liver transplants -high cost-low expertise

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Home > Focus > Story Print this Page| Email this page   Liver transplants plagued by high cost, lack of expertise Rita Dutta – Mumbai High cost and failure rate due to lack of professional expertise deal a crippling blow to more than half a lakh patients in India requiring orthotopic liver transplantations (OLT) every year. Experts highlight the need to address the issue at various levels including laymen and general practitioners alike as late referrals have restricted patients from availing successful liver transplants. The gravity of the situation is reflected in the fact that while patients listed for OLT would not live beyond one to two years, not more than 10 OLTs are conducted annually and only around 100 patients have received transplant in India so far. According to estimates, a 400-500 bed hospital, would have at least 100 patients dying of liver disease annually, who could have been saved by a transplant. Says Dr Gourdas Choudhuri, head of the department of gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, “In our institute, with 60 beds in gastroenterology, the mortality rate of admitted patients (2000 per year), most of whom are serious to critical, is around 10 per cent (200 deaths per year), of which 70 per cent (140 deaths per year) is due to liver failure. Most of them would be considered potential candidates for liver transplantation.” A major bottleneck is the whopping cost of transplant, which ranges from Rs four lakh to Rs 25 lakh. The expensive UW solution, plasma fractioners, blood cell separators, blood bank support, prolonged ICU stay (from two weeks to a month) and immunosuppressants contribute to the cost. Explains a consultant in surgical gastroenterology and specialist in hepato-biliary-pancreatic disorders and liver transplantation Dr Sudeep Shah of P D Hinduja Hospital, “The UW solution preservative costs Rs 20,000 a litre and one requires at least three litres of it. In addition is the cost of two supramajor surgeries, on the donor and the recipient. And at least 12 units of blood, platelets and fresh frozen plasma are to be kept ready for the surgery.” Reportedly, some hospitals hire chartered flights to get livers from other cities, adding another Rs four to Rs five lakh to the procedure. According to managing director and liver transplant specialist of Hyderabad-based Global Hospital Dr K Ravindranath, lack of co-ordination between liver surgeon, liver specialist, anaesthesiologist, immunologist and lab medicine specialist has plagued liver transplantation. “With most specialists being attached to various hospitals, it’s difficult to bring them on one platform at the same time. The hospital management should be blamed for their short-sightedness regarding this,” said Dr Ravindranath, who has conducted 12 OLTs at Global Hospital, out of which 10 have been successful. According to estimates, not more than 25 surgeons in India are trained to conduct liver surgery. Gangaram Hospital, Apollo Indrapastha and AIIMS in New Delhi, Global Hospital in Hyderabad, SGPGIMS in Lucknow, CMC-Vellore, SRMC and Stanley Medical College in Chennai, Jaslok Hospital and P D Hinduja Hospital in Mumbai conduct OLT. Dr Sanjay Nagral, surgeon and liver transplant specialist, Jaslok Hospital, blames the lack of expertise on the part of medicos for patients not receiving OLTs. “OLT is not a regular surgical exercise. For conducting it, surgeons, physicians and anaesthesiologists need to receive special training from the US or the UK,” says Dr Nagral, who was in the team of surgeons which conducted a living-related liver transplant in India on a 14-year-old girl in 1998 at Jaslok Hospital. OLT is technically difficult as it involves accurate dissection and suturing of several tissues from liver, blood vessels and bile ducts and needs two teams of surgeons and staff to work simultaneously, one on the donor and the other on the recipient. “A liver transplant is ten times more difficult than a heart or kidney transplant,” avers Dr Ravindranath. Experts attribute lack of awareness among medicos and laymen alike for the less number of OLTs. Surgeons even complain of “lack of confidence” of physicians, GPs and gastroenterologists in referring patients for liver transplants to surgeons. “Physicians are not forthcoming about referring patients requiring liver transplant to us. And even if some are aware, they think it’s futile to inform patients about a technique which is not practiced widely,” rues Dr Nagral. “Success breeds success and unless many liver transplants are performed, people will not have confidence and without confidence, we will not perform many,” says Dr Shah, who was in the team of surgeons which conducted a multi-organ transplant (kidney and liver) at Hinduja Hospital in January, 2004. It’s to be noted that success rate of OLT in India is a modest 50 per cent in comparison with 80 per cent of the west. Many hospitals conducting OLT had initially recorded failures, indicating the complexity of the procedure. For instance, the first three liver transplants conducted at SGPGIMS four years ago, were not successful. For the remaining seven performed in the last one-and-a half year, the success rate has been around 50 per cent, informs Dr Choudhuri. According to Dr Ravindranath, around 50 per cent of the success of the transplant depends on the surgeons and the rest on the support services. “So, even if the surgeon conducts a successful transplant, improper support system can result in the patient losing his life,” says he. The life expectancy of 80 per cent of OLT patients is one year and 70 per cent for 10 years.“If the initial months after OLT are successfully passed, mortality rate is about 10 per cent in the next 10 years on an average. Loss of the liver graft after the first year is less than five per cent and in a few cases, the original disease may relapse at some stage,” says Dr Shah. Experts say that India would take a few more years to improve upon the success rate of OLT. Others blame lack of networking between different hospitals for patients not receiving OLT. “Organ sharing is marred by regionalism. Though hospitals in Maharashtra have retrieval programme, they refuse to donate organs to other states,” laments an expert. While the huge cost holds back patients from going to private hospitals, public hospitals do not evince interest because of the requirement of vast infrastructure. Says Dr Philip Abraham, a consultant gastroentrologist at P D Hinduja Hospital, “Public hospitals do not conduct OLTs as the infrastructure and costs involved for it can be utilised for treating a host of other ailments.” Interestingly, medicos are hesitant about advocating live-related OLT than cadaveric, though both are permitted under the Transplantation Of Human Organs Act. “In live-related donation, we are putting the life of the donor also at risk. That’s not ethical,” opines Dr Nagral. To which Dr Abraham adds that a surgeon should master OLT by cadaveric donation, before taking up live OLT. They say the time has come for Indian hospitals to have a regular liver transplant programme as OLT costs abroad range from Rs 60 lakh to Rs 80 lakh and listed Indian patients are not preferred over western patients abroad. rita@expresshealthcaremgmt.com Suggestions to improve liver transplant More NGOs should come forward to subsidise the cost. Awareness-creation among medicos to make transplants available to the needy. Networking and organ sharing between different liver transplant centres. Setting up adequate life support systems in more hospitals for maintaining the haemodynamic status of the brain dead till emotional, social and medical preparedness for cadaver organ donation are also required. Necessary changes in law and medical practice to ensure cadaver organ donation on time.

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HC stats -UK- yr2000

 

 

 

Race equality impact assessment

Statistics: Health care services

Research shows that ethnic minority groups generally have poorer health, lack access to some form of health provision, and have lower levels of satisfaction with health provision.

The findings here are drawn from the 1999 Health Survey for England, the 2001 census, the 1999 Ethnic minority Psychiatric Illness Rates in the Community (EMPIRIC) report, NHS Patients Surveys undertaken in 1998 and 2000, and other studies.

Scotland: Analysis of ethnicity in the 2001 Census:

• Health and care

Key points about health and ethnicity

General

• The incidence of coronary heart disease and diabetes is higher than average in ethnic minority groups.
• Asians are more likely than others to have worse reported health and also have long-term illness or disability that restricts daily activities.
• The recent Ethnic Minorities and Mental Health report highlighted ethnic differentials in the incidence of common mental disorders, physical health, use of services and social and support networks.
• The National Survey of NHS Patients, a series of surveys carried out between 1998 and 2002 and more recent surveys carried out locally by NHS trusts under the auspices of Commission for Health Improvement show that, generally, people from ethnic minorities have lower levels of satisfaction with health services.

In more detail

The 1999 Health Survey for England found that:

• Pakistani and Bangladeshi people generally reported having worse health than the general population.
• Asians and Black Caribbeans were more likely to suffer from diabetes than the general population.
• Pakistani and Bangladeshi men had higher rates of cardiovascular disease.
• In all ethnic minority groups except the Irish, people were less likely to drink alcohol, or consumed smaller amounts, than in the general population.
• Bangladeshi and Irish men were more likely than the general population to smoke, and both Bangladeshi men and women were more likely to chew tobacco than other Asian groups.
• Rates of hospital attendance were the same for all ethnic minority groups in comparison to the general population, with the exception of Chinese men and women who had lower rates of inpatient, outpatient and day patient attendance rates.

The 1999 Ethnic Minority Psychiatric Illness Rates In the Community (EMPIRIC) survey found that:

• Pakistani and Bangladeshi women had higher rates of common mental disorders, such as anxiety and depression, than the white group.
• Pakistani and Bangladeshi people were more likely to have worse ‘social functioning’, and higher levels of chronic strain, than the general population. The findings suggest, though, that this may be related to socio-economic factors.
• Asian men, and Pakistani and Bangladeshi women were the most likely to have spoken to a doctor within the last six months

Data from recent surveys of NHS patients in 1998 and 2000 show that:

• People from ethnic minority groups are significantly more likely than average to report unfavourably on their experiences of health services.

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Self-reported health

The 1999 Health Survey for England, whose results have been standardised to take account of age differentials between different ethnic groups, found that:

• Pakistani and Bangladeshi men and women reported worse general health than the general population. Risk ratios (in relation to a value of 1.0 for the general population) for bad and very bad health for men and women were 2.94 and 3.57, respectively, for Pakistanis, and 3.91 and 3.31 for Bangladeshi men and women, respectively.
• Corresponding risk ratios for Black Caribbean women (1.81), Indian men (1.64) and Indian women (2.63) were also higher than in the general population.

The 2001 Census found that:

• Asians aged 50 or over have higher rates of limiting long-term illness than members of any other ethnic groups.

Table 1: Percentage of people with a limiting long-term illness by age and ethnic group, England and Wales Census 2001)

Age	White %	Asian/Asian British %	Black/Black British %	Mixed %	Chinese/Other ethnic group %
0-15	4	4	5	5	3
16-49	10	10	10	11	5
50-64	26	40	34	32	22
All people aged 65 and over	51	60	54	49	48

The fourth National Survey of Ethnic Minorities, carried out in 1994, found that reported health varied according to housing tenure. Across all ethnic groups, those who owned their own homes were less likely than those who rented to report fair or worse health.

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Physical health

The 1999 Health Survey for England and Wales found that:

• Pakistanis and Bangladeshis of both sexes were more than five times as likely as the general population to have diabetes, and Indian men and women were almost three times as likely.
• Rates of diabetes among Black Caribbeans were also significantly higher than in the general population (risk ratios 2.51 for men and 4.19 for women).
• Rates of diabetes among the Chinese and Irish groups were not significantly different from the general population.
• Pakistani and Bangladeshi men had rates of cardiovascular disease (CVD), about 60% to 70% higher than men in the general population, while Chinese men had lower rates (risk ratio 0.63). The picture was similar for women, with Chinese women having lower rates of CVD conditions (0.71) than women in general, while Pakistani (1.45) and Bangladeshi (1.43) women had higher rates. Prevalence of CVD conditions was also higher among Black Caribbean women (1.33).

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Infant mortality

The only available data regarding ethnic differences in rates of infant mortality is from the register of infant deaths in England and Wales (Office of National Statistics). The register only provides breakdowns of rates of infant deaths by mother’s country of birth, which is not a certain indicator of ethnic group.

The figures for 2002 show that the rates of perinatal deaths (within three months of birth) per 1,000 live births and still births were:

• 7.8 for mothers born in the United Kingdom;
• 8.8 for mothers born in the Irish Republic;
• 10.5 for mothers born in Bangladesh;
• 10.6 for mothers born in India;
• 14.5 for mothers born in Pakistan; and
• 15.4 for mothers born in the Caribbean.

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Mental health

The most recent major survey of rates of mental illness among ethnic minorities is the 1999 Ethnic Minority Psychiatric Illness Rates in the Community study (EMPIRIC). Its findings contradict two key assertions that have been based on previous research: first, there are apparently high rates of schizophrenia and other forms of psychosis among African Caribbean people; and second,there are low rates of mental illness among Asian people.

The EMPIRIC survey found that:

• The prevalence of common mental disorders (CMD – anxiety and depression) was very similar in all groups, with the exception of the Irish, for whom this rate was higher than in the White group.
• The pattern among women was more complex. White, Irish and Black Caribbean women had similar rates of CMD, while Indian and Pakistani women had significantly higher rates of CMD. Bangladeshi women had very low rates of CMD.
• Rates of pyschosis among Black Caribbean men were the same among white men after adjusting for age. However, rates of psychosis were twice as high for Black Caribbean women as for white women. The survey did not find any significant differences in rates of psychosis among other groups.
• People of Pakistani or Bangladeshi origin experienced worse ’social functioning’ than people from other ethnic groups, and Bangladeshis experienced greater chronic strains compared with all other groups. However, other findings from the survey suggest that factors such as age and employment status may have influenced these findings.

The 1999 EMPIRIC survey included a qualitative study of 116 people, from six ethnic groups, who had some form of mental illness or experienced some form of mental distress. Key issues that emerged from the respondents’ own accounts of their circumstances included:

• Family problems, family bereavement, employment issues and racism as recurring themes.
• Indications that tools for diagnosing mental illness may not be culturally appropriate for some groups, and may lead to misdiagnosis.

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Alcohol consumption

The 1999 Health Survey for England found that men and women from all ethnic minority groups (except White Irish) were less likely to drink alcohol than the general population and consumed smaller amounts. Overall, the findings show that:

• Some 7% of men from the general population were non-drinkers, compared with 5% of Irish men, 13% of Black Caribbean men, 30% of Chinese men, 33% of Indian men, 91% of Pakistani men and 96% Bangladeshi men.
• Higher proportions of women than men were non-drinkers, both in the general population and among ethnic minority groups. Of the general population, 12% of women reported being non-drinkers compared with 10% of Irish women, 18% of Black Caribbean women, 41% Chinese women, 64% Indian women, 97% Pakistani women and 99% Bangladeshi women.
• 46% of men in the general population drank more than the government recommended guideline of no more than 3 to 4 units per day.White Irish men were more likely than any other ethnic group to drink in excess of the recommended limit (58%). All other ethnic minority groups were much less likely than the general population to have consumed alcohol in excess of the daily guidelines.
• The proportion of women drinking more than government recommended guidelines (no more than 2 to 3 units per day) was 29% for the general population, and 37% for White Irish women. The next ethnic group most likely to exceed the guidelines was Black Caribbean (17%). The proportion of women from other ethnic minority groups exceeding this limit was much lower – only 5% on Indian women, 1% of Pakistani women, and less than one percent of Bangladeshi women.
• Among 8 to 15-year-olds, 40% of boys and 32% of girls in the general population reported ever having drunk alcohol. Indian and Chinese children were much less likely to report ever having drunk alcohol, and reported rates of alcohol use were particularly low among Pakistani and Bangladeshi children.

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Tobacco use

The 1999 Health Survey for England found that smoking was more common among certain ethnic groups.

• 27% of men in the general population reported being smokers compared with 44% of Bangladeshi men, 39% of Irish men and 35% of Black Caribbean men. Indian (23%) Pakistani (26%) and Chinese (17%) men were less likely to report being smokers.
• 27% of women in the general population reported being smokers compared with 33% of Irish women, 25% of Black Caribbean women, 9% of Chinese women, 6% of Indian women, 5% of Pakistani women and 1% of Bangladeshi women.
• In the 8-15 age group, among the general population, 19% of boys and 21% of girls reported ever having smoked a cigarette. Compared with the general population, Irish girls were more likely and Indian, Pakistani, Bangladeshi and Chinese children less likely to report ever having smoked.
• The survey found that Bangladeshis (both men and women) were more likely than other South Asian groups to report chewing tobacco. 19% of Bangladeshi men and 26% of Bangladeshi women reported chewing tobacco compared with between 2% and 6% for Indian and Pakistani men and women, respectively.

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Access to health care services

This section draws together quantitative data on patterns of accessing services among different ethnic groups and findings from qualitative studies that examine barriers to accessing services for ethnic minority groups, and ethnic minorities’ views of services.

Patterns in accessing health services

Consultation with a GP

• The 1999 Minority Psychiatric Illness Rates In the Community (EMPIRIC) study found that:
• Women from every ethnic group were more likely than men to have spoken to a doctor within the last six months.
• Bangladeshi individuals were the most likely to have seen or spoken to a doctor within that time (77% of men and 85% women).
• White individuals were the least likely to have done so (58% of men and 71% of women).
• After adjusting the results for age differences, Asian men and Pakistani and Bangladeshi women were more likely than other groups to have spoken to a doctor within the last six months. However, the fact that certain groups access services more does not indicate that services are adequately meeting their needs. See the section on perceptions of services below.

Hospital attendance rates

• The 1999 Health Survey for England found that rates of hospital attendance were the same for ethnic minority groups as for the general population, with the exception that Chinese men and women had lower rates of inpatient, outpatient and day patient attendance than the general population.

Access to mental health services

• The 1999 EMPIRIC survey found that the level of access to counsellors and psychologists was highest among the White, Irish and Black Caribbean groups.

Barriers to accessing health services

The Centre for Health Studies at Warwick University conducted a systematic review of the evidence regarding the issues surrounding access to health services for ethnic minority groups in London, an area with a high ethnic minority population.

Key issues that the review identified as leading to differential rates in accessing health services among different ethnic groups included:

• user ignorance
• language and literacy difficulties
• cultural differences (relating to religion, gender or work patterns)
• the different needs of different populations
• the location of service delivery

The review yielded the following findings:

Primary care services

There appear to be no major barriers to the use of GPs.

Women’s health services

Some studies have indicated a low uptake of maternity services by ethnic minority women. Access to these services may be obstructed by a lack of cultural sensitivity in service provision, and by language barriers.

Services for sexually transmitted diseases

There is evidence of a need for improved information and raising awareness among ethnic minority communities.

Cancer treatment services

Although access rates are similar among different ethnic groups, there is evidence that low levels of awareness regarding cancer among ethnic minority populations could be an important barrier to access.

Mental health services

The Black Caribbean population is more likely to be admitted to psychiatric units and more likely to be locked in wards or detained under the Mental Health Act.

Specialist management treatment services for heart disease

There is some evidence that Asian patients experience particular delays in accessing these services.

Services for the elderly

Poor knowledge and experience of services were barriers that obstructed access to services by elderly people.

Services for children

The factors inhibiting access by women to maternity services inevitably affect children, as do adult problems in accessing services generally.

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Perceptions of health services

The NHS has carried out several National Surveys of NHS Patients designed to contribute to monitoring the performance of the NHS as it is seen by patients. The first survey covered General Practice (1998), the second covered Coronary Heart Disease (2000) and the latest has covered Cancer (2000).

In each of the surveys the sample groups varied in size. Bearing this in mind, a clear message from all three surveys has been that ethnic minority groups were more likely than average to report unfavourably on their experiences in respect of:

• waiting times;
• understanding explanations;
• trust in doctors and nurses;
• being treated with respect and dignity; and
• help with pain relief.

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References

• Office for National Statistics, Health Statistics Quarterly, Issue 20, Winter 2003.
• Sproston and Nazaroo (eds.) (2002) Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) – Quantitative Report, London: HMSO
• Erins et al (eds) (2001), Health Survey for England – The Health of Minority Ethnic Groups 1999, London: HMSO
• Centre for Health Studies, Warwick University, (2001), Systematic review of ethnicity and health service access for London, unpublished
• NHS Patients Surveys
• Modood et al, (1997), Ethnic minorities in Britain: Diversity and Disadvantage, London: Policy Studies Institute

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IHC stats july 2004

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Home > Analysis > Story Print this Page| Email this page   Just a dose of healthcare statistics Dhiraj Sharma Healthcare is one of the most essential services in any growing society. Propelled by an affluent and health conscious growing middleclass, the healthcare industry in India grew by more than 13 per cent per annum in the last decade. Market India’s healthcare industry is estimated at Rs 1,500 billion or USD 34 billion. This works out to USD 34 per capita which is 6 per cent of GDP. Of this 15 per cent is publicly financed, four per cent is from social insurance, one per cent private insurance and the remaining 80 per cent being out of pocket as user fees (80 per cent of which goes to the private sector). Two thirds of the users are purely out-of pocket users and 90 per cent of them are from the poorest section. Healthcare statistics India has 5,03,900 doctors, 7,37,000 nurses, 162 medical colleges, 143 pharmacy colleges and 3,50,000 chemists. There are 15,097 hospitals accounting for 8,70,161 hospital beds in India. There is an extensive three-tiered government healthcare infrastructure comprising 23,000 Primary Health Centres(PHC) and 1,37,000 sub-centres serving the semi-urban and rural areas and 3000 (CHC) Community Health Centres-(Source: OPPI 2000 Estimates) India stands India’s health expenditure is 5.6 per cent of GDP, whereas most established market economies spend 7-10 per cent of GDP on health. USA spends over 14 per cent. US has 2,340 doctors as compared to India’s 143 doctors for very 10,000 people On an average, 80 out of every 1,000 children die. This figure is just 9 in the US and 30 for every 1,000 in Thailand. Life Expectancy in India is amongst the lowest at 55.5 years compared to US at 75.5 years and 66.5 years for Thailand. Compared to Brazil’s 4300 beds, India has only 1,600 beds. Potential The potential of health services sector is immense in India as there are more than 140 million upper and middle class, growing at over four per cent per annum with combined annual income of over Rs 820,000 crore. These people have confidence in healthcare products and services offered by private hospitals. The quality of healthcare has improved considerably with the availability of world class high-tech medical equipment and information technology. However, the low penetration of health insurance is limiting the growth of these world-class services. Privatisation of insurance sector has led to spurt in health care services. Less than 10 per cent of the Indian population is covered by some form of health insurance. Insurance is expected to be the main driver for raising quality consciousness and increased demand for better standards, hospital accreditation and Patient / Management Information Systems. The voluntary health insurance market estimated at Rs 4 billion is expected to be Rs 130 billion by 2005. The healthcare business for IT services comprises of players like government, insurance companies, consumer and corporate hospitals is about Rs 500 crore which is a pittance compared to the contribution of healthcare industry to national GDP which is growing at a rate of about 10-15 percent annually. The MBPO (medical business process outsourcing) will be the next boom the Indian knowledge economy will witness as it has massive potential for outsourcing within the US healthcare industry. This time outsourcing won’t be the once fashionable and now dead medical transcription, but would be more for processes like medical billing, claim processing, disease coding and forms processing which easily gives returns of USD 16-18 per person per hour, much higher than the billing rates in other BPO verticals. According to a Frost and Sullivan Study, the Indian medical hardware market (equipment and devices) is estimated at Rs 65.32 billion in 2001, growing at 12 per cent per annum, which is almost double the market size in 1993. With India becoming a healthcare destination, Health Tourism Industry, stands at Rs 1200-1500 crores, and growing at a rate of 30 per cent annually is bound to grow at a more faster rate. Lower production costs and skilled workforce has attracted multinationals to set up R & D and production centres in India. In the long run these R&D centres will help develop low-cost medicines for the Indian market. The Astra-Zeneca centre in Bangalore is a testament to this. The road ahead In order to capitalise on all these opportunities, we have to create a conducive environment by: Attracting investment Granting infrastructure status to the healthcare sector. Create fiscal policies, like providing low interest rate loans, introducing tax holidays for investment in low per capita income states, reducing import/excise duty for medical equipment, et cetera, to promote investment in healthcare services. Facilitating various clearances and certification like medical registration number, building number, anti-pollution certificate etc. Changing the legislation Mandating the employers to buy group or individual medical insurance for their employees to ensure a certain minimum financial coverage. Mandating the private sector units, that take advantage of improved fiscal policies, to commit resources to remote rural/under developed sectors. Create an autonomous body to standardise on medical messaging, codes and vocabulary, content and format, identification standards and security. Mandate the healthcare service providers to transmit selected patient data to the government for analysis. This data will be analysed to identify trends and evolve policies. Create a national database of health care providers, their facilities and services. This will create awareness among the population towards quality health care. Streamline the process of handling patient grievances. Create a nation-wide agency to deal with patient requests like ambulance hotline, emergency/first-aid consultation, trauma help-line etc. IT initiatives Sharing of patient information between providers, with patient and payers. Security and privacy services. Need for standards for messaging, codes and vocabulary (CPT, ICD), content and format standards (MR, lab report) To witness a successful revolution in healthcare, we need to bring these arrays of activities together. If this works for India over the next decade, the vast population living in rural and urban areas will bear the fruit of success “If Information is Power, Health Information is Life.” The writer is a business analyst with FCG Software Services (India) Pvt. Ltd. Email:dsharma@fcg.com

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