Inequalities in rates of renal replacement therapy in England: does it matter who you are or where you live?

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review

BACKGROUND

Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.

METHODS

We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.

RESULTS

Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.

CONCLUSIONS

Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Factors affecting access to dialysis for patients with end-stage kidney disease in Sub-Saharan Africa: A scoping review

AIMS

This scoping review examined the factors affecting access to dialysis for patients with end-stage kidney disease in Sub-Saharan Africa.

DESIGN

Scoping review.

METHODS

The scoping review is conducted following the Joanna Briggs Institute methodology for scoping reviews and modelled by Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review.

RESULTS

A descriptive content analysis of 30 included articles revealed three main findings affecting access and use of dialysis: Health system-related factors, health provider-related factors and patient factors.

PATIENT OR PUBLIC CONTRIBUTION

Equity in renal replacement therapy access and use will require concerted advocacy for good public policy, healthcare delivery, workforce capacity and education.

Complex Interventions Across Primary and Secondary Care to Optimize Population Kidney Health: A Systematic Review and Realist Synthesis to Understand Contexts, Mechanisms, and Outcomes

BACKGROUND

CKD affects 850 million people worldwide and is associated with high risk of kidney failure and death. Existing, evidence-based treatments are not implemented in at least a third of eligible patients, and there is socioeconomic inequity in access to care. While interventions aiming to improve delivery of evidence-based care exist, these are often complex, with intervention mechanisms acting and interacting in specific contexts to achieve desired outcomes.

METHODS

We undertook realist synthesis to develop a model of these context-mechanism-outcome interactions. We included references from two existing systematic reviews and from database searches. Six reviewers produced a long list of study context-mechanism-outcome configurations based on review of individual studies. During group sessions, these were synthesized to produce an integrated model of intervention mechanisms, how they act and interact to deliver desired outcomes, and in which contexts these mechanisms work.

RESULTS

Searches identified 3371 relevant studies, of which 60 were included, most from North America and Europe. Key intervention components included automated detection of higher-risk cases in primary care with management advice to general practitioners, educational support, and non-patient-facing nephrologist review. Where successful, these components promote clinician learning during the process of managing patients with CKD, promote clinician motivation to take steps toward evidence-based CKD management, and integrate dynamically with existing workflows. These mechanisms have the potential to result in improved population kidney disease outcomes and cardiovascular outcomes in supportive contexts (organizational buy-in, compatibility of interventions, geographical considerations). However, patient perspectives were unavailable and therefore did not contribute to our findings.

CONCLUSIONS

This systematic review and realist synthesis describes how complex interventions work to improve delivery of CKD care, providing a framework within which future interventions can be developed. Included studies provided insight into the functioning of these interventions, but patient perspectives were lacking in available literature.

Ethical issues with geographical variations in the provision of health care services

Geographical variations are documented for a wide range of health care services. As many such variations cannot be explained by demographical or epidemiological differences, they are problematic with respect to distributive justice, quality of care, and health policy. Despite much attention, geographical variations prevail. One reason for this can be that the ethical issues of geographical variations are rarely addressed explicitly. Accordingly, the objective of this article is to analyse the ethical aspects of geographical variations in the provision of health services. Applying a principlist approach the article identifies and addresses four specific ethical issues: injustice, harm, lack of beneficence, and paternalism. Then it investigates the normative leap from the description of geographical variations to the prescription of right care. Lastly, the article argues that professional approaches such as developing guidelines, checklists, appropriateness criteria, and standards of care are important measures when addressing geographical variations, but that such efforts should be accompanied and supported by ethical analysis. Hence, geographical variations are not only a healthcare provision, management, or a policy making problem, but an ethical one. Addressing the ethical issues with geographical variations is key for handling this crucial problem in the provision of health services.

Fine-scale geographic variations of rates of renal replacement therapy in northeastern France: Association with the socioeconomic context and accessibility to care

Background

The strong geographic variations in the incidence rates of renal replacement therapy (RRT) for end-stage renal disease are not solely related to variations in the population's needs, such as the prevalence of diabetes or the deprivation level. Inequitable geographic access to health services has been involved in different countries but never in France, a country with a generous supply of health services and where the effect of the variability of medical practices was highlighted in an analysis conducted at the geographic scale of districts. Our ecological study, performed at the finer scale of townships in a French area of 8,370,616 inhabitants, investigated the association between RRT incidence rates, socioeconomic environment and geographic accessibility to healthcare while adjusting for morbidity level and medical practice patterns.

Methods

Using data from the Renal Epidemiology and Information Network registry, we estimated age-adjusted RRT incidence rates during 2010–2014 for the 282 townships of the area. A hierarchical Bayesian Poisson model was used to examine the association between incidence rates and 18 contextual variables describing population health status, socioeconomic level and health services characteristics. Relative risks (RRs) and 95% credible intervals (95% CrIs) for each variable were estimated for a 1-SD increase in incidence rate.

Results

During 2010–2014, 6,835 new patients ≥18 years old (4231 men, 2604 women) living in the study area started RRT; the RRT incidence rates by townships ranged from 21 to 499 per million inhabitants. In multivariate analysis, rates were related to the prevalence of diabetes [RR (95% CrI): 1.05 (1.04–1.11)], the median estimated glomerular filtration rate at dialysis initiation [1.14 (1.08–1.20)], and the proportion of incident patients ≥ 85 years old [1.08 (1.03–1.14)]. After adjusting for these factors, rates in townships increased with increasing French deprivation index [1.05 (1.01–1.08)] and decreased with increasing mean travel time to reach the closest nephrologist [0.92 (0.89–0.95]).

Conclusion

These data confirm the influence of deprivation level, the prevalence of diabetes and medical practices on RRT incidence rates across a large French area. For the first time, an association was found with the distance to nephrology services. These data suggest possible inequitable geographic access to RRT within the French health system.

Canadian Senior Renal Leaders Community of Practice: Vulnerable Populations With Chronic Kidney Disease-Evidence to Inform Policy

Purpose:

Low socioeconomic status, race, ethnicity, and rural/remote populations are all associated with disparities in access, care, and outcomes for chronic kidney disease (CKD). There have been different interventions supported by Canadian renal programs to address these disparities. This article reviews the evidence for impact of strategies to reduce inequities experienced by vulnerable populations living with or at risk of CKD and to collate and share interprovincial targeted interventions through the newly formed “Canadian Senior Renal Leaders Community of Practice” focused on translating evidence into clinical practice and policy.

Source of Information:

A literature search of Medline, CINAHL, PubMed, and Google Scholar from 2008 to 2018 identified 13 reports of processes and interventions that have been implemented in Australia, Canada, and the United States to reduce inequities in CKD care and can be categorized into 3 broad areas: (1) early screening and prevention, (2) disease management and dialysis, and (3) pretransplant. Web sites from each Canadian jurisdiction and from Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) Network were used to assess the current state of Canadian initiatives.

Methods:

Reviews were completed to gather information on renal initiatives for vulnerable populations, including (1) identification of populations that experience disparities in access to care or in outcomes in the context of CKD prevention and treatment and (2) interventions that have been implemented to reduce disparities in access, care, and outcomes for vulnerable populations with CKD. A current state summary of Canadian initiatives related to vulnerable populations was conducted through a review of publicly available information, including a review of renal program Web sites and a review of current projects related to vulnerable populations that are part of Can-SOLVE CKD. Can-SOLVE CKD is a Canadian Institutes of Health Research Strategy for Patient-Oriented Research (CIHR-SPOR) funded research network to transform the care of people affected by kidney disease.

Key Findings:

Interventions to improve inequities in access to CKD screening, disease management, and care are successful when developed with community engagement, provided to the patient in their own environment, and tailored to specific populations. Many provincial renal programs have implemented initiatives to support vulnerable populations with or at risk of CKD. Current projects funded through CIHR SPOR focus on underserved populations and involve partnerships with Indigenous populations. Many renal programs in Canada had or were in the process of implementing interventions to support vulnerable populations with CKD; however, information about the initiatives were not readily available online despite a strong interest and opportunity to support interprovincial knowledge sharing. Despite this common interest, little information is systematically shared between Canadian jurisdictions to support interprovincial sharing to promote evidence-informed policy and program development. Efforts will be made through the newly formed Canadian Senior Renal Leaders Community of Practice to collaborate and share learnings to inform future program and policy development, implementation, and evaluation.

Limitations:

As this was not a systematic review, literature search only encompassed studies published in English between 2008 and 2018. It is possible that populations and interventions were overlooked during the search and through the screening process. Furthermore, the controversial definition of “vulnerable” and literature that only came from Canada, the United States, and Australia limits the generalizability of this review.

Incidence and factors associated with geographical relocation in patients receiving renal replacement therapy

BACKGROUND

Renal replacement therapy (RRT) places a burden on patients, and geographical relocation for easier access to healthcare facilities is a necessity for some. Incidence and factors associated with relocation has not been comprehensively examined at a national level. We aimed to determine proportion, incidence, characteristics of RRT patients who relocate and relocation rate by remoteness of residence and dialysis modality.

METHODS

Retrospective cohort analysis using Australian and New Zealand Dialysis and Transplant Registry to examine RRT patients in Australia from January 2005 to December 2015. Relocation incidence was calculated for remoteness of residence and RRT modality as rate per 100 patient years. Factors associated with relocation were examined using competing risk regression models with death as a competing event.

RESULTS

Of 24,676 incident patients on RRT, 5888 (23.9%) relocated with a median time of 1.6 years [IQR 0.7-3.4] years. Relocation incidence was 7.9 per 100 patient years and increased from major cities to very remote regions (7.2 to 48.8 per 100 patient years respectively, p < 0.001). Remoteness of residence was associated with geographical relocation in competing risk analysis especially in remote (SHR 1.20, 95%CI 1.01, 1.41 p = 0.034) and very remote regions (SHR 3.51 95% 3.05, 4.04 p < 0.001). Aboriginal or Torres Strait Islander ethnicity, compared to Caucasian, was independently associated with relocation (SHR 1.18, 95% CI 1.06,1.31, p = 0.002) while transplant patients were less likely to relocate compared to haemodialysis patients (HR 0.37, 95%CI 0.34, 0.39, p < 0.001).

CONCLUSIONS

Relocation in patients receiving RRT is associated with remoteness of residence, RRT modality and ethnicity. Reasons for relocation and its impact on patient wellbeing and outcome should be further explored.

Accessibility of cooling centers to heat-vulnerable populations in New York State

Introduction

Spending a few hours to cool down in a cooling center reduces the impact of heat on health. But limited or lack of accessibility of these facilities is often a barrier to their utilization. The objective of this study was to assess accessibility of the cooling centers to heat-vulnerable populations in New York State (NYS) by various modes of transportation.

Methods

We estimate the proximity of 377 cooling centers to general and heat-vulnerable populations in NYS (excluding New York City (NYC)) and determine their accessibility via walking, public transportation and driving. Distances between tract populations and nearest cooling center, and between cooling centers and public transportation stops were estimated. Accessibility in four metropolitan regions was determined via public transportation while accessibility in heat-vulnerable rural areas was estimated via driving.

Results

Distances to nearest cooling center ranged from 0 to 53.2 miles with only a third of NYS population within walking distance (0.5 miles) of a cooling center. About 51% of heat-vulnerable tracts were within 0.5 miles, with an average distance of 2.4 miles to the nearest cooling center. Within the four metro politan regions 80% of cooling centers within 0.5 miles of a public transportation stop. All cooling centers in heat-vulnerable tracts were accessible via public transportation. In rural heat-vulnerable tracts, driving distances averaged at about 18 miles.

Conclusions

In urban areas many residents were not within walking distance of a cooling center, but most, and nearly all in the most heat-vulnerable areas, were within walking distance of public transportation to a cooling center. In rural locations distances were longer, and accessibility is a greater issue. Cooling centers can be a valuable resource for general and heat-vulnerable populations during an extreme heat event. When planning and implementing cooling centers, it is therefore important to improve accessibility and address other barriers that can hamper their utilization.

The association between socioeconomic status and prevalence of chronic kidney disease: A cross-sectional study among rural residents in eastern China

To investigate the prevalence of chronic kidney disease (CKD) among eastern Chinese rural residents and analyze the relationship between socioeconomic conditions and CKD.A cross-sectional survey of 1713 adults, enrolled from 4 villages in the north-central part of Zhejiang province in eastern China was conducted by collecting data on socioeconomic status, physical examination, and laboratory investigations. CKD was defined as estimated glomerular filtration rate < 60 mL/min per 1.73 m or urinary albumin/creatinine ratio more than 30 mg/g. The crude and adjusted prevalence of CKD was estimated and the association of socioeconomic status was analyzed by logistic regression.A total of 1654 adults (96.53%) completed the screening, and 1627 (98.37%) of them had complete questionnaire and test information. The standardized prevalence of CKD adjusted by age and sex was 9.21% (95% confidence interval, 7.8-10.63). People with hypertension, hyperglycemia, hyperuricemia, high fasting blood glucose, and high body mass index had higher risk for CKD. Socioeconomic status was found to be partly related to CKD, especially educational level and occupational nature.A high prevalence of CKD was observed among rural residents in north-central Zhejiang province in eastern China. Socioeconomic statuses were partly related to the prevalence of CKD.

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.

Geovariation in Fracture Risk among Patients Receiving Hemodialysis

BACKGROUND AND OBJECTIVES

Fractures are a major source of morbidity and mortality in patients receiving dialysis. We sought to determine whether rates of fractures and tendon ruptures vary geographically.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data from the US Renal Data System were used to create four yearly cohorts, 2007-2010, including all eligible prevalent patients on hemodialysis in the United States on January 1 of each year. A secondary analysis comprising patients in a large dialysis organization conducted over the same period permitted inclusion of patient-level markers of mineral metabolism. Patients were grouped into 10 regions designated by the Centers for Medicare and Medicaid Services and divided by latitude into one of three bands: south, <35°; middle, 35° to <40°; and north, ≥40°. Poisson regression was used to calculate unadjusted and adjusted region-level rate ratios for events.

RESULTS

Overall, 327,615 patients on hemodialysis were included. Mean (SD) age was 61.8 (15.0) years old, 52.7% were white, and 55.0% were men. During 716,962 person-years of follow-up, 44,014 fractures and tendon ruptures occurred, the latter being only 0.3% of overall events. Event rates ranged from 5.36 to 7.83 per 100 person-years, a 1.5-fold rate difference across regions. Unadjusted region-level rate ratios varied from 0.83 (95% confidence interval, 0.81 to 0.85) to 1.20 (95% confidence interval, 1.18 to 1.23), a 1.45-fold rate difference. After adjustment for a wide range of case mix variables, a 1.33-fold variation in rates remained. Rates were higher in north and middle bands than the south (north rate ratio, 1.18; 95% confidence interval, 1.13 to 1.23; middle rate ratio, 1.13; 95% confidence interval, 1.10 to 1.17). Latitude explained 11% of variation, independent of region. A complementary analysis of 87,013 patients from a large dialysis organization further adjusted for circulating mineral metabolic parameters and protein energy wasting yielded similar results.

CONCLUSIONS

Rates of fractures vary geographically in the United States dialysis population, even after adjustment for known patient characteristics. Latitude seems to contribute to this phenomenon, but additional analyses exploring whether other factors might influence variation are warranted.

Association Between Remoteness to a Health Care Facility and Incidence of Ambulance Calls in Rural Areas of Japan

Objectives:

Whether traffic remoteness from health care service in rural areas influences usage of ambulance service has not been well investigated. This study aimed to evaluate the relation between remoteness to health care facilities and incidence of ambulance calls in rural areas of Japan.

Methods:

We analyzed 155 rural communities of Hiroshima. Data were obtained on all ambulance dispatches from 2010 to 2012. Driving time was calculated from each community to the closest primary/secondary and tertiary health care facility (equivalent to tertiary emergency care centers). We estimated the incidence rate and the incidence rate ratio (IRR) of ambulance calls for each 10-minute increase in the driving time, using generalized log-linear regression models, and evaluated the effect among each specific subgroup of emergency level and season.

Results:

During the study period, the median incidence rate was 436 per 10 000 people in targeted communities. When driving time to the closest primary/secondary facility increased by an increment of 10 minutes, there was a significant increase in the IRR of ambulance calls, especially during colder seasons (IRR: 1.29 [95% confidence interval: 1.11-1.49]), and this relation was also obtained for most emergency levels. In comparison, there was no such increase in IRRs observed for driving time to a tertiary facility.

Conclusion:

This study indicated a positive association between remoteness to primary/secondary medical facilities and the frequency of ambulance calls. The remoteness to a primary/secondary health care may induce an increase in ambulance calls, particularly during cold seasons.

Disparities in treatment rates of paediatric end-stage renal disease across Europe: insights from the ESPN/ERA-EDTA registry

BACKGROUND

Considerable disparities exist in the provision of paediatric renal replacement therapy (RRT) across Europe. This study aims to determine whether these disparities arise from geographical differences in the occurrence of renal disease, or whether country-level access-to-care factors may be responsible.

METHODS

Incidence was defined as the number of new patients aged 0-14 years starting RRT per year, between 2007 and 2011, per million children (pmc), and was extracted from the ESPN/ERA-EDTA registry database for 35 European countries. Country-level indicators on macroeconomics, perinatal care and physical access to treatment were collected through an online survey and from the World Bank database. The estimated effect is presented per 1SD increase for each indicator.

RESULTS

The incidence of paediatric RRT in Europe was 5.4 cases pmc. Incidence decreased from Western to Eastern Europe (-1.91 pmc/1321 km, P < 0.0001), and increased from Southern to Northern Europe (0.93 pmc/838 km, P = 0.002). Regional differences in the occurrence of specific renal diseases were marginal. Higher RRT treatment rates were found in wealthier countries (2.47 pmc/€10 378 GDP per capita, P < 0.0001), among those that tend to spend more on healthcare (1.45 pmc/1.7% public health expenditure, P < 0.0001), and among countries where patients pay less out-of-pocket for healthcare (-1.29 pmc/11.7% out-of-pocket health expenditure, P < 0.0001). Country neonatal mortality was inversely related with incidence in the youngest patients (ages 0-4, -1.1 pmc/2.1 deaths per 1000 births, P = 0.10). Countries with a higher incidence had a lower average age at RRT start, which was fully explained by country GDP per capita.

CONCLUSIONS

Inequalities exist in the provision of paediatric RRT throughout Europe, most of which are explained by differences in country macroeconomics, which limit the provision of treatment particularly in the youngest patients. This poses a challenge for healthcare policy makers in their aim to ensure universal and equal access to high-quality healthcare services across Europe.

Mass screening for chronic kidney disease in rural and remote Canadian first nations people: methodology and demographic characteristics

Background

Screening the general population for Chronic Kidney Disease is not currently recommended.. Rural and remote Canadian First Nations people suffer a disproportionate burden of Kidney Failure. The First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) project intends to test the hypothesis that a mobile, mass screening initiative available to all First Nations people 10 years of age and older residing in rural and/or remote communities, is feasible, will improve health outcomes and is cost effective.

Objectives

The objective of this manuscript is to describe the key elements required to design, implement and evaluate such a program and describe key characteristics of our screened cohort.

Design

Methods and cohort description.

Setting

11 First Nations communities within 2 Tribal Councils in Manitoba, Canada.

Patients

All First Nations individuals between the ages of 10–80 living in the 11communities were eligible for the screening initiative.

Measurements

Screening Rates achieved within communities.

Methods

An interdisciplinary team partnership was established between the Diabetes Integration Project and the Manitoba Renal Program. Stakeholder consultation was obtained and protocols developed to mass screen community members using point of care testing equipment. All people screened were risk stratified, counselled and referred to nephrologists as required in real time, based on risk.

Results

As of August 31, 2014, 1480 people in 11 communities over 2 Tribal Councils have been successfully screened. A mean screening rate of 21% of all community members eligible (aged 10–80) has been achieved. All patients at intermediate or high risk of kidney failure have been seen by nephrologists within 1 month of screening.

Limitations

Long term outcomes of kidney failure rates not assessed for at least 5 years. Alternative public health initiatives to reduce kidney failure not investigated.

Conclusions

Point of care mass screening, real time risk prediction and counselling of First Nations people at high risk of Kidney Failure is feasible in rural and remote communities. Further analysis of this cohort will describe theepidemiology of CKD in these communities, and test the cost effectiveness of this strategy.

Electronic supplementary material

The online version of this article (doi:10.1186/s40697-015-0046-9) contains supplementary material, which is available to authorized users.

Chronic kidney disease, albuminuria and socioeconomic status in the Health Surveys for England 2009 and 2010

BACKGROUND

Renal replacement therapy rates are inversely related to socioeconomic status (SES) in developed countries. The relationship between chronic kidney disease (CKD) and SES is less clear. This study examined the relationships between SES and CKD and albuminuria in England.

METHODS

Data from the Health Survey for England 2009 and 2010 were combined. The prevalence of CKD 3-5 and albuminuria was calculated, and logistic regression used to determine their association with five individual-level measures and one area-level measure of SES.

RESULTS

The prevalence of CKD 3-5 was 5.2% and albuminuria 8.0%. Age-sex-adjusted CKD 3-5 was associated with lack of qualifications [odds ratio (OR) 2.27 (95% confidence interval 1.40-3.69)], low income [OR 1.50 (1.02-2.21)] and renting tenure [OR 1.36 (1.01-1.84)]. Only tenure remained significant in fully adjusted models suggesting that co-variables were on the causal pathway. Albuminuria remained associated with several SES measures on full adjustment: low income [OR 1.55 (1.14-2.11)], no vehicle [OR 1.38 (1.05-1.81)], renting [OR 1.31 [1.03-1.67)] and most deprived area-level quintile [OR 1.55 (1.07-2.25)].

CONCLUSIONS

CKD 3-5 and albuminuria were associated with low SES using several measures. For albuminuria this was not explained by known measured causal factors.

The increase in renal replacement therapy (RRT) incidence has come to an end in Sweden-analysis of variations by region over the period 1991-2010

BACKGROUND

Renal replacement therapy (RRT) incidence has increased significantly in Sweden during the past decades. This study analyses variations in time and regional trends in RRT incidence in Sweden, adjusted for age and gender, focusing on the impact change in incidence during the last decade.

METHODS

Using data from the Swedish Renal Registry (SRR) (21 counties in Sweden, total population 9 million), we identified all incident subjects starting RRT from 1991 through 2010. Only individuals alive following 90 days of RRT start were included. Gender- and age-specific standardized RRT incidences on an annual and regional basis were calculated, and differences between counties and variations over time were examined. We compared the overall age and gender-adjusted RRT incidence rates for Sweden by calendar year. Furthermore, we also calculated the age and gender-adjusted RRT incidence in each county during two time periods (1991-1999 versus 2000-2010).

RESULTS

There were 20 172 new subjects treated with RRT between January 1991 and December 2010. The most common cause of end-stage renal disease (ESRD) was diabetes (24%) and hypertension/renal vascular disease (19%), followed by glomerulonephritis (16%). Sixty-four percent of new patients were male; the median age when commencing RRT was 66 years (10-90 percentiles; 39-80). The overall standardized RRT incidence reached its peak in 2000, and slowly decreased thereafter. A decrease in RRT incidence was observed over the study period in eight regions. The standardized RRT incidence varied between the different counties, from 0.82 to 1.19.

CONCLUSIONS

Adjusted for demographic changes in the population, an overall decrease in RRT incidence was observed from the year 2000 onwards-suggesting that the previously reported steady increase in RRT incidence is coming to an end in Sweden. Noteworthy differences were found between counties and in 8 out of 21 counties, a decreased incidence of RRT was found. Further studies need to identify the factors that contribute to this decrease.

The impact of travel time on geographic distribution of dialysis patients

Backgrounds

The geographic disparity of prevalence rates among dialysis patients is unclear. We evaluate the association between travel time to dialysis facilities and prevalence rates of dialysis patients living in 1,867 census areas of Hiroshima, Japan. Furthermore, we study the effects of geographic features (mainland or island) on the prevalence rates and assess if these effects modify the association between travel time and prevalence.

Methods

The study subjects were all 7,374 people that were certified as the “renal disabled” by local governments in 2011. The travel time from each patient to the nearest available dialysis facility was calculated by incorporating both travel time and the capacity of all 98 facilities. The effect of travel time on the age- and sex-adjusted standard prevalence rate (SPR) and 95% confidence intervals (CIs) at each census area was evaluated in two-level Poisson regression models with 1,867 census areas (level 1) nested within 35 towns or cities (level 2). The results were adjusted for area-based parameters of socioeconomic status, urbanity, and land type. Furthermore, the SPR of dialysis patients was calculated in each specific subgroup of population for travel time, land type, and combination of land type and travel time.

Results

In the regression analysis, SPR decreased by 5.2% (95% CI: −7.9–−2.3) per 10-min increase in travel time even after adjusting for potential confounders. The effect of travel time on prevalence was different in the mainland and island groups. There was no travel time-dependent SPR disparity on the islands. The SPR among remote residents (>30 min from facilities) in the mainland was lower (0.77, 95% CI: 0.71–0.85) than that of closer residents (≤30 min; 0.95, 95% CI: 0.92–0.97).

Conclusions

The prevalence of dialysis patients was lower among remote residents. Geographic difficulties for commuting seem to decrease the prevalence rate.

The impact of rural hospital closures on equity of commuting time for haemodialysis patients: simulation analysis using the capacity-distance model

Background

Frequent and long-term commuting is a requirement for dialysis patients. Accessibility thus affects their quality of lives. In this paper, a new model for accessibility measurement is proposed in which both geographic distance and facility capacity are taken into account. Simulation of closure of rural facilities and that of capacity transfer between urban and rural facilities are conducted to evaluate the impacts of these phenomena on equity of accessibility among dialysis patients.

Methods

Post code information as of August 2011 of all the 7,374 patients certified by municipalities of Hiroshima prefecture as having first or third grade renal disability were collected. Information on post code and the maximum number of outpatients (capacity) of all the 98 dialysis facilities were also collected. Using geographic information systems, patient commuting times were calculated in two models: one that takes into account road distance (distance model), and the other that takes into account both the road distance and facility capacity (capacity-distance model). Simulations of closures of rural and urban facilities were then conducted.

Results

The median commuting time among rural patients was more than twice as long as that among urban patients (15 versus 7 minutes, p < 0.001). In the capacity-distance model 36.1% of patients commuted to the facilities which were different from the facilities in the distance model, creating a substantial gap of commuting time between the two models. In the simulation, when five rural public facilitiess were closed, Gini coefficient of commuting times among the patients increased by 16%, indicating a substantial worsening of equity, and the number of patients with commuting times longer than 90 minutes increased by 72 times. In contrast, closure of four urban public facilities with similar capacities did not affect these values.

Conclusions

Closures of dialysis facilities in rural areas have a substantially larger impact on equity of commuting times among dialysis patients than closures of urban facilities. The accessibility simulations using thecapacity-distance model will provide an analytic framework upon which rational resource distribution policies might be planned.