Centre-level variation in the survival of patients receiving haemodialysis in India: findings from a nationwide private haemodialysis network

Background There are no large studies examining survival in patients receiving haemodialysis in India or considering centre-level effects on survival. We measured survival variation between dialysis centres across India and evaluated the extent to which differences are explained by measured centre characteristics. Methods This is a multilevel analysis of patient survival in centres of the NephroPlus dialysis network consisting of 193 centres across India. Patients receiving haemodialysis at a centre for ≥90 days between April 2014 and June 2019 were included, with analyses restricted to centres with ≥10 such patients. The primary outcome was all-cause mortality, measured from 90 days after joining a centre. Proportional hazards models with shared frailty were used to model centre- and patient-level effects on survival. Findings Amongst 23,601 patients (median age 53 years; 29% female), the unadjusted centre-specific 180-day Kaplan–Meier survival estimates ranged between 55% (95% confidence interval [CI] 38–80%) and 100%, with a median of 88% (interquartile interval 83%–92%). After accounting for multilevel factors, estimated 180-day survival ranged between 83% (73–89%) and 97% (95–98%), with 90% 180-day survival in the average centre. The mortality rate in patients attending rural centres was 32% (Hazard Ratio 1.32; 95% CI 1.06–1.65) higher than those at urban centres in adjusted analyses. Multiple patient characteristics were associated with mortality. Interpretation This is the first national benchmark for survival amongst dialysis patients in India. Centre- and patient-level characteristics are associated with survival but there remains unexplained variation between centres. As India continues to widen dialysis access, ongoing quality improvement programs will be an important part of ensuring that patients experience the best possible outcomes at the point of care. Funding This project received no external funding.