Proximity Does Not Equal Access: Racial Disparities in Access to High Quality Dialysis Facilities

Assessing knowledge of end-stage kidney disease and treatment options in hospitalized African American patients undergoing hemodialysis

OBJECTIVE

African Americans are more likely to develop end-stage kidney disease (ESKD) than whites and face multiple inequities regarding ESKD treatment, renal replacement therapy (RRT), and overall care. This study focused on determining gaps in participants' knowledge of their chronic kidney disease and barriers to RRT selection in an effort to identify how we can improve health care interventions and health outcomes among this population.

METHODS

African American participants undergoing hemodialysis were recruited from an ongoing research study of hospitalized patients at an urban Midwest academic medical center. Thirty-three patients were interviewed, and the transcribed interviews were entered into a software program. The qualitative data were coded using template analysis to analyze text and determine key themes. Medical records were used to obtain demographic and additional medical information.

RESULTS

Three major themes emerged from the analysis: patients have limited information on ESKD causes and treatments, patients did not feel they played an active role in selecting their initial dialysis unit, and interpersonal interactions with the dialysis staff play a large role in overall unit satisfaction.

DISCUSSION

Although more research is needed, this study provides information and suggestions to improve future interventions and care quality, specifically for this population.

Individual- and Community-Level Socioeconomic Status and Deceased Donor Renal Transplant Outcomes

BACKGROUND

This study examined the relationship between socioeconomic status (SES), race, and ethnicity and clinical outcomes following deceased donor kidney transplant (DDKT) at a high-volume transplant center.

METHODS

This retrospective cohort study used regression models and survival analyses to examine the relationship between individual- and community-level SES, race, and ethnicity and DDKT outcomes (i.e., delayed graft function, graft failure, mortality) adjusting for potential confounders.

RESULTS

The analytic sample included 3366 patients; 40.7% (n = 1370) were female, the mean age was 54.7 (SD = 13.3) years, 49.3% were non-Hispanic White, and the median follow-up time was 39.5 months (IQR = 24.2-68.1). Patients living in the most disadvantaged communities (using the US Census data) had a higher likelihood of delayed graft function (adjusted relative risk [RR] = 1.12, p = 0.042) and a higher hazard of mortality (adjusted hazard ratio [HR] = 1.32, p = 0.025) compared to patients living in the least disadvantaged communities. Patients without a high school diploma had a higher risk of delayed graft function compared to patients with an associate degree or more (RR = 1.37, p < 0.001). Patients with public insurance coverage had a higher risk of delayed graft function (RR = 1.24, p < 0.001) and a higher hazard of mortality (HR = 1.37, p < 0.001) and graft failure (HR = 1.71, p < 0.001) compared to patients without public insurance. There were no differences in graft failure or mortality by race and ethnicity.

CONCLUSIONS

SES was not consistently associated with outcomes following DDKT; however, many of the predictors were associated with delayed graft function. With a large and diverse sample size, these findings further the heterogeneity of the present renal transplant research suggesting the need for further investigation to guide implementation of innovative strategies and interventions.

Receiving hemodialysis in Hispanic ethnic dense communities is associated with better adherence and outcomes among young patients: a retrospective analysis of the Dialysis Outcomes and Practice Patterns Study

BACKGROUND

Hispanic ethnic density (HED) is a marker of better health outcomes among Hispanic patients with chronic disease. It is unclear whether community HED is associated with mortality risk among ethnically diverse patients receiving maintenance hemodialysis.

METHODS

A retrospective analysis of patients in the United States cohort of the Dialysis Outcomes and Practice Patterns Study (DOPPS) database (2011-2015) was conducted (n = 4226). DOPPS data was linked to the American Community Survey database by dialysis facility zip code to obtain % Hispanic residents (HED). One way ANOVA and Kruskal Wallis tests were used to estimate the association between tertiles of HED with individual demographic, clinical and adherence characteristics, and facility and community attributes. Multivariable Cox proportional hazards models were used to estimate the mortality hazard ratio (HR) and 95% CIs by tertile of HED, stratified by age; a sandwich estimator was used to account for facility clustering.

RESULTS

Patients dialyzing in facilities located in the highest HED tertile communities were younger (61.4 vs. 64.4 years), more commonly non-White (62.4% vs. 22.1%), had fewer comorbidities, longer dialysis vintage, and were more adherent to dialysis treatment, but had fewer minutes of dialysis prescribed than those in the lowest tertile. Dialyzing in the highest HED tertile was associated with lower hazard of mortality (HR, 0.86; 95% CI, 0.72-1.00), but this association attenuated with the addition of individual race/ethnicity (HR, 0.92; 95% CI, 0.78-1.09). In multivariable age-stratified analyses, those younger than 64 showed a lower hazard for mortality in the highest (vs. lowest) HED tertile (HR, 0.66; 95% CI, 0.49-0.90). Null associations were observed among patients ≥ 64 years.

CONCLUSIONS

Treating in communities with greater HED and racial/ethnic integration was associated with lower mortality among younger patients which points to neighborhood context and social cohesion as potential drivers of improved survival outcomes for patients receiving hemodialysis.

Racial/Ethnic Residential Segregation, Neighborhood Health Care Provision, and Choice of Pediatric Health Care Provider Across the USA

Much research has been conducted that demonstrates a link between racial/ethnic residential segregation and health care outcomes. We suggest that minority segregated neighborhoods may have diminished access to organizations and that this differential access may contribute to differences in health care outcomes across communities. We analyze this specifically using the case of pediatric health care provider choice. To examine this association, we estimate a series of multinomial logistic regression models using restricted data with ZIP code level geoidentifiers from the 2011-2012 National Survey of Children's Health (NSCH). We find that racial/ethnic residential segregation is related to a greater reliance on non-ideal forms of health care, such as clinics, and hospital outpatient departments, instead of pediatric physician's offices. This association is at least partially attenuated by the distribution of health care facilities in the local area, physician's offices, and health care practitioners in particular. Additionally, families express greater dissatisfaction with these other forms of care compared to physician's offices, demonstrating that the lack of adequate health care provision is meaningful for health care outcomes. This study expands the literature by examining how the siting of health organizations has consequences for individuals residing within these areas.

The Role of Social Risk Factors in Dialysis Quality and Patient Outcomes Under a Medicare Quality Incentive Program

BACKGROUND

There have been critical improvements in dialysis care and mortality in the last decade. These improvements track with the implementation of the end-stage renal disease (ESRD) Quality Incentive Program (QIP) beginning in 2012, which aligns Medicare payments to dialysis facilities with performance on quality measures. This study explores whether the improvements in dialysis care and patient outcomes under the ESRD QIP have been shared equally among patient groups.

METHODS

Our analyses focus on 4 social risk factors: Black race, Hispanic ethnicity, dual eligibility for Medicare and Medicaid, and rurality. We estimated multivariable regressions using longitudinal Medicare and Consolidated Renal Operations in a Web-Enabled Network data.

RESULTS

ESRD QIP payment reductions were more common at dialysis facilities with higher proportions of Black and dual-eligible ESRD patients. Patients with dual eligibility and Black race had persistently worse relative outcomes as the ESRD QIP was implemented. This finding was true for differences in outcomes when comparing patients within and across facilities and was not affected by the addition of specific quality measures to the ESRD QIP measure set. Hispanic patients and patients at rural facilities have generally not had worse outcomes since the start of the ESRD QIP.

CONCLUSIONS

There is no evidence of widening disparities in dialysis care or patient outcomes across patient groups under the ESRD QIP, which is a longstanding and well-publicized concern with value-based purchasing programs. Relative changes between patient groups since the start of ESRD QIP have not favored any patient group. Many disparities in dialysis quality measures and assessment of dialysis facility payment reductions persist.

County-Level Dialysis Facility Supply and Distance Traveled to Facilities among Incident Kidney Failure Patients

Background

The availability of dialysis facilities and distance traveled to receive care can impact health outcomes for patients with newly onset kidney failure. We examined recent changes in county-level number of dialysis facilities between 2012 and 2019 and assessed the association between county-level dialysis facility supply and the distance incident kidney failure patients travel to receive care.

Methods

We conducted a cross-sectional study of 828,427 adult patients initiating in-center hemodialysis for incident kidney failure between January 1, 2012, and December 31, 2019. We calculated the annual county-level number of dialysis facilities, and counties were categorized as having zero, one, two, or three or more dialysis facilities at the time of treatment initiation. We then measured the distance traveled between a patient's home address and dialysis facility at treatment initiation (in miles) and evaluated the association between county-level number of dialysis facilities and distance traveled to initiate treatment.

Results

The average annual county-level number of facilities increased from 1.8 to 2.3 between 2012 and 2019. In our study period, 5% of incident adult kidney failure patients resided in a county that had zero dialysis facilities between 2012 and 2019. Compared with counties with three or more dialysis facilities, patients living in counties with no facilities in our study period traveled 14.3 miles (95% CI, 13.4 to 15.2) further for treatment.

Conclusions

Kidney failure patients in counties that had no dialysis facilities traveled further, limiting their access to dialysis. Counties with no dialysis facilities at the end of the study period were more rural and had higher poverty than other counties.

Understanding the Tradeoffs Between Travel Burden and Quality of Care for In-center Hemodialysis Patients

BACKGROUND

Renal dialysis is a lifesaving but demanding therapy, requiring 3 weekly treatments of multiple-hour durations. Though travel times and quality of care vary across facilities, the extent to which patients are willing and able to engage in weighing tradeoffs is not known. Since 2015, Medicare has summarized and reported quality data for dialysis facilities using a star rating system. We estimate choice models to assess the relative roles of travel distance and quality of care in explaining patient choice of facility.

RESEARCH DESIGN

Using national data on 2 million patient-years from 7198 dialysis facilities and 4-star rating releases, we estimated travel distance to patients' closest facilities, incremental travel distance to the next closest facility with a higher star rating, and the difference in ratings between these 2 facilities. We fit mixed effects logistic regression models predicting whether patients dialyzed at their closest facilities.

RESULTS

Median travel distance was 4 times that in rural (10.9 miles) versus urban areas (2.6 miles). Higher differences in rating [odds ratios (OR): 0.56; 95% confidence interval (CI): 0.50-0.62] and greater area deprivation (OR: 0.50; 95% CI: 0.48-0.53) were associated with lower odds of attending one's closest facility. Stratified models were also fit based on urbanicity. For rural patients, excess travel was associated with higher odds of attending the closer facility (per 10 miles; OR: 1.05; 95% CI: 1.04-1.06). Star rating differences were associated with lower odds of receiving care from the closest facility among urban (OR: 0.57; 95% CI: 0.51-0.63) and rural patients (OR: 0.18; 95% CI: 0.08-0.44).

CONCLUSIONS

Most dialysis patients have higher rated facilities located not much further than their closest facility, suggesting many patients could evaluate tradeoffs between distance and quality of care in where they receive dialysis. Our results show that such tradeoffs likely occur. Therefore, quality ratings such as the Dialysis Facility Compare (DFC) Star Rating may provide actionable information to patients and caregivers. However, we were not able to assess whether these associations reflect a causal effect of the Star Ratings on patient choice, as the Star Ratings served only as a marker of quality of care.

Risk Factors for Recurrent Staphylococcus aureus Bacteremia

BACKGROUND

To understand the clinical, bacterial, and host characteristics associated with recurrent Staphylococcus aureus bacteremia (R-SAB), patients with R-SAB were compared to contemporaneous patients with a single episode of SAB (S-SAB).

METHODS

All SAB isolates underwent spa genotyping. All isolates from R-SAB patients underwent pulsed-field gel electrophoresis (PFGE). PFGE-indistinguishable pairs from 40 patients underwent whole genome sequencing (WGS). Acute phase plasma from R-SAB and S-SAB patients was matched 1:1 for age, race, sex, and bacterial genotype, and underwent cytokine quantification using 25-analyte multiplex bead array.

RESULTS

R-SAB occurred in 69 (9.1%) of the 756 study patients. Of the 69 patients, 30 experienced relapse (43.5%) and 39 reinfection (56.5%). Age, race, hemodialysis dependence, presence of foreign body, methicillin-resistant Staphyloccus aureus, and persistent bacteremia were individually associated with likelihood of recurrence. Multivariate risk modeling revealed that black hemodialysis patients were nearly 2 times more likely (odds ratio [OR] = 9.652 [95% confidence interval [CI], 5.402-17.418]) than white hemodialysis patients (OR = 4.53 [95% CI, 1.696-10.879]) to experience R-SAB. WGS confirmed PFGE interpretations in all cases. Median RANTES (regulated on activation, normal T cell expressed and secreted) levels in acute phase plasma from the initial episode of SAB were higher in R-SAB than in matched S-SAB controls (P = .0053, false discovery rate < 0.10).

CONCLUSION

This study identified several risk factors for R-SAB. The largest risk for R-SAB is among black hemodialysis patients. Higher RANTES levels in R-SAB compared to matched controls warrants further study.

Distancing the socially distanced: Racial/ethnic composition's association with physical distancing in response to COVID-19 in the U.S

Social distancing prescribed by policy makers in response to COVID-19 raises important questions as to how effectively people of color can distance. Due to inequalities from residential segregation, Hispanic and Black populations have challenges in meeting health expectations. However, segregated neighborhoods also support the formation of social bonds that relate to healthy behaviors. We evaluate the question of non-White distancing using social mobility data from Google on three sites: workplaces, grocery stores, and recreational locations. Employing hierarchical linear modeling and geographically weighted regression, we find the relation of race/ethnicity to COVID-19 distancing is varied across the United States. The HLM models show that compared to Black populations, Hispanic populations overall more effectively distance from recreation sites and grocery stores: each point increase in percent Hispanic was related to residents being 0.092 percent less likely (p< 0.05) to visit recreational sites and 0.127 percent less likely (p< 0.01) to visit grocery stores since the onset of COVID-19. However, the GWR models show there are places where the percent Black is locally related to recreation distancing while percent Hispanic is not. Further, these models show the association of percent Black to recreation and grocery distancing can be locally as strong as 1.057 percent (p< 0.05) and 0.989 percent (p< 0.05), respectively. Next, the HLM models identified that Black/White residential isolation was related to less distancing, with each point of isolation residents were 11.476 percent more likely (p< 0.01) to go to recreational sites and 7.493 percent more likely (p< 0.05) to visit grocery stores compared to before COVID-19. These models did not find a measurable advantage/disadvantage for Black populations in these places compared to White populations. COVID-19 policy should not assume disadvantage in achieving social distancing accrue equally to different racial/ethnic minorities.

Racial/Ethnic Inequities in Access to High-Quality Dialysis Treatment in Chicago: Does Neighborhood Racial/Ethnic Composition Matter?

OBJECTIVES

Blacks and Hispanics face a higher incidence rate of end-stage renal disease (ESRD) and tend to experience poorer access to quality health care compared with Whites. Income, education, and insurance coverage differentials are typically identified as risk factors, but neighborhood-level analyses may provide additional insights. We examine whether neighborhood racial composition contributes to racial/ethnic inequities in access to high-quality dialysis care in Chicago.

METHODS

Data are drawn from the United States Renal Data System merged to the ESRD Quality Incentive Program file and the American Community Survey (2005-2009) for facility and neighborhood characteristics (N = 2797). Outcomes included (1) spatial access (travel time to dialysis facilities) and (2) realized access (actual use of quality care). Neighborhood racial/ethnic composition was categorized into four types: predominantly White, Black, and Hispanic neighborhoods, and racially integrated neighborhoods.

RESULTS

Blacks lived closer to a dialysis facility but traveled the same distance to their own dialysis compared with Whites. Hispanics had longer travel time to any dialysis than Whites, and the difference between Hispanics and Whites became no longer significant after adjusting for neighborhood racial/ethnic composition. Blacks and Hispanics had better access to a high-quality facility if they lived in integrated neighborhoods (OR = 1.85 and 3.77, respectively, p < 0.01) or in neighborhoods with higher concentrations of their own race/ethnicity (OR = 1.68 for Blacks in Black neighborhoods and 1.92 for Hispanics in Hispanic neighborhoods, p < 0.05) compared with Whites in predominantly White neighborhoods.

CONCLUSION

Expanding opportunities for Blacks and Hispanics to gain access to racially integrated and minority neighborhoods may help alleviate racial/ethnic inequities in access to quality care among kidney disease patients.

Ethical challenges in nephrology: a call for action

The American Society of Nephrology, the European Renal Association-European Dialysis and Transplant Association and the International Society of Nephrology Joint Working Group on Ethical Issues in Nephrology have identified ten broad areas of ethical concern as priority challenges that require collaborative action. Here, we describe these challenges - equity in access to kidney failure care, avoiding futile dialysis, reducing dialysis costs, shared decision-making in kidney failure care, living donor risk evaluation and decision-making, priority setting in kidney disease prevention and care, the ethical implications of genetic kidney diseases, responsible advocacy for kidney health and management of conflicts of interest - with the aim of highlighting the need for ethical analysis of specific issues, as well as for the development of tools and training to support clinicians who treat patients with kidney disease in practising ethically and contributing to ethical policy-making.

Understanding the Link between Neighborhoods and Kidney Disease

Neighborhoods are where we live, learn, work, pray, and play. Growing evidence indicates that neighborhoods are an important determinant of health. The built features of our neighborhoods, such as the ways in which the streets are designed and connected and the availability of green spaces and transit stops, as well as the social features, such as the trust among neighbors and the perceptions of safety, may influence health through multiple pathways, such as access to important resources, psychosocial stress, and health behaviors. In particular, the extant literature consistently documents an association between neighborhood features and renal-associated conditions, such as cardiovascular disease, hypertension, diabetes, and obesity. There is also some evidence suggesting an association between neighborhood poverty and ESKD. The link between neighborhood and earlier stages of CKD, however, has been less clear, with most studies documenting no association. It may be that the neighborhood measures used in previous studies do not capture features of the neighborhood important for earlier stages of disease development and progression. It may also be that our current biomarkers (e.g., eGFR) and urine protein are not able to pick up very early forms of renal damage because of the kidney's overall high reserve capacity. This paper critically reviews the state of the literature on neighborhood and renal disease, with recommendations for neighborhood measures in future research. Neighborhoods are designed, built, and informed by policy, and thus, they are amenable to intervention, making them a potentially powerful way to improve renal health and reduce health inequalities at the population level.

The current and future landscape of dialysis

The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis — particularly haemodialysis and most notably in high-income countries (HICs) — the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization.

Dialysis is a life-saving therapy; however, costs of dialysis are high, access is inequitable and outcomes are inadequate. This Review describes the current landscape of dialysis therapy from an epidemiological, economic, ethical and patient-centred framework, and describes initiatives that are aimed at stimulating innovations in the field to one that supports high-quality, high-value care.

The global dialysis population is growing rapidly, especially in low-income and middle-income countries; however, worldwide, a substantial number of people lack access to kidney replacement therapy, and millions of people die of kidney failure each year, often without supportive care.

The costs of dialysis care are high and will likely continue to rise as a result of increased life expectancy and improved therapies for causes of kidney failure such as diabetes mellitus and cardiovascular disease.

Patients on dialysis continue to bear a high burden of disease, shortened life expectancy and report a high symptom burden and a low health-related quality of life.

Patient-focused research has identified fatigue, insomnia, cramps, depression, anxiety and frustration as key symptoms contributing to unsatisfactory outcomes for patients on dialysis.

Initiatives to transform dialysis outcomes for patients require both top-down efforts (that is, efforts that promote incentives based on systems level policy, regulations, macroeconomic and organizational changes) and bottom-up efforts (that is, patient-led and patient-centred advocacy efforts as well as efforts led by individual teams of innovators).

Patients, payors, regulators and health-care systems increasingly demand improved value in dialysis care, which can only come about through true patient-centred innovation that supports high-quality, high-value care.

Early Delays in Insurance Coverage and Long-term Use of Home-based Peritoneal Dialysis

BACKGROUND

Uninsured patients with end-stage renal disease face barriers to peritoneal dialysis (PD), a type of home dialysis that is associated with improved quality of life and reduced Medicare costs. Although uninsured patients using PD at dialysis start receive retroactive Medicare coverage for required predialysis services, coverage only applies for the calendar month of dialysis start. Thus, initiating dialysis later in the month yields longer retroactive coverage.

OBJECTIVES

To examine whether differences in retroactive Medicare were associated with decreased long-term PD use.

RESEARCH DESIGN

We exploited the dialysis start date using a regression discontinuity design on a national cohort from the US Renal Data System.

SUBJECTS

36,256 uninsured adults starting dialysis between January 1, 2006 and December 31, 2014.

MEASURES

PD use at dialysis days 1, 90, 180, and 360.

RESULTS

Starting dialysis on the first versus last day of the calendar month was associated with an absolute decrease in PD use of 2.7% [95% confidence interval (CI), 1.5%-3.9%], or a relative decrease of 20% (95% CI, 12%-27%) at dialysis day 360. The absolute decrease was 5.5% (95% CI, 3.5%-7.2%) after Medicare established provider incentives for PD in 2011 and 7.2% (95% CI, 2.5%-11.9%) after Medicaid expansion in 2014. Patients were unlikely to switch from hemodialysis to PD after the first month of dialysis (probability of 6.9% in month 1, 1.5% in month 2, and 0.9% in month 4).

CONCLUSIONS

Extending retroactive coverage for preparatory dialysis services could increase PD use and reduce overall Medicare spending in the uninsured.

Evaluating Residential Segregation's Relation to the Clustering of Poor Health across American Cities

Residential segregation by race/ethnicity is widely recognized as a leading source of health disparities. Not clear from past research, however, is the overall health burden cities face due to clustering brought about by segregation. This study builds on previous research by directly measuring how spatially unequal health outcomes are within segregated cities. Utilizing Census-tract data from the Center for Disease Control and Prevention's 500 Cities project, we examine how different dimensions of spatial segregation are associated with the clustering of poor self-rated health in cities. We make novel usage of the Global Moran's I statistic to measure the spatial clustering of poor health within cities. We find spatial segregation is associated with poor health clustering, however the race/ethnicity and dimension of segregation matter. Our study contributes to existing research on segregation and health by unpacking the localized associations of residential segregation with poor health clustering in U.S. cities.

Racial/Ethnic and Insurance Status Disparities in Distance Traveled to Access Children's Hospital Care for Severe Illness: the Case of Children with Leukodystrophies

Families of children with special health care needs may travel substantial distances to access specialized health care. However, it is not known how race/ethnicity, insurance status, and access to disease-specific specialty care affect travel distances. This analysis examines patients aged 18 years or younger who were discharged from a Pediatric Health Information System (PHIS) children's hospital (n = 52) with a diagnosis of an inherited leukodystrophy between October 1, 2015, and September 30, 2018 (n = 950 patients). Leukodystrophies are rare but very serious neurological illnesses, with elevated mortality and morbidity rates. Bivariate and hierarchical generalized linear models reveal that white children, privately insured children, and children visiting leukodystrophy specialist centers travel farther for children's hospital care. These findings indicate that socially privileged families travel greater distances to obtain specialized health care, which could affect clinical outcomes.

Achieving equity in dialysis care and outcomes: The role of policies

Socially disadvantaged persons, including racial and ethnic minorities, individuals with low incomes, homeless persons, and non-US citizens bear a disproportionate burden of end-stage kidney disease (ESKD). Inequities in nephrology referral, vascular access, use of home dialysis modalities, kidney transplantation, and mortality are prominent. Public policies, including the Patient Protection and Affordable Care Act, end-stage renal disease Quality Incentive Program, and the Prospective Payment System, were enacted to improve healthcare access and dialysis care. Here, we highlight inequities in dialysis care and outcomes, how current ESKD and other public policies may influence or exacerbate these inequities, and gaps in the literature needed to inform future policies toward achieving equity in ESKD. We give special attention to the 2019 Advancing American Kidney Health Executive Order, which has high potential to radically transform dialysis care.

Spatial barriers and the bypassing of nearby dental clinics for dental services: a secondary data analysis in Korea

OBJECTIVE

This study aimed to calculate the distance patients travel to dental clinics, the rate of bypassing nearby dental clinics and the distance covered when bypassing nearby dental clinics, and explored factors associated with patients' spatial access to dental clinics.

DESIGN

A secondary data analysis.

SETTING

Korea Health Panel.

PARTICIPANTS

We included users of dental care services from 2008 to 2011. A total of 2375 patients and 15 978 dental visits were analysed.

PRIMARY OUTCOME MEASURES

Korea Health Panel data (2008-2011) were used to geocode patients' and healthcare facilities' addresses. The distance travelled was calculated using road network information. To analyse the panel data, we adopted a generalised estimating equation: geographical measures on the choice of dental care facility were examined based on sex, age, educational level, equivalent income, treatment details and regional classification.

RESULTS

The median distance travelled to a dental clinic was 1.8 km, which is farther for rural (8.4 km) than for urban (1.5 km) patients. The bypass rate was 58.9%. Patients bypassing nearby dental clinics travelled 9.6 times farther for dental care (p<0.001). Unlike bypass distance, travel distance was not associated with equivalent income. People with higher education and those with implants/orthodontic treatment were more likely to bypass nearby dental clinics and travelled 1.27 times and 1.17 times farther (p<0.01), respectively.

CONCLUSIONS

Given the spatial barrier to available dental resources, factors associated with spatial access were mostly the same between travel and bypass distance except for equivalent income. The findings of this study suggest that spatial distance acts as a utilisation barrier and demands additional opportunity cost. At the same time, patients' preferences for services also increase their willingness to bypass nearby dental clinics and travel greater distances.

Racial Disparities in Invasive Methicillin-resistant Staphylococcus aureus Infections, 2005-2014

Background

Despite substantial attention to the individual topics, little is known about the relationship between racial disparities and antimicrobial-resistant and/or healthcare-associated infection trends, such as for methicillin-resistant Staphylococcus aureus (MRSA).

Methods

We analyzed Emerging Infections Program 2005-2014 surveillance data (9 US states) to determine whether reductions in invasive MRSA incidence (isolated from normally sterile body sites) affected racial disparities in rates. Case classification included hospital-onset (HO, culture >3 days after admission), healthcare-associated community onset (HACO, culture ≤3 days after admission and dialysis, hospitalization, surgery, or long-term care residence within 1 year prior), or community-associated (CA, all others). Negative binomial regression models were used to evaluate the adjusted rate ratio (aRR) of MRSA in black patients (vs in white patients) controlling for age, sex, and temporal trends.

Results

During 2005-2014, invasive HO and HACO (but not CA) MRSA rates decreased. Despite this, blacks had higher rates for HO (aRR, 3.20; 95% confidence interval [CI], 2.35-4.35), HACO (aRR, 3.84; 95% CI, 2.94-5.01), and CA (aRR, 2.78; 95% CI, 2.30-3.37) MRSA. Limiting the analysis to chronic dialysis patients reduced, but did not eliminate, the higher HACO MRSA rates among blacks (aRR, 1.83; 95% CI, 1.72-1.96), even though invasive MRSA rates among dialysis patients decreased during 2005-2014. These racial differences did not change over time.

Conclusions

Previous reductions in healthcare-associated MRSA infections have not affected racial disparities in MRSA rates. Improved understanding of the underlying causes of these differences is needed to develop effective prevention interventions that reduce racial disparities in MRSA infections.

Racial disparities in kidney transplant waitlist appearance in Chicago: Is it race or place?

BACKGROUND

Prior work has demonstrated how neighborhood poverty and racial composition impact racial disparities in access to the deceased donor kidney transplant waitlist, both nationally and regionally. We examined the association between neighborhood characteristics and racial disparities in time to transplant waitlist in Chicago, a diverse city with continued neighborhood segregation.

METHODS

Using data from the United States Renal Data System (USRDS) and the US Census, we investigated time from dialysis initiation to kidney transplant waitlisting for African American and white patients in Chicago using cause-specific proportional hazards analyses, adjusting for individual sociodemographic and clinical characteristics, as well as neighborhood poverty and racial composition.

RESULTS

In Chicago, African Americans are significantly less likely than whites to appear on the renal transplant waitlist (HR 0.73, P < .05). Compared to whites in nonpoor neighborhoods, African Americans in poor neighborhoods are significantly less likely to appear on the transplant waitlist (HR 0.61, P < .05). Over 69% of African Americans with ESRD live in these neighborhoods.

CONCLUSIONS

Consistent with national data, African Americans in Chicago have a lower likelihood of waitlisting than whites. This disparity is explained in part by neighborhood poverty, which impacts the majority of African American ESRD patients in Chicago.

Ethical issues in dialysis therapy

Treatment for end-stage kidney disease is a major economic challenge and a public health concern worldwide. Renal-replacement therapy poses several practical and ethical dilemmas of global relevance for patients, clinicians, and policy makers. These include how to: promote patients' best interests; increase access to dialysis while maintaining procedural and distributive justice; minimise the influence of financial incentives and competing interests; ensure quality of care in service delivery and access to non-dialytic supportive care when needed; minimise the financial burden on patients and health-care system; and protect the interests of vulnerable groups during crisis situations. These issues have received comparatively little attention, and there is scant ethical analysis and guidance available to decision makers. In this Health Policy, we provide an overview of the major ethical issues related to dialysis provision worldwide, identify priorities for further investigation and management, and present preliminary recommendations to guide practice and policy.

Availability of Healthcare Resources and Colorectal Cancer Outcomes Among Non-Hispanic White and Non-Hispanic Black Adults

This study aims to examine if access to healthcare, measured through the availability of medical resources at the neighborhood level, influences colorectal cancer (CRC) stage, treatment and survival using the Surveillance Epidemiology and Ends Result (SEER) dataset (November 2012), linked with the 2004 Area Resource File. A cross-sectional study was conducted to determine the association between availability of healthcare resources and CRC outcomes among non-Hispanic Black (n = 9162) and non-Hispanic White patients (n = 97,264). CRC patients were identified using the SEER*Stat program, and individual socio-demographic, clinical, and county-level healthcare access variables were obtained for each patient. Among NH-W patients, residence in counties with lower number of oncology hospitals was associated with increased odds of late stage diagnosis (OR 1.09, 95 % CI 1.04-1.14), reduced odds of receiving surgery (OR 0.83, 95 % CI 0.74-0.92) and higher hazard rates (HR 1.09, 95 % CI 1.06-1.12). There were no significant associations among NH-B patients. Increased availability of healthcare resources improves CRC outcomes among NH-W patients. However, future studies are required to better understand healthcare utilization patterns in NH-B neighborhoods, and identify other important dimensions of healthcare access such as affordability, acceptability and accommodation.

Contributions to Racial Disparity in Mortality among Children with Down Syndrome

OBJECTIVE

To evaluate whether racial differences across a variety of medical factors collected in a longitudinal clinical database at a specialty clinical for children with Down syndrome provide insight into contributors to racial disparity in mortality.

STUDY DESIGN

Comprehensive medical histories of 763 children receiving medical care at a Down syndrome specialty clinic were retrospectively reviewed regarding prenatal, postnatal, and medical issues, as well as subspecialty referrals. Frequency calculations and logistic regression were performed. The National Death Index was used to query death record databases to correlate medical histories with mortality data.

RESULTS

Prenatal drug use and intubation were significantly more frequent, but hyperbilirubinemia was significantly less frequent, in black children compared with white children with Down syndrome. Among children with Down syndrome aged <5 years, significant increases in referral to cardiology were seen for black children compared with white children. Trends were seen in an increased incidence of congenital heart disease for black children. Correlations with death records did not demonstrate differences in rates of cardiac-related deaths. Minimal racial disparity was seen for all other measures investigated.

CONCLUSION

Racial disparity in mortality exists, but the underlying cause remains unidentified despite use of a comprehensive, longitudinal database of individuals with Down syndrome and review of death records. Referrals to cardiology might be a clue to the underlying cause, perhaps as an indicator of access to care, but cardiac disease does not account for the disparity in mortality.