Higher mortality among remote compared to rural or urban dwelling hemodialysis patients in the United States

Waitlist Time, Age, and Social Vulnerability: Impact on the Survival Benefit of Deceased Donor Kidney Transplantation Versus Long-term Dialysis Among Patients With End-stage Renal Disease

BACKGROUND

We sought to define the survival benefit of kidney transplantation versus long-term dialysis relative to waitlist time on dialysis, social vulnerability, and age among end-stage renal transplant candidates.

METHODS

End-stage renal disease patients who were candidates for their first deceased donor kidney transplantation between 2008 and 2020 were identified using the US Renal Data System. Survival probabilities for patient survival were compared using the restricted mean survival times (RMSTs) across different age and social vulnerability index (SVI) ranges.

RESULTS

Among 149 923 patients, 68 795 (45.9%) patients underwent a kidney transplant and 81 128 (54.1%) remained on dialysis. After propensity-score matching (n = 58 035 in each cohort), the 5-y RMST difference between kidney transplant and dialysis demonstrated an increasing trend in mean life-years gained within 5 y of follow-up relative to advancing age (<30 y: 0.40 y, 95% confidence interval, 0.36-0.44 y versus >70 y: 0.75 y, 95% confidence interval, 0.70-0.80 y). Conversely, disparities in 5-y RMSTs remained consistent relative to social vulnerability (median 5-y RMST difference: 0.62 y comparing low versus high SVI). When considering waitlist duration, stratified analyses demonstrated increasing trends across different age groups with the largest RMST differences observed among older patients aged ≥70 y. Notably, longer waitlist durations (>3 y) yielded more pronounced RMST differences compared with shorter durations (<1 y).

CONCLUSIONS

These data underscore the survival benefit associated with kidney transplantation over long-term dialysis across various age and SVI ranges. Transplantation demonstrated a greater advantage among older patients who had a longer waitlist duration.

Availability and Quality of Dialysis Care in Rural versus Urban US Counties

INTRODUCTION

Rural areas face significant disparities in dialysis care compared to urban areas due to limited access to dialysis facilities, longer travel distances, and a shortage of healthcare professionals. The objective of this study was to conduct a national examination of rural-urban differences in quality of dialysis care offered across counties in the USA.

METHODS

Data were gathered from Medicare-certified dialysis facilities in 2020 from the Centers for Medicare and Medicaid Services website. To identify high-need counties, county-level estimated crude prevalence of diabetes in adults was obtained from the 2022 CDC PLACES data portal. Our analysis reviewed 3,141 counties in the USA. The primary outcome measured was whether the county had a dialysis facility. Among those counties that had a dialysis facility, additional outcomes were the average star rating, whether peritoneal dialysis was offered, and whether home dialysis was offered.

RESULTS

The type of services offered by dialysis facilities varied significantly, with peritoneal dialysis being the most commonly offered service (50.8%), followed by home hemodialysis (28.5%) and late-shift services (16.0%). These service availabilities are more prevalent in urban facilities than in rural facilities. The Centers for Medicare and Medicaid Services Five Star Quality ratings were quite different between urban and rural facilities, with 40.4% of rural facilities having a ranking of five, compared to 27.1% in urban.

CONCLUSION

The majority of rural counties lack a single dialysis facility. Counties with high rates of chronic kidney disease, diabetes, and blood pressure, deemed high need, were less likely to have a highly rated dialysis facility. The findings can be used to further inform targeted efforts to increase diabetes educational programming and design appropriate interventions to those residing in rural communities and high-need counties who may need it the most.

Examining the Relationship between Dietary Intake, Socioeconomic Status, and Systolic Blood Pressure of Adults on Hemodialysis in Quito, Ecuador

Background

In Ecuador, the number of adults on hemodialysis (HD) continues to rise. Currently, the effect dietary habits and socioeconomic status (SES) have on blood pressure is not known for those on HD.

Objectives

The objectives of this study focused on adults on HD in Quito, Ecuador to 1) assess the relationship between dietary intake and SES; 2) compare dietary intake to the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines; and 3) explore the relationship between dietary intake and systolic blood pressure.

Methods

This cross-sectional study was conducted at the dialysis center within Eugenio Espejo Specialties Hospital in Quito, Ecuador between May and June 2022 among 50 adults on HD. Three 24-h recalls were used to determine average dietary intake and the 25-item Instituto Nacional de Estadística y Censos-Stratification of SES was used to determine SES. Electrolytes and 2 blood pressure readings were collected. Qualitative narrative data analysis was performed to identify themes using NVivo v12. T-tests of independence, simple, and multiple linear regressions using age and sex as confounders were conducted using R and a P < 0.05 was deemed as statistically significant.

Results

On an average, 76% of participants consumed <25 kcal/kg body weight energy and 64% consumed <1 g protein/kg body weight. Participants consumed less energy and protein compared with the KDOQI guidelines (P < 0.05). Positive relationships were observed with potassium and blood pressure (β = 0.020, P < 0.05) and SES with energy, protein, and phosphorus (P < 0.05). Themes that were identified as contributing to dietary intake were limited knowledge, lack of consistency with dietary information, and limited appetite.

Conclusions

Findings from this study indicate that the focus should be on improving energy and protein intake for this population.

Differences in Outcomes by Place of Origin among Hispanic Patients with Kidney Failure

SIGNIFICANCE STATEMENT

Hispanic patients are known to have a higher risk of kidney failure and lower rates of home dialysis use and kidney transplantation than non-Hispanic White patients. However, it is unknown whether these outcomes differ within the Hispanic community, which is heterogeneous in its members' places of origins. Using United States Renal Data System data, the authors found similar adjusted rates of home dialysis use for patients originating from places outside the United States and US-born Hispanic patients, whereas the adjusted risk of mortality and likelihood of transplantation differed depending on place (country or territory) of origin. Understanding the heterogeneity in kidney disease outcomes and treatment within the Hispanic community is crucial in designing interventions and implementation strategies to ensure that Hispanic individuals with kidney failure have equitable access to care.

BACKGROUND

Compared with non-Hispanic White groups, Hispanic individuals have a higher risk of kidney failure yet lower rates of living donor transplantation and home dialysis. However, how home dialysis, mortality, and transplantation vary within the Hispanic community depending on patients' place of origin is unclear.

METHODS

We identified adult Hispanic patients from the United States Renal Data System who initiated dialysis in 2009-2017. Primary exposure was country or territory of origin (the United States, Mexico, US-Puerto Rico, and other countries). We used logistic regression to estimate differences in odds of initiating home dialysis and competing risk models to estimate subdistribution hazard ratios (SHR) of mortality and kidney transplantation.

RESULTS

Of 137,039 patients, 44.4% were US-born, 30.9% were from Mexico, 12.9% were from US-Puerto Rico, and 11.8% were from other countries. Home dialysis rates were higher among US-born patients, but not significantly different after adjusting for demographic, medical, socioeconomic, and facility-level factors. Adjusted mortality risk was higher for individuals from US-Puerto Rico (SHR, 1.04; 95% confidence interval [CI], 1.01 to 1.08) and lower for Mexico (SHR, 0.80; 95% CI, 0.78 to 0.81) and other countries (SHR, 0.83; 95% CI, 0.81 to 0.86) compared with US-born patients. The adjusted rate of transplantation for Mexican or US-Puerto Rican patients was similar to that of US-born patients but higher for those from other countries (SHR, 1.22; 95% CI, 1.15 to 1.30).

CONCLUSIONS

Hispanic people from different places of origin have similar adjusted rates of home dialysis but different adjusted rates of mortality and kidney transplantation. Further research is needed to understand the mechanisms underlying these observed differences in outcomes.

Rural and urban differences in quality of dementia care of persons with dementia and caregivers across all domains: a systematic review

BACKGROUND

There are challenges in healthcare service delivery in rural areas, and this may be especially true for persons with dementia, who have higher needs to access to the healthcare system, and may have difficulties to commute easily and safely to these services. There is a growing body of literature regarding geographical disparities, but there is no comprehensive systematic review of geographical differences in persons with dementia across all domains of care quality. Therefore, the objective of this study is to conduct a systematic review of the literature on rural and urban differences in quality of dementia care outcomes of persons with dementia across all quality-of-care domains.

METHODS

We performed a digital search in Ovid MEDLINE on July 16, 2019, updated on May 3, 2021, for French or English records. We selected studies that reported outcome from at least one domain of quality of dementia care (Access, Integration, Effective Care, Efficient Care, Population Health, Safety, and Patient-Centered) in both rural and urban persons with dementia or caregivers. We used rigorous, systematic methods for screening, selection, data extraction and we analyzed outcomes reported by at least two studies using vote counting and appraised the certainty of evidence. Finally, we explored sources of heterogeneity.

RESULTS

From the 38 included studies, we found differences in many dementia care domains. Rural persons with dementia had higher mortality rates (Population Health), lower visits to any physicians (Access), more hospitalizations but shorter stays (Integration), higher antipsychotic medications (Safety), lower use of home care services and higher use of nursing home (Patient-Centered Care) compared to urban persons with dementia.

CONCLUSIONS

This comprehensive portrait of rural-urban differences in dementia care highlights possible geographically based inequities and can be used by researchers and decision makers to guide development of more equitable dementia care policies.

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.

Dialysis attendance patterns and health care utilisation of Aboriginal patients attending dialysis services in urban, rural and remote locations

Background

Aboriginal people in the Northern Territory (NT) suffer the heaviest burden of kidney failure in Australia with most living in remote areas at time of dialysis commencement. As there are few dialysis services in remote areas, many Aboriginal people are required to relocate often permanently, to access treatment. Missing dialysis treatments is not uncommon amongst Aboriginal patients but the relationship between location of dialysis service and dialysis attendance (and subsequent hospital use) has not been explored to date.

Aim

To examine the relationships between location of dialysis service, dialysis attendance patterns and downstream health service use (overnight hospital admissions, emergency department presentations) among Aboriginal patients in the NT.

Methods

Using linked hospital and dialysis registry datasets we analysed health service activity for 896 Aboriginal maintenance dialysis patients in the NT between 2008 and 2014. Multivariate linear regression and negative binomial regression analyses explored the associations between dialysis location, dialysis attendance and health service use.

Results

We found missing two or more dialysis treatments per month was more likely for Aboriginal people attending urban services and this was associated with a two-fold increase in the rate of hospital admissions and more than three-fold increase in ED presentations. However, we found higher dialysis attendance and lower health service utilisation for those receiving care in rural and remote settings. When adjusted for age, time on dialysis, region, comorbidities and residence pre-treatment, among Aboriginal people from remote areas, those dialysing in remote areas had lower rates of hospitalisations (IRR 0.56; P < 0.001) when compared to those who relocated and dialysed in urban areas.

Conclusion

There is a clear relationship between the provision and uptake of dialysis services in urban, rural and remote areas in the NT and subsequent broader health service utilisation. Our study suggests that the low dialysis attendance associated with relocation and care in urban models for Aboriginal people can potentially be ameliorated by access to rural and remote models and this warrants a rethinking of service delivery policy. If providers are to deliver effective and equitable services, the full range of intended and unintended consequences of a dialysis location should be incorporated into planning decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07628-9.

A Quantitative and Qualitative Study on Patient and Physician Perceptions of Nephrology Telephone Consultation During COVID-19

BACKGROUND

COVID-19 required rapid adoption of virtual modalities to provide care for patients with a chronic disease. Care was initially provided by telephone, which has not been evaluated for its effectiveness by patients and providers. This study reports patients' and nephrologists' perceptions and preferences surrounding telephone consultation in a chronic kidney disease (CKD) clinic.

OBJECTIVE

To evaluate patient and physician perspectives on the key advantages and disadvantages of telephone consultations in a nephrology out-patient clinic setting.

DESIGN

Cross-sectional observational survey study.

SETTING

General nephrology clinic and a multidisciplinary kidney care clinic in London, Ontario, Canada.

PARTICIPANTS

Patients with CKD who were fluent in English and participated in at least one telephone consultation with a nephrologist during the COVID-19 pandemic.

METHODS AND MEASUREMENTS

Nephrologists' and participants' input facilitated the development of both patient and nephrologist surveys. Participants provided self-reported measures in 5 domains of satisfaction: user experience, technical quality, perceived effectiveness on well-being, perceived usefulness, and effect on interaction. Nephrologists provided self-reported measures within 6 categories: general experience, time management, medication changes, quality of care, job satisfaction, and challenges/strengths. Descriptive statistics were used to present data. Content analysis was performed on 2 open-ended responses.

RESULTS

Of the 372 participants recruited, 235 participated in the survey (63% response). In all, 79% of the participants were ≥65 years old and 91% were white. Telephone consultation was a comfortable experience for 68%, and 73% felt it to be a safer alternative during the pandemic. Although 65% perceived no changes to health care access, most reported spending less time and fewer resources on transit and parking. Disadvantages to telephone consultation included a lack of physical examination and reduced patient-physician rapport. Eleven of 14 nephrologists were surveyed, with most reporting confidence in the use of telephone consultation. Physician barriers to telephone consultation included challenges with communications and lack of technology to support telephone clinics.

LIMITATIONS

Our survey included a majority of older, white participants, which may not be generalizable to other participants particularly those of other ages and ethnicity.

CONCLUSION

Although both patients and nephrologists adapted to telephone consultations, there remain opportunities to further explore populations and situations that would be better facilitated with an in-person visit. Future research in virtual care will require measurement of health care outcomes and economics.

TRIAL REGISTRATION

Not applicable as this was a survey.

Renal staffs' understanding of patients' experiences of transition from peritoneal dialysis to in-centre haemodialysis and their views on service improvement: A multi-site qualitative study in England and Australia

INTRODUCTION

Many studies have explored patients' experiences of dialysis and other treatments for kidney failure. This is the first qualitative multi-site international study of how staff perceive the process of a patient's transition from peritoneal dialysis to in-centre haemodialysis. Current literature suggests that transitions are poorly coordinated and may result in increased patient morbidity and mortality. This study aimed to understand staff perspectives of transition and to identify areas where clinical practice could be improved.

METHODS

Sixty-one participants (24 UK and 37 Australia), representing a cross-section of kidney care staff, took part in seven focus groups and sixteen interviews. Data were analysed inductively and findings were synthesised across the two countries.

RESULTS

For staff, good clinical practice included: effective communication with patients, well planned care pathways and continuity of care. However, staff felt that how they communicated with patients about the treatment journey could be improved. Staff worried they inadvertently made patients fear haemodialysis when trying to explain to them why going onto peritoneal dialysis first is a good option. Despite staff efforts to make transitions smooth, good continuity of care between modalities was only reported in some of the Australian hospitals where, unlike the UK, patients kept the same consultant. Timely access to an appropriate service, such as a psychologist or social worker, was not always available when staff felt it would be beneficial for the patient. Staff were aware of a disparity in access to kidney care and other healthcare professional services between some patient groups, especially those living in remote areas. This was often put down to the lack of funding and capacity within each hospital.

CONCLUSIONS

This research found that continuity of care between modalities was valued by staff but did not always happen. It also highlighted a number of areas for consideration when developing ways to improve care and provide appropriate support to patients as they transition from peritoneal dialysis to in-centre haemodialysis.

Equivalence of care? Accessibility and availability of dialysis services for older prisoners in Switzerland

PURPOSE

According to the principle of equivalence of care, health care in prison has to be of the same standard and quality as in the general population. This study aims to determine the geographic accessibility of dialysis services for older prisoners and the older general population in Switzerland and whether accessibility and availability of dialysis care are equivalent.

DESIGN/METHODOLOGY/APPROACH

Spatial accessibility analysis incorporated four different data types: population data, administrative data, street network data and addresses of prisons and hemodialysis services.

FINDINGS

Analysis revealed that the average travel time to the nearest dialysis service was better for prisoners (11.5 min) than for the general population (14.8 min). However, dialysis service for prisoners is hampered by the necessary lead-time in correctional settings, which, ultimately, leads to longer overall access times (36.5 min). Accordingly, the equivalence of dialysis care for older Swiss prisoners is not entirely respected for availability and accessibility.

ORIGINALITY/VALUE

The strength of the study lies in the combination of ethical principles and the highly tangible results of a spatial accessibility analysis. The ethics-driven empirical analysis provides arguments for policy-makers to review the current practices.

Survival of South African patients on renal replacement therapy

Background

The majority of South Africans rely on a resource-constrained public healthcare sector, where access to renal replacement therapy (RRT) is strictly rationed. The incidence of RRT in this sector is only 4.4 per million population (pmp), whereas it is 139 pmp in the private sector, which serves mainly the 16% of South Africans who have medical insurance. Data on the outcomes of RRT may influence policies and resource allocation. This study evaluated, for the first time, the survival of South African patients starting RRT based on data from the South African Renal Registry.

Methods

The cohort included patients with end-stage kidney disease who initiated RRT between January 2013 and September 2016. Data were collected on potential risk factors for mortality. Failure events included stopping treatment without recovery of renal function and death. Patients were censored at 1 year or upon recovery of renal function or loss to follow-up. The 1-year patient survival was estimated using the Kaplan–Meier method and the association of potential risk factors with survival was assessed using multivariable Cox proportional hazards regression.

Results

The cohort comprised 6187 patients. The median age was 52.5 years, 47.2% had diabetes, 10.2% were human immunodeficiency virus (HIV) positive and 82.2% had haemodialysis as their first RRT modality. A total of 542 patients died within 1 year of initiating RRT, and overall 1-year survival was 90.4% [95% confidence interval (CI) 89.6–91.2]. Survival was similar in patients treated in the private sector as compared with the public healthcare sector [hazard ratio 0.93 (95% CI 0.72–1.21)]. Higher mortality was associated with older age and a primary renal diagnosis of ‘Other’ or ‘Aetiology unknown’. When compared with those residing in the Western Cape, patients residing in the Northern Cape, Eastern Cape, Mpumalanga and Free State provinces had higher mortality. There was no difference in mortality based on ethnicity, diabetes or treatment modality. The 1-year survival was 95.9 and 94.2% in HIV-positive and -negative patients, respectively. One-fifth of the cohort had no data on HIV status and the survival in this group was considerably lower at 77.1% (P < 0.001).

Conclusions

The survival rates of South African patients accessing RRT are comparable to those in better-resourced countries. It is still unclear what effect, if any, HIV infection has on survival.

Rural chronic disease research patterns in the United Kingdom, United States, Canada, Australia and New Zealand: a systematic integrative review

Background

People living in rural and remote communities commonly experience significant health disadvantages. Geographical barriers and reduced specialist and generalist services impact access to care when compared with metropolitan context. Innovative models of care have been developed for people living with chronic diseases in rural areas with the goal of overcoming these inequities. The aim of this paper was to describe the characteristics and outcomes of studies investigating innovative models of care for people living with chronic disease in rural areas of developed countries where a metropolitan comparator was included.

Methods

An integrative systematic review was undertaken. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method was used to understand the empirical and theoretical data on clinical outcomes for people living with chronic disease in rural compared with metropolitan contexts and their models of care in Australia, New Zealand, United States, Canada and the United Kingdom.

Results

Literature searching revealed 620 articles published in English between 1st January 2000 and 31st March 2019. One hundred sixty were included in the review including 68 from the United States, 59 from Australia and New Zealand (5), 21 from Canada and 11 from the United Kingdom and Ireland. 53% (84) focused on cardiovascular disease; 27% (43) diabetes mellitus; 8% (12) chronic obstructive pulmonary disease; and 13% (27) chronic kidney disease. Mortality was only reported in 10% (16) of studies and only 18% (29) reported data on Indigenous populations.

Conclusions

This integrated review reveals that the published literature on common chronic health issues pertaining to rural and remote populations is largely descriptive. Only a small number of publications focus on mortality and comparative health outcomes from health care models in both urban and non-urban populations. Innovative service models and telehealth are together well represented in the published literature but data on health outcomes is relatively sparse. There is significant scope for further directly comparative studies detailing the effect of service delivery models on the health outcomes of urban and rural populations. We believe that such data would further knowledge in this field and help to break the deadly synergy between increased rurality and poorer outcomes for people with chronic disease.

The relationship between hemodialysis mortality and the Chinese medical insurance type

Objectives: In China, there are two major medical insurance models: the Urban Basic Medical Insurance (UBMI) and the New Cooperative Medical Scheme (NCMS). The aim of the present study was to evaluate the association of the medical insurance type of patients undergoing hemodialysis (HD) with their survival.

Methods: We retrospectively analyzed the end-stage renal disease adult patients initiating HD between January 2010 and December 2014 in Zhejiang province, followed up through 31 December 2015. Patients who had received HD for over 3 months were separated into two groups, based on different medical insurance type. Demographic, clinical data, and clinical outcomes were analyzed. The survival rates were calculated by using the Kaplan–Meier method.

Results: A total of 6779 patients (59 ± 16 years old, 4331 males (63.9%)) with UBMI and 7177 (59 ± 16 years old, 3778 males (52.8%)) with NCMS enrolled from 226 hemodialysis units. Compared with UBMI group, patients with NCMS had a smaller percentage of hypertensive nephropathy, diabetes mellitus and arteriovenous fistula, faced with more problems in anemia, hypoalbuminemia and metabolism of calcium and phosphorous. The 1-, 3- and 5-year survival rates were 95.4, 84.4, and 74.1% in UBMI group, 93.1, 79.7, and 67.7% in NCMS group, respectively. Patients with NCMS showed higher all-cause mortality compared with UBMI (p < 0.001). In multivariate Cox proportional hazards model, NCMS was independently associated with higher mortality (AHR = 1.53; 95% CI 1.38 ∼ 1.68).

Conclusions: The medical insurance model was independently associated with HD patient survival, NCMS was associated with increased mortality among patients undergoing maintenance hemodialysis in China.

Telehealth awareness in a US urban peritoneal dialysis clinic: From 2018 to 2019

The 2018 Bipartisan Budget Act in the United States extended telehealth access to Medicare beneficiaries who receive home dialysis in which two of three monthly visits in a quarter may be performed by telehealth after three initial face-to-face monthly visits. The originating site (where the patient is located) can be a dialysis unit or the patient's home and without geographic restriction. Patient awareness and interest in this new telehealth benefit in urban patients has not been well characterized. Patients receiving peritoneal dialysis (PD) treatment located in an urban facility completed a survey to ascertain knowledge of telehealth and readiness and willingness to participate in telehealth for their monthly visit. A total of 30 patients participated: 37% who completed the survey had heard of telehealth and 40% were able to define telehealth in words and correctly identify an example of telehealth. None of the patients were aware of the 2018 US Bipartisan Budget Act which extended telehealth assess to Medicare beneficiaries. Almost everyone had a mobile phone (83%), owned a computer (50%), and had access to Internet services (90%). The majority of patients (73%) were willing to use telehealth services for their monthly visit with the physician. PD patients living in an urban setting appear to be ready and interested in using telehealth to perform their monthly visit with the physician.

Freestanding Dialysis Facility Quality Incentive Program Scores and Mortality Among Incident Dialysis Patients in the United States

RATIONALE & OBJECTIVE

The Centers for Medicare & Medicaid Services introduced the Quality Incentive Program (QIP) along with the bundled payment reform to improve the quality of dialysis care in the United States. The QIP has been criticized for using easily obtained laboratory indicators without patient-centered measures and for a lack of evidence for an association between QIP indicators and patient outcomes. This study examined the association between dialysis facility QIP performance scores and survival among patients after initiation of dialysis.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Study participants included 84,493 patients represented in the US Renal Disease System's patient-level data who had initiated dialysis between January 1, 2013, and December 1, 2013, and who did not, during the first 90 days after dialysis initiation, die, receive a transplant, or become lost to follow-up. Patients were followed up for the study outcome through March 31, 2014.

PREDICTOR

Dialysis facility QIP scores.

OUTCOME

Mortality.

ANALYTICAL APPROACH

Using a unique facility identifier, we linked Medicare freestanding dialysis facility data from 2015 with US Renal Disease System patient-level data. Kaplan-Meier product limit estimator was used to describe the survival of study participants. Cox proportional hazards regression was used to assess the multivariable association between facility performance scores and patient survival.

RESULTS

Excluding patients who died during the first 90 days of dialysis, 11.8% of patients died during an average follow-up of 5 months. Facilities with QIP scores<45 (HR, 1.39; 95% CI, 1.15-1.68) and 45 to<60 (HR, 1.21; 95% CI, 1.10-1.33) had higher patient mortality rates than facilities with scores≥90.

LIMITATIONS

Because the Centers for Medicare & Medicaid Services have revised QIP criteria each year, the findings may not relate to years other than those studied.

CONCLUSIONS

Dialysis facilities characterized by lower QIP scores were associated with higher rates of patient mortality. These findings need to be replicated to assess their consistency over time.

The relationship between hemodialysis mortality and the Chinese medical insurance type

Objective: In China, there are two major medical insurance models: the Urban Basic Medical Insurance (UBMI) and the New Cooperative Medical Scheme (NCMS). The aim of the present study was to evaluate the association of the medical insurance type of patients undergoing hemodialysis (HD) with their survival. Methods: We retrospectively analyzed the end-stage renal disease adult patients initiating HD between January 2010 and December 2014 in Zhejiang province, followed up through 31 December 2015. Patients who had received HD for over 3 months were separated into two groups, based on different medical insurance type. Demographic, clinical data, and clinical outcomes were analyzed. The survival rates were calculated by using the Kaplan-Meier method. Results: A total of 6779 patients (59 ± 16 years old, 4331 males (63.9%)) with UBMI and 7177 (59 ± 16 years old, 3778 males (52.8%)) with NCMS enrolled from 226 hemodialysis units. Compared with UBMI group, patients with NCMS had a smaller percentage of hypertensive nephropathy, diabetes mellitus and arteriovenous fistula, faced with more problems in anemia, hypoalbuminemia and metabolism of calcium and phosphorous. The 1-, 3- and 5-year survival rates were 95.4%, 84.4%, and 74.1% in UBMI group, 93.1%, 79.7%, and 67.7% in NCMS group, respectively. Patients with NCMS showed higher all-cause mortality compared with UBMI (p < .001). In multivariate Cox proportional hazards model, NCMS was independently associated with higher mortality (AHR = 1.53; 95% CI 1.38 ∼ 1.68). Conclusions: The medical insurance model was independently associated with HD patient survival, NCMS was associated with increased mortality among patients undergoing maintenance hemodialysis in China.

Associations between access to healthcare, environmental quality, and end-stage renal disease survival time: Proportional-hazards models of over 1,000,000 people over 14 years

Prevalence of end-stage renal disease (ESRD) in the US increased by 74% from 2000 to 2013. To investigate the role of the broader environment on ESRD survival time, we evaluated average distance to the nearest hospital by county (as a surrogate for access to healthcare) and the Environmental Quality Index (EQI), an aggregate measure of ambient environmental quality composed of five domains (air, water, land, built, and sociodemographic), at the county level across the US. Associations between average hospital distance, EQI, and survival time for 1,092,281 people diagnosed with ESRD between 2000 and 2013 (age 18+, without changes in county residence) from the US Renal Data System were evaluated using proportional-hazards models adjusting for gender, race, age at first ESRD service date, BMI, alcohol and tobacco use, and rurality. The models compared the average distance to the nearest hospital (<10, 10-20, >20 miles) and overall EQI percentiles [0-5), [5-20), [20-40), [40-60), [60-80), [80-95), and [95-100], where lower percentiles are interpreted as better EQI. In the full, non-stratified model with both distance and EQI, there was increased survival for patients over 20 miles from a hospital compared to those under 10 miles from a hospital (hazard ratio = 1.14, 95% confidence interval = 1.12-1.15) and no consistent direction of association across EQI strata. In the full model stratified by average hospital distance, under 10 miles from a hospital had increased survival in the worst EQI strata (median survival 3.0 vs. 3.5 years for best vs. worst EQI, respectively), however for people over 20 miles from a hospital, median survival was higher in the best (4.2 years) vs worst (3.4 years) EQI. This association held across different rural/urban categories and age groups. These results demonstrate the importance of considering multiple factors when studying ESRD survival and future efforts should consider additional components of the broader environment.

Socioeconomic status and mortality among dialysis patients: a systematic review and meta-analysis

BACKGROUND

The reported association between individual indicators of socioeconomic status (SES) and mortality in dialysis patients was inconsistent in previous studies. We performed a meta-analysis to identify the association between SES and mortality of dialysis population.

METHODS

The meta-analysis was conducted in accordance with MOOSE guidelines. Cohorts evaluating the association between SES indicators (income, education and occupation) and mortality in dialysis patients were included. Random-effects models were used to pool the adjusted relative risk (RR) from individual studies. Heterogeneity was assessed by Cochrane's Q and the I² statistic. Subgroup analyses and sensitivity analyses were performed to identify sources of heterogeneity and to evaluate the robustness of findings.

RESULTS

Fourteen studies were finally included. In hemodialysis patients, increased mortality was associated with lower level of income (RR = 1.08, 95%CI [1.01-1.16], P = 0.035; I² = 87.9%, P < 0.001) and occupation (RR = 1.63, 95%CI [1.11-2.38], P = 0.013; I² = 0.0%, P = 0.601). However, no significant association was identified for education (RR = 1.43, 95%CI [0.92-2.25]; P = 0.112; I² = 68.3%,P = 0.001). In patients receiving peritoneal dialysis, lower level of income (RR = 1.80, 95%CI [1.12-2.88],P = 0.015; I² = 75.9%, P = 0.042), education (RR = 1.27, 95%CI [1.13-1.43], P < 0.001; I² = 0.0%, P = 0.684), and occupation (RR = 3.42, 95% CI [1.35-8.70], P = 0.010) were risk factors for increased mortality. Subgroup analysis showed the association between SES indicators and mortality in hemodialysis differed according to geographic locations and study designs.

CONCLUSION

Lower SES (measured by income, education, and occupation) tends to be associated with higher mortality in patients receiving maintenance dialysis. But the magnitude of the associations varied for different individual indicators of SES.

Non-medical facilitators and barriers towards accessing haemodialysis services: an exploration of ethical challenges

BACKGROUND

Like most of the sub-Saharan countries, Tanzania faces significant increase in the number of patients diagnosed with an end-stage renal disease (ESRD) among which only a few manage to receive chronic haemodialysis services (CHD). Yet little is known about the non-medical facilitators and barriers towards accessing these services and the associated ethical challenges.

METHODS

A phenomenological study design which employed a qualitative approach was used. The study was conducted at the dialysis unit harboured within Muhimbili National Hospital. Data were collected from purposively sampled health care providers and ESRD patients by using in-depth interviews. Text data obtained were analysed based on inductive and deductive content analysis methods to formulate major themes.

RESULTS

Fourteen key informants were interviewed including nephrologists, renal nurses, social workers, nutritionists and ESRD patients. Three major themes were formulated: a) non-medical facilitators towards accessing CHD services which enshrines two sub-themes (membership to health insurance scheme and family support), (b) non-medical barriers towards accessing CHD services which enshrines four sub-themes (affordability of treatment costs, geographical accessibility, availability of CHD resources and acceptability of treatment procedures) and lastly (c) ethical challenges associated with accessing CHD services which also enshrines three sub-themes (dual role of health care providers, patients autonomy in decision making, and treatment disparity).

CONCLUSION

Non-medical facilitators to access CHD benefits few patients whereas non-medical barriers leave many ESRD patients untreated or partially treated. On the other hand, ethical challenges like treatment inequality are quickly gaining momentum. There is a need for guideline highlighting importance, position, and limitation of non-medical factors in the delivery of CHD services in Tanzania and other developing countries.

Market Competition and Health Outcomes in Hemodialysis

OBJECTIVE

To examine whether market competition is associated with improved health outcomes in hemodialysis.

DATA SOURCES

Secondary analysis of data from a national dialysis registry between 2001 and 2011.

STUDY DESIGN

We conducted one- and two-part linear regression models, using each hospital service area (HSA) as its own control, to examine the independent associations among market concentration and health outcomes.

DATA COLLECTION

We selected cohorts of patients receiving in-center hemodialysis in the United States at the start of each calendar year. We used information about dialysis facility ownership and the location where patients received dialysis to measure an index of market concentration-the Hirschman-Herfindahl Index (HHI)-for HSA and year, which ranges from near zero (perfect competition) to one (monopoly).

PRINCIPAL FINDINGS

An average reduction in HHI by 0.2 (one standard deviation in 2011) was associated with 2.9 fewer hospitalizations per 100 patient-years (95 percent CI, 0.4 to 5.4). If these findings were generalized to the entire in-center hemodialysis population, this would translate to 8,100 (95 percent CI 1,200 to 15,000) fewer hospitalizations in 2011. There was no association between change in market competition and mortality.

CONCLUSIONS

Market competition in dialysis may lead to improved health outcomes.

Catheter-related blood stream infections in hemodialysis patients: a prospective cohort study

Background

For people requiring hemodialysis, infectious mortality is independently associated with geographic distance from a nephrologist. We aimed to determine if differential management of catheter-related blood stream infections (CRBSIs) could explain poorer outcomes.

Methods

We prospectively collected data from adults initiating hemodialysis with a central venous catheter between 2005 and 2015 in Alberta, Canada. We collected indicators of CRBSI management (timely catheter removal, relapsing bacteremia); frequency of CRBSIs; hospitalizations; predictors of CRBSIs, and bacteremia. We evaluated indicators and infectious episodes as a function of the shortest distance by road to the closest nephrologist’s practice: <50 (referent); 50–99; and ≥100 km.

Results

One thousand one hundred thirty-one participants were followed for a median of 755 days (interquartile range (IQR) 219, 1465) and used dialysis catheters for a median of 565 days (IQR 176, 1288). Compared to the referent group, there was no significant difference in the rate ratio (RR) of CRBSI in the 50–100 and >100 km distance categories: RR 1.63; 95% confidence interval (CI) (0.91, 2.91); RR 0.84 (95% CI 0.44, 1.58); p = 0.87, respectively or in bacteremia: RR 1.42; (95% CI 0.83, 2.45); RR 0.79 (95% CI 0.45,1.39) p = 0.74, respectively. There were no differences in indicators of appropriate CRBSI management or hospitalizations according to distance. The overall incidence of CRBSIs was low (0.19 per 1000 catheter days) as was the frequency of relapse. Only liver disease was independently associated with CRBSI (RR 2.11; 95% CI 1.15, 3.86).

Conclusions

The frequency and management of CRBSIs did not differ by location; however, event rates were low.

Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review

OBJECTIVES

To investigate whether there is an association between differences in travel time/travel distance to healthcare services and patients' health outcomes and assimilate the methodologies used to measure this.

DESIGN

Systematic Review. We searched MEDLINE, Embase, Web of Science, Transport database, HMIC and EBM Reviews for studies up to 7 September 2016. Studies were excluded that included children (including maternity), emergency medical travel or countries classed as being in the global south.

SETTINGS

A wide range of settings within primary and secondary care (these were not restricted in the search).

RESULTS

108 studies met the inclusion criteria. The results were mixed. 77% of the included studies identified evidence of a distance decay association, whereby patients living further away from healthcare facilities they needed to attend had worse health outcomes (eg, survival rates, length of stay in hospital and non-attendance at follow-up) than those who lived closer. 6 of the studies identified the reverse (a distance bias effect) whereby patients living at a greater distance had better health outcomes. The remaining 19 studies found no relationship. There was a large variation in the data available to the studies on the patients' geographical locations and the healthcare facilities attended, and the methods used to calculate travel times and distances were not consistent across studies.

CONCLUSIONS

The review observed that a relationship between travelling further and having worse health outcomes cannot be ruled out and should be considered within the healthcare services location debate.

Geographic disparities in mortality among the end stage renal disease patients: an analysis of the United States Renal Data System, 2007-08

The study was conducted to determine the association between mortality, rurality, and distance from the treatment facility of the patients with ESRD. The United States Renal Data System (USRDS) for the year 2007-08 was utilized to conduct analysis of 181,349 subjects. After adjusting for all other covariates, the odds of mortality were higher among patients in urban and isolated areas (18.1 miles or more from the dialysis facility), compared with those who were living closer (≤3.3 miles, OR 1.08, 95 % CI 1.05-1.12). Conversely, patients living in isolated rural (0-≤3.3 miles, OR 0.95, 95 % CI 0.81-0.96), small adjacent rural (8.1-≤18.1 miles, OR 0.90, 95 % CI 0.77-0.96) and Micropolitan rural quartiles (>18.1 miles, OR 0.96, 95 % CI 0.92-0.97) had lower odds of mortality than their urban counterparts. The Accountable Care Organizations must devise strategies to cater ESRD patients living in remote areas.

Baseline Predictors of Mortality among Predominantly Rural-Dwelling End-Stage Renal Disease Patients on Chronic Dialysis Therapies in Limpopo, South Africa

BACKGROUND

Dialysis therapy for end-stage renal disease (ESRD) continues to be the readily available renal replacement option in developing countries. While the impact of rural/remote dwelling on mortality among dialysis patients in developed countries is known, it remains to be defined in sub-Saharan Africa.

METHODS

A single-center database of end-stage renal disease patients on chronic dialysis therapies treated between 2007 and 2014 at the Polokwane Kidney and Dialysis Centre (PKDC) of the Pietersburg Provincial Hospital, Limpopo South Africa, was retrospectively reviewed. All-cause, cardiovascular, and infection-related mortalities were assessed and associated baseline predictors determined.

RESULTS

Of the 340 patients reviewed, 52.1% were male, 92.9% were black Africans, 1.8% were positive for the human immunodeficiency virus (HIV), and 87.5% were rural dwellers. The average distance travelled to the dialysis centre was 112.3 ± 73.4 Km while 67.6% of patients lived in formal housing. Estimated glomerular filtration rate (eGFR) at dialysis initiation was 7.1 ± 3.7 mls/min while hemodialysis (HD) was the predominant modality offered (57.1%). Ninety-two (92) deaths were recorded over the duration of follow-up with the majority (34.8%) of deaths arising from infection-related causes. Continuous ambulatory peritoneal dialysis (CAPD) was a significant predictor of all-cause mortality (HR: 1.62, CI: 1.07-2.46) and infection-related mortality (HR: 2.27, CI: 1.13-4.60). On multivariable cox regression, CAPD remained a significant predictor of all-cause mortality (HR: 2.00, CI: 1.29-3.10) while the risk of death among CAPD patients was also significantly modified by diabetes mellitus (DM) status (HR: 4.99, CI: 2.13-11.71).

CONCLUSION

CAPD among predominantly rural dwelling patients in the Limpopo province of South Africa is associated with an increased risk of death from all-causes and infection-related causes.

The impact of social disadvantage in moderate-to-severe chronic kidney disease: an equity-focused systematic review*

It is unclear whether a social gradient in health outcomes exists for people with moderate-to-severe chronic kidney disease (CKD). We critically review the literature for evidence of social gradients in health and investigate the ‘suitability’ of statistical analyses in the primary studies. In this equity-focused systematic review among adults with moderate-to-severe CKD, factors of disadvantage included gender, race/ethnicity, religion, education, socio-economic status or social capital, occupation and place of residence. Outcomes included access to healthcare, kidney disease progression, cardiovascular events, all-cause mortality and suitability of analyses. Twenty-four studies in the pre-dialysis population and 34 in the dialysis population representing 8.9 million people from 10 countries were included. In methodologically suitable studies among pre-dialysis patients, a significant social gradient was observed in access to healthcare for those with no health insurance and no home ownership. Low income and no home ownership were associated with higher cardiovascular event rates and higher mortality [HR 1.94, 95% confidence interval (CI) 1.27–2.98; HR 1.28, 95% CI 1.04–1.58], respectively. In methodologically suitable studies among dialysis patients, females, ethnic minorities, those with low education, no health insurance, low occupational level or no home ownership were significantly less likely to access cardiovascular healthcare than their more advantaged dialysis counterparts. Low education level and geographic remoteness were associated with higher cardiovascular event rates and higher mortality (HR 1.54, 95% CI 1.01–2.35; HR 1.21, 95% CI 1.08–1.37), respectively. Socially disadvantaged pre-dialysis and dialysis patients experience poorer access to specialist cardiovascular health services, and higher rates of cardiovascular events and mortality than their more advantaged counterparts.

Association of increased travel distance to dialysis units with the risk of anemia in rural chronic hemodialysis elderly

Geographic remoteness has been found to influence health-related outcomes negatively. As reported in the literature, rural dialysis patients have a higher risk of mortality with increasing travel distance to dialysis units. However, few studies have focused on the impact of travel distances on the development of dialysis complications. We utilized a prospectively collected chronic hemodialysis patient cohort from a rural regional hospital for analysis. Data on demographics, comorbidities, and serum laboratory results were obtained. Correlation analyses between travel distance to dialysis units and dialysis complications were conducted, and significantly correlated parameters were entered into multivariate logistic regression models to determine their exact associations. A total of 46 rural chronic hemodialysis patients were enrolled, with an average age higher than others in the literature. Significant correlation was found between travel distance and serum hemoglobin levels (R(2) = -0.34, P value = 0.029). Multivariate logistic regression found that every 1 km increase in travel distance was associated with an increased risk of anemia (hemoglobin <9 g/dL) (odds ratio 1.46; P value = 0.01). Sensitivity analyses further showed that the associated risk was partially attenuated by serum albumin (odds ratio 1.83; P value = 0.07) and ferritin (odds ratio 1.39; P value = 0.08) levels. This is the first study to demonstrate the association between increased travel distance to dialysis units and the risk of anemia in chronic dialysis patients, especially elderly. Malnutrition, inflammation, and atherosclerosis syndrome could be partially responsible for the observed association. Further research is required to confirm our findings.

An instrumental variable approach finds no associated harm or benefit with early dialysis initiation in the United States

The estimated glomerular filtration rate (eGFR) at dialysis initiation has been rising. Observational studies suggest harm, but may be confounded by unmeasured factors. As instrumental variable methods may be less biased we performed a retrospective cohort study of 310,932 patients starting dialysis between 2006 to 2008 and registered in the United States Renal Data System in order to describe geographic variation in eGFR at dialysis initiation and determine its association with mortality. Patients were grouped into 804 health service areas by zip code. Individual eGFR at dialysis initiation averaged 10.8 ml/min/1.73m² but varied geographically. Only 11% of the variation in mean health service areas-level eGFR at dialysis initiation was accounted for by patient characteristics. We calculated demographic-adjusted mean eGFR at dialysis initiation in the health service areas using the 2006 and 2007 incident cohort as our instrument and estimated the association between individual eGFR at dialysis initiation and mortality in the 2008 incident cohort using the 2 stage residual inclusion method. Among 89,547 patients starting dialysis in 2008 with eGFR 5 to 20 ml/min/1.73m², eGFR at initiation was not associated with mortality over a median of 15.5 months [hazard ratio 1.025 per 1 ml/min/1.73m² for eGFR 5 to 14 ml/min/1.73m²; and 0.973 per 1 ml/min/1.73m² for eGFR 14 to 20 ml/min/1.73m²]. Thus, there was no associated harm or benefit from early dialysis initiation in the United States.

The association between geographic proximity to a dialysis facility and use of dialysis catheters

BACKGROUND

Residing remotely from health care resources appears to impact quality of care delivery. It remains unclear if there are differences in vascular access based on distance of one's residence to dialysis centre at time of dialysis initiation, and whether region or duration of pre-dialysis care are important effect modifiers.

METHODS

We studied the association of distance from a patients' residence to the nearest dialysis centre and central venous catheter (CVC) use in an observational study of 26,449 incident adult dialysis patients registered in the Canadian Organ Replacement Registry between 2000-2009. Multivariate logistic regression was used to assess the association between distance in tertiles and CVC use, adjusted for patient demographics and comorbidities. Geographic region and duration of pre-dialysis care were examined as potential effect modifiers.

RESULTS

Eighty percent of patients commenced dialysis with a CVC. Incident CVC use was highest among those living > 20 km from the dialysis centre (OR 1.29 (1.24-1.34)) compared to those living < 5 km from centre. The length of pre-dialysis care and geographic region were significant effect modifiers; among patients residing in the furthest tertile (>20 km) from the nearest dialysis centre, incident CVC use was more common with shorter length of pre-dialysis care (< 1 year) and residence in central regions of the country.

CONCLUSION

Residing further from a dialysis centre is associated with increased CVC use, an effect modified by shorter pre-dialysis care and the geographic region of the country. Efforts to reduce geographical disparities in pre dialysis care may decrease CVC use.

Outcomes of a peritoneal dialysis program in remote communities within Colombia

BACKGROUND AND OBJECTIVE

Colombia is a country of diverse geographic regions, some with mountainous terrain that can make access to urban areas difficult for individuals who live in remote areas. In 2005, a program was initiated to establish remote peritoneal dialysis (PD) centers in Colombia to improve access to PD for patients with end-stage renal disease who face geographic or financial access barriers.

PATIENTS AND METHODS

The present study was a multi-center cohort observational study of prevalent home PD patients who were at least 18 years of age and were being managed by one of nine established remote PD centers in Colombia over a 2-year period. Data were collected from clinical records, databases, and patient interviews. Patient survival, incidence of peritonitis, and rate of withdrawal from PD therapy were assessed.

RESULTS

A total of 345 patients were eligible for the study. The majority (87.8%) of patients lived on one to two times a minimum monthly salary (equivalent to US$243 - US$486). On average, patients traveled 1.2 hours and 4.3 hours from their home to their remote PD center or an urban reference renal clinic, respectively. The incidence rate of peritonitis was 2.54 episodes per 100 patient-months of therapy. A bivariate analysis showed a significantly higher risk of peritonitis in patients who were living on less than one times a monthly minimum salary (p < 0.05) or who had a dirt, cement, or unfinished wood floor (p < 0.05). The 1-year and 2-year patient survival rates were 92.44% and 81.55%, respectively. The 1-year and 2-year technique survival rates were 97.27% and 89.78%, respectively.

CONCLUSIONS

With the support of remote PD centers that mitigate geographic and financial barriers to healthcare, home PD therapy is a safe and appropriate treatment option for patients who live in remote areas in Colombia.

Nephrologist caseload and hemodialysis patient survival in an urban cohort

Physician caseload may be a predictor of patient outcomes associated with various medical conditions and procedures, but the association between patient-physician ratio and mortality among patients undergoing hemodialysis has not been determined. We examined whether a higher patient-nephrologist ratio affects patient mortality risk using de-identified data from DaVita dialysis clinics and the U.S. Renal Data System. A total of 41 nephrologists with a caseload of 50-200 hemodialysis patients from an urban California region were retrospectively ranked according to their hemodialysis patient mortality rate during a 6-year period between 2001 and 2007. We calculated all-cause mortality hazard ratios for each nephrologist and compared patient- and provider-level characteristics between the 10 nephrologists with the highest patient mortality rates and the 10 nephrologists with the lowest patient mortality rates. Nephrologists with the lowest patient mortality rates had significantly lower patient caseloads than nephrologists with the highest mortality rates (median [interquartile range], 65 [55-76] versus 103 [78-144] patients per nephrologist, respectively; P<0.001). Additionally, patients treated by nephrologists with the lowest patient mortality rates received higher dialysis doses, had longer sessions, and received more kidney transplants. In demographic characteristic-adjusted analyses, each 50-patient increase in caseload was associated with a 2% increase in patient mortality risk (hazard ratio, 1.02; 95% confidence interval, 1.00 to 1.04; P<0.001). Hence, these results suggest that nephrologist caseload influences hemodialysis patient outcomes, and future research should focus on identifying the factors underlying this association.

High Costs of Dialysis Transportation in the United States: Exploring Approaches to a More Cost-effective Delivery System

Background: The costs of transporting end-stage renal disease (ESRD) patients to dialysis centers are high and growing rapidly. Research has suggested that substantial cost savings could be achieved if medically appropriate transport was made available and covered by Medicare. Objectives: To estimate US dialysis transportation costs from a purchaser's perspective, and to estimate cost savings that could be achieved if less expensive means of transport were utilized. Methods: Costs were estimated using an actuarial model. Travel distance estimates were calculated using GIS software from patient ZIP codes and dialysis facility addresses. Cost and utilization estimates were derived from fee schedules, government reports, transportation websites and peer-reviewed literature. Results: The estimated annual cost of dialysis transportation in the United States is $3.0 billion, half of which is for ambulances. Most other costs are due to transport via ambulettes, wheelchair vans and taxis. Approximately 5% of costs incurred are for private vehicle or public transportation use. If ambulance use dropped to 1% of trips from the current 5%, costs could be reduced by one-third. Conclusions: Decision-makers should consider policies to reduce ambulance use, while providing appropriate levels of care.