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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 4  |  Page : 80-84

Hub-and-spoke centers model of dialysis supported by cashless government scheme in a resource-poor setting: A successful model


Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana, India

Date of Submission27-Jan-2021
Date of Acceptance01-Mar-2021
Date of Web Publication20-Jul-2021

Correspondence Address:
Dr. Manjusha Yadla
Department of Nephrology, Gandhi Medical College, Hyderabad - 500 571, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrnm.jrnm_5_21

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  Abstract 


Introduction: Hub-and-spoke Center Model is initiated, in which peripheral dialysis centers (Spoke Centers) are monitored by Hub Center (Nodal Center). Aim: The aim of the study was to analyze the model of dialysis of Hub-and-Spoke dialysis in our tertiary care center. Methods: Data were collected over a period of 1 year in our center. Functioning of 12 spoke centers, clinicoepidemiological profile of dialysis patients was analyzed. Results: Monitoring the spoke centers included daily interaction with spoke center doctor, nurse, technician, patients through video calling, and guiding them in patient-related problems, infrastructure, reverse osmosis (RO) plant, and administrative issues. Monthly visit by nephrologist to spoke centers and providing outpatient department services to the dialysis patients and scrutinizing the patient data registers, RO plant inspection, water quality analysis data, etc., is being done. Among three hub centers, 30% of patients are being dialyzed in Gandhi Hub-and-Spoke model. Around 6770 sessions of dialysis are done per month for 687 patients registered, with 49% of patients receiving twice weekly hemodialysis. Nearly 25% of machines dedicated to hepatitis B surface antigen and hepatitis C virus-positive patients. Sixty-six patients still on waiting list and less technician staff (one technician/nine patients) indicates need for increasing the machines and staff to improve dialysis care at peripheral centers. Conclusion: Hub-and-Spoke model is an excellent model to provide quality dialysis support to patients in remote areas. Due to increase in dialysis patients, machines and staff need to be increased. Continuous surveillance of the model will help to develop measures/guidelines for effective functioning of the model.

Keywords: Hub and spoke, maintenance dialysis, resource poor


How to cite this article:
Pathakala S, Hariprasad P, Yadla M. Hub-and-spoke centers model of dialysis supported by cashless government scheme in a resource-poor setting: A successful model. J Renal Nutr Metab 2020;6:80-4

How to cite this URL:
Pathakala S, Hariprasad P, Yadla M. Hub-and-spoke centers model of dialysis supported by cashless government scheme in a resource-poor setting: A successful model. J Renal Nutr Metab [serial online] 2020 [cited 2021 Sep 26];6:80-4. Available from: http://www.jrnm.in/text.asp?2020/6/4/80/321987




  Introduction Top


With the increase in number of patients with end-stage renal disease (ESRD), Government of State of Telangana has undertaken the provision of dialysis services through Hub-and-Spoke Center model [Figure 1] to the needy patients. With the earlier model, where dialysis services were provided under cashless government scheme, the centers were standalone centers with reuse program, catering to a limited number of patient as only seven centers were available. With an aim to cater to ever increasing number of ESRD patients with dialysis services under virtual/real supervision by trained nephrologist and with the best quality of using SINGLE USE dialyzer, Government of Telangana State has started this model for the first time in the country, though this was expensive proposal.
Figure 1: Process flow of work at HUB-and-SPOKE model

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Methods

In this present model, three HUB centers are identified to which about 10–16 SPOKE centers are attached. A HUB center is a Government medical college/institution with full-fledged Department of Nephrology constituting faculty and postgraduates pursuing nephrology course of 3 years. A SPOKE center is district hospital/area hospital where specialist such as internal medicine physician or an anesthetist would be the doctor incharge of dialysis unit. The working of SPOKE center is monitored daily by the HUB team through Telesurveillance. A monthly visit to SPOKE centers by the HUB team comprising of nephrologist, transplant coordinator, and Technician-in-Chief of HUB center. Scrutiny of patient registers and reverse osmosis (RO) unit log book are maintained regularly.

Roles and responsibilities of hub hospital, superintendent, and nephrologists are defined in this model such as judging the treatment practices of doctors on dialysis services, monthly review with duty doctors, staff nurses, dialysis technicians, patients through Telemedicine/skype cameras, continuous teaching and training program to all the staff, and monitoring implementation of hemodialysis guidelines [Figure 2] and [Figure 3]. Nephrologist of the hub hospital certifies the diagnosis, scrutinizes the investigations, and gives permission to dialyze the patient at the spoke center. Visits the spoke center once in 3 months and provides outpatient department services, verifies patient records, treatment practices, infrastructure, and RO plant maintenance. All grievances are brought to the notice of higher authorities and sorted accordingly.
Figure 2: Working model of Hub-and-SPOKE model

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Figure 3: Schematic representation of HUB-and-SPOKE model

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Private agency is involved in running the dialysis centers after entering MoU, by providing machines and staff and thorough implementation of hemodialysis guidelines. Private agency is funded by the government of Telangana.

This model is governed by the Government of Telangana, Ministry of Health and Family Welfare through Aarogyasri Health Care Trust.


  Results Top


Of 7970 patients utilizing the hemodialysis services in the State of Telangana, 2040 patients (25.5%) are in Government Hospitals. Of 2070 patients, 687 patients (33.6%) are being dialyzed under our HUB-and-SPOKE center [Table 1]. A total of 6770 sessions are done per month in our model.
Table 1: Base line characteristics in men and women

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Machinery data

A total number of machines installed in our HUB-and-SPOKE center were 87. Of this, 22 machines were for seropositive patients. Machines dedicated for hepatitis C were 17 and machines dedicated for hepatitis B were 5 in number.

Patient data

Baseline characteristics of patients are mentioned in [Table 1]. The mean age of the study population was 44.72 + 12.30 years. Male:female ratio was 2.73:1.

A high number of both the genders were present in center G, and the least number was observed in center K [Figure 3]. Among the existence of comorbidities, hypertension was present in majority compared to diabetes or the combination of diabetes and hypertnsion. A number of patients on thrice and twice weekly dialysis were almost equal (51:49). A number of sessions were highest in HUB center, and among the spoke centers, it was center L with a maximum number of sessions [Table 2].
Table 2: Factors associated with mortality

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With the proportionate percentage utilization of services by men and women (50:38) based on Aarogyasri statistics reports of 2016–2017 and 2017–2018, we analyzed the differences in outcomes based on gender. Mean hemoglobin and mean serum creatinine were observed to be significantly more in males compared to females with men having higher values of hemoglobin and serum creatinine P < 0.05. Diabetic men were more than women. There was no statistically significant difference in other baseline parameters among men and women [Table 3].
Table 3: Correlation between clinical variables and mortality

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The primary outcome of death was analyzed in the study population. Assuming a better cohort survival, Kaplan–Meier analysis was done comparing twice weekly and thrice weekly groups. Factors influencing survival were age, mean vintage of dialysis, and anemia. Other factors assessed in the study did not show a significant association with mortality. Further, on univariate analysis, factors associated with mortality were anemia, mean vintage of dialysis, and older age [Table 3]. When the survival was linked with frequency of dialysis, it was observed that thrice weekly dialysis patients would fare better compared to twice weekly dialysis [Table 4] and [Table 5], the graph depicts that the survival curve was lower for twice weekly dialysis compared to thrice weekly dialysis [Figure 4].
Table 4: Factors influencing survival

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Figure 4: Working model of Hub-and-SPOKE Dialysis Centers

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  Discussion Top


Availability of public health resources to meet the demands of increasing number of end stage organ diseases is meager. Over the last decade, the number of end-stage organ diseases has increased disproportionately to the available health infrastructure. Despite the shortage of human resources, equipment, etc., our state has introduced the availability of dialysis services free of cost to all the eligible below poverty line patients under the cashless Government scheme, Aarogyasri.

A number of patients receiving dialysis services under this scheme are 7970, of which 2070 (<1/3rd) are treated in Government setups. To overcome the human resources, the concept of hub-and-spoke model was introduced. In addition, the introduction of single-use dialyzer protocol was done in government setups under this scheme. Available government setups include:

  • Semiautonomous institute has 16 spoke centers
  • Government Medical Hospital 1 with 9 spoke centers
  • Government Hospital 2 with 12 spoke centers (the present study center).


Aarogyasri report 2017–2018 shows the utilization of health services were maximum with Nephrology which was 18% of total services.[1],[2] This implies that the number of patients needing dialysis services is increasing and the State Government is proportionately allocating resources to the increasing need [Table 3].[1],[2]

It may be too early to embark on the complete success of the hub-and-spoke model. Nevertheless, it can be said that this system of delivery of dialysis services is reaching the needy and the poor. Although the holistic care was planned including vaccination, securing fistula, iron therapy, and antihypertensive drugs, few targets are being met with such as erythropoietin and iron usage.

In our study, men were younger to women (44 years vs. 49 years). Hypertension was present in 57%, combined diabetes, hypertension were present in 22% of the study population. This does not imply that hypertension is common cause of ESRD, but in those on dialysis, hypertension is common, which is well-known fact. An equal number of patients were on thrice Vs. twice weekly dialysis. Twice weekly dialysis is not scientific prescription, but patients used to attend dialysis twice a week due to logistics, problem in transportation.

Despite the introduction of single-use dialyzer, seroconversion was observed to be 4%, which may be due to inadequate universal precautions, lack of periodical evaluation for hepatitis C virus (HCV) viral load, the need for blood transfusions. Under Government scheme, Anti-HCV antibodies are regularly tested for every 3 months. Anti-HCV testing is not standardized and hence results could have been variable. The need for blood transfusions, though decreased compared to the past, still continued to be prevalent at 0–8 blood transfusions per center. A maximum number of blood transfusions were observed in centers C and L.

Mortality was highest in centers C, D, and L. This is in proportion to the number of patients registered. The most common cause of deaths was thought to be cardiovascular/fluid overload. Majority of deaths were at home. Among the hospital-related mortality, fluid overload was most common reason. Deaths at home were assumed to be cardiovascular in nature due to the sudden nature.

Another observation in these centers was the low ratio of technician to patient. It was observed that one technician takes care of nine patients. This is in contrast to the recommended ratio of 3–4:1.[3] Insistence is being laid on the human resource part for recruitment of more personnel to improve total patient care. All the spoke centers are visited on monthly basis by qualified nephrologist [Figure 2]. Daily online rounds are done to address the pertinent issues.

Meeting the demand of the health services in a resource-poor setting is uphill task. Introduction of Hub-and-Spoke model by the State Government is running successfully catering to the demands of the poor and needy dialysis patients. [4,5] Quality health-care facilities and services are not just limited to populated educated urban areas but are spreading to the door of the needy patients in rural areas through this successful model. Further development of the model with increase in manpower, provision of comprehensive kidney drugs along with free surveillance would make it the best model in resource-poor setting.

Factors influencing the primary outcome and death were analyzed. Age and anemia were found to show statistically significant association with mortality. On univariate analysis, the same factors showed a significant association. Mortality was higher in those with vintage of dialysis of few days to 19 months. High 1st year dialysis mortality, which is multifactorial in etiology, has been well described in literature.[4],[5] Although the presence of Hepatitis C status and the duration of dialysis also showed a significant association, the result of this could not be explained.


  Conclusion Top


Access to the dialysis center for patients residing in remote areas is made easily available by establishing spoke centers.

Team work will enhance quality care to dialysis patients free of cost.

Assessment and surveillance of the model will help to develop measures/guidelines for effective functioning of the model.

As the number of maintenance dialysis patients is increasing, expansion of spoke centers is essential to deliver quality dialysis care even in remote areas.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Prashanthi V, Kanakala S. Comprehensive data analysis of aarogyasri scheme progress in Telangana January 2018Journal of Advanced Research in Dynamical and Control Systems 10:421-34.  Back to cited text no. 1
    
2.
Sunitha Reddy Aarogyasri Scheme in Andhra Pradesh, India: Some Critical Reflections June Social Change 2013;43:245-61.  Back to cited text no. 2
    
3.
Desai AA, Bolus R, Nissenson A, Bolus S, Solomon MD, Khawar O, et al. Identifying best practices in dialysis care: Results of cognitive interviews and a national survey of dialysis providers. Clin J Am Soc Nephrol 2008;3:1066-76.  Back to cited text no. 3
    
4.
Khan IH, Catto GR, Edward N, MacLeod AM. Death during the first 90 days of dialysis: A case control study. Am J Kidney Dis 1995;25:276-80.  Back to cited text no. 4
    
5.
Bradbury BD, Fissell RB, Albert JM, Anthony MS, Critchlow CW, Pisoni RL, et al. Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Clin J Am Soc Nephrol 2007;2:89-99.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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