note of the advice of Thabane et al on the role of pilot studies in determining the feasibility of future research25.
Methodologies for the collection and analysis of ESKD treatment data are mature and relatively well defined through decades of experience in the large, longstanding renal registries. The protocol makes use of some of the same data fields and analytic approaches as ANZDATA3, drawing on Australia's long experience of collecting and analysing this kind of information.
This protocol has been approved by the Institutional Ethics Committees at the study hospital sites in Chandigarh and Delhi in northern India and registered with the Clinical Trials Registry–India maintained by the National Institute of Medical Statistics of the Indian Council of Medical Research (CTRI/2014/12/005283)26.
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METHODS Study objectives and design. This pilot study is intended as a proof of concept feasibility study to enable the planning of a more comprehensive national survey. The aims are to 1. Enrol a cohort of ESKD patients in Indian tertiary referral nephrology services in two northern cities (Chandigarh and Delhi),
2. Characterise the demographic and clinical characteristics of patients starting dialysis, including their age, gender, and socio-economic status,
3. Document the cause of ESKD in patients starting dialysis and capture their presentation, recent history, comorbidities, and state of health at the time of commencing dialysis,
4. Record the type of dialysis provided, access, regimen and the associated direct costs of care,
5. Measure the economic impact on the patient and their family of the decision to commence dialysis, including health care related transport and accommodation costs, any loss of livelihood for the patient and family members, and costs associated with sale of assets or borrowing to pay for treatment.
6. Follow up the cohort prospectively and record major health events such as hospitalisation, renal transplantation, cardiovascular events and death,
7. Explore the reasons for ceasing dialysis and examine cause of death via verbal autopsy,
8. Construct a Kaplan Meier life table for survival on dialysis for the first 12 months of treatment, with interim analyses at 3 months and six months.
9. Demonstrate that it is feasible to undertake a prospective cohort study of this type in dialysis patients in India
10. Provide preliminary data to be used in a grant application to support a larger national study with adequate statistical power to address these questions in more depth. 9
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Study sites. The criteria for unit selection will be willingness to enter the study and capacity to undertake clinical research, including an ethical approval apparatus, clinical trial trained nursing and medical staff and access to appropriate IT support.
The pilot study will be conducted at Medanta Hospital (private) in New Delhi and at Post Graduate Institute (PGI) (public) in Chandigarh. Each hospital will provide a study coordinator and hardware.
Subjects. 50 patients in each units = 100 subjects in total in the pilot. These numbers have been determined pragmatically with a view to early implementation of the pilot study.
Inclusion criteria. Patients 18 years or older without life threatening comorbidities commencing either haemodialysis or peritoneal dialysis for the treatment of ESKD.
Exclusion criteria. Start of dialysis in ICU or dialysis initiation for acute kidney injury.
Study process and procedures. One full time local research fellow will be responsible for
the day-to-day conduct of the study. Clinical and demographic data (Table 1) will be recorded at entry to the study. The subjects’ clinical status and current dialysis treatment and any adverse events believed to be related to the study conduct will be recorded at entry (Table 1) then at 1 month, 3 months, 6 months and one year, together with significant clinical events (Table 2). Interim analyses of outcome data will be performed at 3 months, 6 months and 12 months. If patients transfer between dialysis units every effort will be made to continue prospective follow up at the new centre. A dedicated study phone number will be shared with the participants to report any major events while enrolled in study. This service will also function as an informal patient tracking mechanism.
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Informed consent. Patients will provide written informed consent for inclusion in the study. A patient information leaflet and informed consent form have been created in English and Hindi. Patients will be able to withdraw consent if they choose at anytime. The data provided to the research team will not contain any identifiable information. Identifiable information will be retained at the sites.
Confidentiality and privacy. The risk to privacy of participants from the misuse of personal information is low. Staff at the sites involved as well as The George Institute sign a confidentiality agreement at the commencement of employment and receive regular privacy & confidentiality training. All participants will be assigned a study number and only deidentified clinical data will be stored in the computerised data collection system. Access to the clinical data will be via a computer and requires two passwords. Password protected screensavers will be used when information is unattended. The researchers will store study data on a secure network, protected by a firewall. All digital files will be password protected. Any paper documents generated from this project will be scanned and stored electronically on a secure network and, if not scanned, will be stored in a locked cabinet in the research office of The George Institute for Global Health, India. All data will be reported in aggregated form and there is no potential for reports or presentations to publically identify any individual or organization.
Data storage and record retention. Data will be stored as outlined above. Researchers will be provided with de-identified data and this dataset will be retained by the researchers for 7 years following the conclusion of the study to ensure it is available for academic queries regarding the results or methodology.
Outcome measures. Primary outcome measure. Survival on ESKD therapy. 11
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Secondary outcome measures. ESKD treatment modality chosen (PD, HD, transplant), modality survival (changes from one treatment modality to another), transplantation events (source of donor, time to transplantation, immunosuppression regimen), transplantation outcomes (patient survival, graft survival), voluntary withdrawal from treatment and reasons for withdrawal, direct and indirect costs, economic impact on the patient and their family.
Assessment of safety. This is a prospective observational cohort study with no interventions. The likelihood of a study participant suffering harm from participation in this research is thought to be remote. The risks to patient privacy and confidentiality are considered to be minimal as no patient identifying data will leave study sites and the researchers will not have access to identifiable data. All data will be reported in aggregated form with a minimum cell size of 5 to reduce the potential for reports or presentations to identify any individual or organization. Any adverse events thought to be related specifically to the conduct of the study will be reported to the study Steering Committee to then to the supervising Ethics Committee(s) .
Statistics. A descriptive statistical analysis of all study participants will be presented. Survival profile of patient will be provided by means of Kaplan-Meier survival curves stratified by some baseline characteristics such as gender, socio-economic status and type of dialysis treatment. Log rank test will be used to test any significance difference in survival
between groups. All time-to-event secondary endpoints will be analysed using the same principles. The other type of outcomes will be described, mean and standard deviation for continuous outcomes with frequency / ratio for binary outcomes. Quantified differences in
patients’ characteristics will be assessed by means of hazard ratio for time-to-event outcomes, mean difference for continuous outcomes and relative risk for binary outcomes.
Data collection, management and quality assurance. Consideration will be given to the practicality of using direct data entry into a web-based online data collection system rather 12
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than paper clinical record forms. Access to the data collection system will be restricted to approved study personnel and will require a username and password. All patient identifiers, demographics, and health information will be stored securely on computer servers with password protection in a locked room of a secure building with onsite security personnel and card access at the coordinating centre. Access to the data will require a username/password combination with study staff only having access to data appropriate to their role in the study.
The researchers will store study data on a secure network, protected by a firewall with no files containing any names or addresses of individual participants. All digital files will be password protected. Any paper documents generated from this project will be scanned and stored electronically on a secure network and, if not scanned, will be stored in a locked cabinet in the research office of The George Institute, India.
All data generated from this project will be stored for 7 year after cessation of the study to ensure availability in the event of academic queries about the methods or results. After this time period, source information will be disposed securely i.e. paper documents will be shredded and computerised data will be permanently erased and back-ups physically destroyed.
Expected outcomes of the study. 1. Feasibility analysis for larger multicentre nationwide study 2. Estimates of survival on dialysis 3. Better understanding of reasons for stopping dialysis 4. Up to date analysis of dialysis costs and funding sources
Ethical considerations and trial registration. Ethical approval has been obtained from the institutional ethics committee at each centre. The study will be performed in accordance with the ethical standards of the Declaration of Helsinki and Declaration of Istanbul.
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Costs. Full funding for this pilot study will be provided by the George Institute for Global Health.
CONCLUSION This pilot study will be the first multicentre prospective study of health outcomes in Indian dialysis patients, and the first to collect detailed information on the economics of dialysis in India and its impact upon patients and their families. This study will inform planning for dialysis services in India and provide feasibility data to support the development of a national registry of dialysis outcomes in Indian patients.
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TABLES Table 1. Data collection at entry to study Demographics and economic status
Medical history
Name (first, last +/- alias) DOB
Sex
Address
Primary Phone
Secondary Phone
Household composition
Employment status
Annual household income bracket
Health insurance status
Out of pocket expenses
Travel cost
Cost of treatment
Income/support
Social supports
Socioeconomic measures
Cause of ESKD
Diabetes
Hypertension
Coronary artery disease
Ischaemic heart disease
Cerebrovascular disease
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Initial Dialysis history
Laboratory results at entry to dialysis
Drug treatment at entry to dialysis
Dialysis Facility
Peripheral vascular disease
Chronic lung disease
TB
Cancer
Smoking
Pre-ESKD care
Other health conditions
Date of first dialysis
Type of dialysis
Prescription (Duration/number of sessions)
Access type
Potassium
Creatinine
Urea
Haemoglobin
Erythropoetin
Phosphate binders
Herbal medicines
Quality of life
Number of chairs
Sessions offered
Staffing: nurses/technicians
Staff:patient ratio
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Table 2. Data collection at intervals 1 month, 3 months, 6 months, 1 year Economic outcomes
Major clinical events
Current dialysis history
Employment Status
Current Out of pocket expenses
Travel cost
Cost of treatment
Current income bracket
Social supports
Socioeconomic measures
Source of funds for ESKD treatment
Still alive? Yes/No
Cause of death if deceased. Verbal autopsy
Change in modality of ESKD
Nature of change
Reason for change
Renal transplant?
Source of kidney
Graft still working
If no, reason for loss
Unplanned hospitalisation
Cardiovascular events
Cancer
AE related to study
Date of first dialysis
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Most recent lab data
Current drugs
Quality of life
Current Type of dialysis
Prescription (Duration/number of sessions)
Access type
Potassium
Creatinine
Urea
Haemoglobin level
Erythropoietin
Phosphate binders
Herbal medicines
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