Introduction:
A Geographical information system (GIS) links locational (spatial) and database (tabular) information which enables a person to visualize patterns, relationships, trends of diseases, a process which gives entirely new perspective to data analysis that cannot be seen in tabular or list format. Hardware, software, data, methods, and people are five important components of GIS. (1)
Countries across the globe are facing an increased burden of non-communicable diseases (NCDs), which were once considered as ‘Diseases of the Rich’. As late as 2010, only 0.8% of total aid for health from World Health Organization was devoted to prevention and control of NCDs. However, that changed in 2011 when the UN General Assembly held a high-level meeting on NCDs and adopted a far-reaching Political Declaration which acknowledged that the threat of NCDs constitutes one of the major challenges for development in the 21st century, undermining social and economic progress throughout the world. (2)
NCDs are the leading cause of death globally. In 2015, they caused 71% of all deaths globally (41 million) up from 60% in 2000. The leading causes of NCD deaths are Cardiovascular diseases, cancers, diabetes and Chronic Kidney disease. As per Global Burden of Disease Study (2015), the number of deaths due to Chronic Kidney Disease rose by over 31% from the year 2005 to 2015, making it one of the fastest rising causes of death. (3)
As per estimates, about 10% of the entire world’s population has CKD (asymptomatic or symptomatic). (4) Studies have shown that some particular races, including South Asians especially from India, Pakistan, Bangladesh and Sri Lanka are more prone to developing CKD. (5) Although there is limited data on the prevalence of Chronic Kidney Disease (CKD) in India, it is expected to grow exponentially with drastic rise in prevalence of hypertension and diabetes coupled with increasing life expectancy. While the etiology and prevalence of CKD varies throughout India, a recent study done in Karnataka put the figure of CKD Stage-G3 prevalence at 6.3%. (6)
End Stage Kidney Disease (ESRD) is an advanced stage of kidney disease where kidneys have lost almost all their ability to function. Once CKD progresses to ESRD, the only treatment modality that a patient is left with is either dialysis or Kidney transplantation. In India there are over 130,000 patients receiving dialysis, but only 0.4 dialysis centers per million population. (7) Only 4,000 kidney transplants are performed every year in India. The United States with a population of quarter of India’s performs 16,000 such operations per year. In view of dearth of organ donors and high costs associated with organ transplantation, dialysis is the only option that most CKD patients are left with.
The shortage of nephrologists, late referral of patients, inadequate health awareness about preventive measures and a lack of more cost-effective alternatives like renal transplantation or peritoneal dialysis (PD) are important issues in the provision of care to ESRD patients. Unequal distribution of nephrologists, with a concentration in large cities and in the private sector are major barriers to equitable provision of dialysis to all sections of the society. (8) Inadequate insurance coverage further aggravates the situation. Furthermore, ~70% of those who start dialysis in India eventually give up dialysis due to financial constraints or death. Only 10–20% of dialysis patients in India continue long-term treatment.
GIS has been successfully employed in UK to examine perceived and predicted accessibility of general practices and spatial distribution of patients. (9) Recently, in Jeddah (10) and Riyadh (11), the Saudi Arabian government is using GIS to identify health accessibility and hospital services utilization to plan new hospitals and strengthen the public health system. In India, researchers from Banaras Hindu University and Indira Gandhi National Open University have also used GIS for district level healthcare planning at Varanasi. (12) However, there is dearth of literature on use of GIS in establishing satellite/telemedicine centers or extra mural services for an existing hospital. Keeping these facts in view, there is a need to improve the accessibility of dialysis and reach out to the masses. Setting up extra-mural services can improve accessibility to dialysis and reduce the mortality and morbidity due to this disease. New business models which intend to move dialysis services out of the hospital walls and closer to the patient, like chain of standalone dialysis centers, ambulance equipped with mobile dialysis unit and home dialysis programs can prove to be a boon for CKD patients.
Problem Statement
The study was carried out in a 2032 bedded tertiary care super-specialty hospital. The hospital has all basic specialties and well equipped super specialty departments and caters to approximately 2700 outpatients daily with around 250 inpatient admissions per day. The hospital has a 19 bedded dialysis unit. Dialysis is done in 4 shifts of 6 hours every day. While the process of dialysis takes 4 to 5 hours, rest of the time in the shift is used for cleaning and upkeep of the machine. Hence, theoretically, a maximum of 76 dialysis procedures can be conducted per day in the dialysis unit. The dialysis slots are allotted via appointment system and utilization of our dialysis unit is close to 100%. As a result, there is no room to accommodate new patients of CKD and many patients who wish to undergo dialysis at our hospital had to be referred elsewhere due to limited appointment slots.
Expansion of the same center is not possible due to space constraints. Hence the objective was to find ways to reach out to patients requiring dialysis by providing extramural dialysis services. For this purpose, it was decided to identify the catchment area of patients who come to this center for undergoing haemodialysis on outpatient basis and to assess their willingness to undergo dialysis at a new standalone dialysis center located near their home or mobile dialysis unit.
Aims & Objectives
1) To identify and map the catchment areas of outpatients undergoing dialysis in this hospital onto a GIS.
2) To assess the perception of CKD patients about extramural dialysis services and their willingness to adopt these.
Methodology
Study Design: The observational study was conducted at a tertiary care teaching hospital. Retrospective analysis of demographic data of all patients who underwent dialysis on outpatient basis at this hospital from June 2018 to January 2020 was obtained from the IT department. The data was deidentified to protect patient privacy. The geospatial location of the patients, in the form of Pin Codes (which is a six digit numeric postal code system used by Indian Post), were obtained from patient’s addresses and plotted on to a Geographical Information System (GIS) to depict the catchment area.
Study Tool: A self-administered cross-sectional survey questionnaire was prepared to assess factors like duration since affected, aspects like family income, distance travelled per dialysis session, mode of travel, transportation expenses, reasons for missing appointments; in addition to gauging their willingness towards undergoing dialysis at a standalone dialysis centre or at a mobile dialysis unit. The questionnaire was validated by hospital administrators, nephrologists, and administered to outpatients undergoing haemodialysis at this hospital via Google Forms weblink. Sample size: n=100 (one third of total patients).
Results
A total of 336 CKD patients underwent dialysis in this hospital on outpatient basis in the last 18 months. Another 62 were advised dialysis but could not be accommodated due to non-availability of appointment for new patients. A total of 120 unique pin-codes were obtained from the addresses of these patients and plotted onto the GIS.
Out of 336 patients, the youngest patient was 12 years old while the eldest was 82 years. Mean age was 57 years (± 13.7), median of 54.5 years. 57% were male and 43% female.
It was found that 86% of our patients belong to Udupi district, with few patients coming from adjacent districts. District is the administrative unit in India. Figure 1 below shows the pin code plot on the map.
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Figure 1: Pin Code Plot of Haemodialysis patients’ addresses |
The blue bubble in the map indicates the location of our hospital. 50% of observations were encompassed when a proximity circle of 10 miles (16.1 km) radius was drawn with our hospital at the center, meaning that half of our patients live within 16.1 km of our hospital. As expected, most of our patients were concentrated in and around this town and the center of district. Apart from this, another hotspot was found in the northern part of district, about 50 kilometers away.
The responses to the questionnaire were downloaded in CSV format and analyzed using Microsoft Excel. It was found that on an average, patients had been undergoing dialysis since last 3.5 years (± 1.2 years). About 54% of respondents were suffering from hypertension and 60% from diabetes, 36% had both co-morbidities, 4 people had Hepatitis (blood transmissible diseases). 100% of patients concurred that there is a gross shortage of dialysis centres in this district. The median number of dialysis centres in which patients had their outpatient dialysis till date was 4.
Of the patients, 85% claimed to have attended at least twice a week dialysis sessions in last one month. A family member accompanied 74% of patients and 18% were accompanied by a neighbor or a friend, while only 8% came alone for dialysis. Around two thirds of our patients claimed to have travelled 15 to 30 kilometers from their home to the hospital for dialysis session. About 67% of them were not the main decision makers in family. About 82% patients used family’s or friend’s or relative’s private vehicle to come, while 14% used public transport, and only 4% claimed to come by hiring a cab for every session. The average time spent by patients in travelling to hospital and back to their home was 130 mins (± 43 mins) and average expenses incurred in travelling each day was Rs. 321 (± 215).
About 29% of the patients confessed that they had missed dialysis sessions on multiple occasions in the last one year because there was no one to accompany them, while 12% did it due to financial constraints.
Family income was 5 lakh to 10 lakh per annum in 42%, and 28% had income above 10 lakh INR per annum, 30% had income below 5 lakh per annum.
About 71% patients were comfortable with the idea of undergoing dialysis at a Standalone Dialysis Clinic/Dialysis franchise run by the parent hospital which is located close to their home, 19% said they would still prefer to travel to the parent hospital for dialysis, while 10% were still undecided. Regarding mobile dialysis services, only 58% patients were comfortable with this idea, 27% said they would rather travel to the parent hospital for dialysis, while 15% were undecided.
Patients were willing to pay Rs. 370 (± 139) extra per dialysis session in case they are able to avail the same services at a standalone dialysis center near their residences. Similarly, for availing dialysis services via a mobile dialysis unit, patients were willing to shell out Rs. 390 (± 155) more per session. In a day, at least 3 people can be served by single machine in 8 hours duration.
Discussion
Geospatial data is being used across the world to optimize locations for satellite clinics and new hospitals. The GIS data can provide valuable insight for expanding or establishing new healthcare services. A cross-sectional questionnaire-based survey was employed in UK, similar to our study. (13) In a study, done in Germany in 2015 using GIS, the authors had suggested spatial general practitioner availability was lesser in rural areas when compared to urban areas. Globally also similar gradients were seen. (14) GIS mapping helps in improved decision making, increasing efficiency and better visualization of data.
Although there is limited data on the prevalence of CKD in India, it is expected to grow exponentially with drastic rise in prevalence of hypertension and diabetes coupled with increasing life expectancy. Compared to the westerners, it is seen that Indian patients have to start undergoing dialysis at a much younger age, thus requiring more dialysis sessions. Studies have shown that more than half of India’s dialysis needs are unmet. (15)
Our study found out two main clusters from where the hospital receives most of its CKD patients, one being the center of city and the other in the northern part of district. As expected, only few patients were coming from the southern part of the district. Setting up standalone dialysis centers in these areas coupled with intensive marketing can help the patients get quality dialysis services near their doorstep, and at the same time help the parent hospital to ramp up its revenue. On the other hand, services like Mobile Dialysis Ambulance can be started to cater to patients who do live in a GIS hotspot area and have to travel 50 kms or more for every dialysis session. We are interviewing few hospital owners in these areas, discussing various business models. Our study also brought to light multiple difficulties being faced by CKD patients, including financial aspects, problems pertaining to transportation and being accompanied by a family member/friend for every visit to the hospital. Since 30% patients surveyed were from lower income families, and because setting up a dialysis center/mobile dialysis unit is capital intensive and requires rigorous infrastructure setup, the machines for setting up new dialysis centres can be procured with the help of philanthropists or NGOs. In similar setting, a study done on transportation costs of family to avail treatment, low income group were less than 40% of the profile of patients and it took 10% of their annual savings to take care of single hospitalization.
Attendants of all 100 patients were comfortable with the idea of undergoing dialysis at a standalone dialysis center near their home or in a mobile dialysis van. Even though many patients had financial difficulties, still most of them were willing to pay an extra sum of money for availing convenience of home dialysis since it solves the problem of transportation, cuts down the travel time and reduces the need of an accompanying person. This shows that the patients will enthusiastically embrace these new business models. The findings of the study were forwarded to the top management and department of finance to expand the existing dialysis facilities and chalk out feasible financial models for dialysis to benefit the patients and society as a whole.
Conclusion
It was found that patients want to be compliant to treatment, however, they sometimes have to miss their dialysis session due to reasons beyond their control, like financial issues or problem in transportation or unavailability of appointments for dialysis session.
Institutional Ethics Committee: IEC 465 / 2018, Kasturba Medical College, Manipal.
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