Impact of remote location on quality care delivery and relationships to adverse health outcomes in patients with diabetes and chronic kidney disease

Identifying Frailty in Older Adults in Rural Victoria, Australia: A Secondary Analysis of Population Health Data

Objectives: To determine the prevalence of frailty among community-dwelling older adults in regional Victoria, Australia. Methods: Frailty status of 376 participants from the Crossroads II cross-sectional study was assessed by selected markers of frailty. The selected variables were psychometrically tested. Associations between frailty and socio-demographic, environmental and health factors were analysed using chi-square, ANOVA and binary logistic regression (BLR). Results: Estimated prevalence of frailty was 39.4%. BLR indicated that frailty decreased with higher educational attainment, (OR = .23; 95% CI: .10-.51) increased for divorced/separated participants (OR = 2.68; 95% CI: 1.29-5.56) and when having three (OR = 3.27; 95% CI: 1.07-9.98), four (OR = 7.20; 95% CI: 2.22-23.31) or five or more chronic conditions (OR = 9.18; 95% CI: 2.83-29.72). Discussion: Frailty in this Australian regional community-dwelling sample was higher than other studies conducted in urban areas of Australia. Present results highlight the importance of exploring the multidimensionality of the frailty construct to have a better understanding which factors are associated with the development of this syndrome.

Factors Affecting Adherence to Hemodialysis Therapy Among Patients With End-Stage Renal Disease Attending In-Center Hemodialysis in Al-Ahsa Region, Saudi Arabia

Background Chronic kidney disease (CKD) and end-stage renal disease (ESRD) are global health concerns, with ESRD requiring renal replacement therapy (RRT). Hemodialysis is a prevalent modality for RRT. However, access to hemodialysis is challenging for rural patients due to geographical barriers and limited nephrology services. This research aims to identify factors influencing adherence to hemodialysis sessions among rural ESRD patients, addressing travel, healthcare infrastructure, and socioeconomic factors. Materials and methods A cross-sectional study of 154 participants was conducted from July 06 to September 10, 2023 at Al-Jaber Dialysis Center in Al-Ahsa, Saudi Arabia. It included adult CKD patients on hemodialysis who were interviewed to assess factors influencing hemodialysis adherence using a structured questionnaire. Results Our study assessed hemodialysis adherence in 154 patients in Al-Ahsa, Saudi Arabia. Gender distribution was nearly equal (male = 54.5%), with the majority aged 41-60, married, and residing in downtown areas. Hypertension (43.9%) and diabetes (32.3%) were the prevalent comorbidities. Most patients received thrice-weekly dialysis (96.15%), with family cars as the primary transportation mode (55.2%). Hypertension (43.3%) and diabetic nephropathy (40.9%) were the leading causes of CKD. Approximately 26% missed dialysis, with health issues and transportation difficulties being common reasons. Notably, adherence correlated with female gender, lower education, and family car transportation mode. Social support significantly influenced adherence, highlighting its importance in maintaining hemodialysis adherence. Conclusion Our study identified various sociodemographic and dialysis-related factors influencing adherence among hemodialysis patients in the Al-Ahsa region, Saudi Arabia. Notably, factors such as gender, education level, and transportation means significantly influenced adherence. Adequate family and social support were associated with better adherence. These findings highlight the importance of tailored interventions addressing these factors to enhance hemodialysis adherence and ultimately improve patient outcomes in this population.

Guideline-discordant inhaler regimens after COPD hospitalization: associations with rurality, drive time to care, and fragmented care - a United States cohort study

Background

Many patients receive guideline-discordant inhaler regimens after chronic obstructive pulmonary disease (COPD) hospitalization. Geography and fragmented care across multiple providers likely influence prescription of guideline-discordant inhaler regimens, but these have not been comprehensively studied. We assessed patient-level differences in guideline-discordant inhaler regimens by rurality, drive time to pulmonary specialty care, and fragmented care.

Methods

Retrospective cohort analysis using national Veterans Health Administration (VA) data among patients who received primary care and prescriptions from the VA. Patients hospitalized for COPD exacerbation between 2017 and 2020 were assessed for guideline-discordant inhaler regimens in the subsequent 3 months. Guideline-discordant inhaler regimens were defined as short-acting inhaler/s only, inhaled corticosteroid (ICS) monotherapy, long-acting beta-agonist (LABA) monotherapy, ICS + LABA, long-acting muscarinic antagonist (LAMA) monotherapy, or LAMA + ICS. Rural residence and drive time to the closest pulmonary specialty care were obtained from geocoded addresses. Fragmented care was defined as hospitalization outside the VA. We used multivariable logistic regression models to assess associations between rurality, drive time, fragmentated care, and guideline-discordant inhaler regimens. Models were adjusted for age, sex, race/ethnicity, Charlson Comorbidity Index, Area Deprivation Index, and region.

Findings

Of 33,785 patients, 16,398 (48.6%) received guideline-discordant inhaler regimens 3 months after hospitalization. Rural residents had higher odds of guideline-discordant inhalers regimens compared to their urban counterparts (adjusted odds ratio [aOR] 1.18 [95% CI: 1.12-1.23]). The odds of receiving guideline-discordant inhaler regimens increased with longer drive time to pulmonary specialty care (aOR 1.38 [95% CI: 1.30-1.46] for drive time >90 min compared to <30 min). Fragmented care was also associated with higher odds of guideline-discordant inhaler regimens (aOR 1.56 [95% CI: 1.48-1.63]).

Interpretation

Rurality, long drive time to care, and fragmented care were associated with greater prescription of guideline-discordant inhaler regimens after COPD hospitalization. These findings highlight the need to understand challenges in delivering evidence-based care.

Funding

NIHNCATS grants KL2TR002492 and UL1TR002494.

Financial toxicity experienced by rural Australian families with chronic kidney disease

AIM

Chronic kidney disease (CKD) and its treatment places a financial burden on healthcare systems and households worldwide, yet little is known of its financial impact, on those who reside in rural settings. We aimed to quantify the financial impacts and out-of-pocket expenditure experienced by adult rural patients with CKD in Australia.

METHODS

A web based structured survey was completed between November 2020 and January 2021. English speaking participants over 18 years of age, diagnosed with CKD stages 3-5, those receiving dialysis or with a kidney transplant, who lived in a rural location in Australia.

RESULTS

In total 77 (69% completion rate) participated. The mean out of pocket expenses were 5056 AUD annually (excluding private health insurance costs), 78% of households experienced financial hardship with 54% classified as experiencing financial catastrophe (out-of-pocket expenditure greater than 10% of household income). Mean distances to access health services for all rural and remote classifications was greater than 50 kilometres for specialist nephrology services and greater than 300 kilometres for transplanting centres. Relocation for a period greater than 3 months to access care was experienced by 24% of participants.

CONCLUSION

Rural households experience considerable financial hardship due to out-of-pocket costs in accessing treatment for CKD and other health-related care, raising concerns about equity in Australia, a high-income country with universal healthcare.

Deprivation and chronic kidney disease-a review of the evidence

The relationship between socioeconomic deprivation and health is inequitable. Chronic kidney disease (CKD) is an archetypal disease of inequality, being more common amongst those living in deprivation. The prevalence of CKD is rising driven by an increase in lifestyle-related conditions. This narrative review describes deprivation and its association with adverse outcomes in adults with non-dialysis-dependent CKD including disease progression, end-stage kidney disease, cardiovascular disease and all-cause mortality. We explore the social determinants of health and individual lifestyle factors to address whether patients with CKD who are socioeconomically deprived have poorer outcomes than those of higher socioeconomic status. We describe whether observed differences in outcomes are associated with income, employment, educational attainment, health literacy, access to healthcare, housing, air pollution, cigarette smoking, alcohol use or aerobic exercise. The impact of socioeconomic deprivation in adults with non-dialysis-dependent CKD is complex, multi-faceted and frequently under-explored within the literature. There is evidence that patients with CKD who are socioeconomically deprived have faster disease progression, higher risk of cardiovascular disease and premature mortality. This appears to be the result of both socioeconomic and individual lifestyle factors. However, there is a paucity of studies and methodological limitations. Extrapolation of findings to different societies and healthcare systems is challenging, however, the disproportionate effect of deprivation in patients with CKD necessitates a call to action. Further empirical study is warranted to establish the true cost of deprivation in CKD to patients and societies.

Priorities for peer support delivery among adults living with chronic kidney disease: a patient-oriented consensus workshop

BACKGROUND

Peer support can address the informational and emotional needs of people living with chronic kidney disease (CKD) and enable self-management. We aimed to identify preferences and priorities for content, format and processes of peer support delivery for patients with non-dialysis CKD and their loved ones.

METHODS

Using a patient-oriented research approach, we conducted a half-day, virtual consensus workshop with stakeholder participants from across Canada, including patients, caregivers, peer mentors and clinicians. Using personas (fictional characters), participants discussed and voted on preferences for delivery of peer support across format, content and process categories. We analyzed transcripts from small- and large-group discussions inductively using content analysis.

RESULTS

Twenty-one stakeholders, including 9 patients and 4 caregivers, participated in the workshop. In the voting exercise on format, participants prioritized peer mentor matching, programming for both patients and caregivers, and flexible scheduling. For content, participants prioritized informational and emotional support focus, and for process, they prioritized leveraging kidney care programs and alternative sources (e.g., social media) for promotion and referral. Analysis of workshop transcripts complemented prioritization results and emphasized tailoring of peer support delivery to accommodate the diversity of people living with CKD and their support needs. This concept was elaborated in 3 themes, namely alignment of program features with needs, inclusive peer support options and multiple access points.

INTERPRETATION

We identified preferences for peer support delivery for people living with CKD and underscore the importance of tailored, flexible programming in this context. Findings could be used to develop, adapt or study CKD-focused peer support interventions.

Perspectives of a proposed patient navigator programme for people with chronic kidney disease in rural communities: Report from national workshops

AIMS

People who live in rural areas have reduced access to appropriate and timely healthcare, leading to poorer health outcomes than their metropolitan-based counterparts. The aims of the workshops were to ascertain participants' perspectives on barriers to access to dialysis and transplantation, to identify and prioritize the roles of a rural patient navigator, to discuss the acceptability and feasibility of implementing this role and identify possible outcomes that could be used to measure the success of the programme in a clinical trial.

METHODS

Rural patients (n = 19), their caregivers (n = 5) and health professionals (n = 18) from Australia participated in three workshops. We analysed the data using thematic analysis.

RESULTS

We identified four themes related to access to dialysis and transplantation: overwhelmed by separate and disconnected health systems, unprepared for emotional toll and isolation, lack of practical support and inability to develop trust and rapport. Four themes related to the role of the patient navigator programme: valuing lived experience, offering cultural expertise, requiring a conduit, and flexibility of the job description. The key roles prioritized by participants were psychological support and networking, provision/consolidation of education, and provision of practical support.

CONCLUSION

Rural patients, caregivers and health professionals believed that programmes that include navigators with lived experience of dialysis and kidney transplantation and cultural expertise, especially for Aboriginal Australians, may have the potential to improve patient experiences in accessing healthcare.

Quality and variation of care for chronic kidney disease in Swiss general practice: A retrospective database study

Background

Chronic kidney disease (CKD) is a common condition in general practice. Data about quality and physician-level variation of CKD care provided by general practitioners is scarce. In this study, we evaluated determinants and variation of achievement of 14 quality indicators for CKD care using electronic medical records data from Swiss general practice during 2013–2019.

Methods

We defined two patient cohorts from 483 general practitioners, one to address renal function assessment in patients with predisposing conditions (n = 47,201, median age 68 years, 48.7% female) and one to address care of patients with laboratory-confirmed CKD (n = 14,654, median age 80 years, 57.5% female). We investigated quality indicator achievement with mixed-effect logistic regression and expressed physician-level variation as intraclass correlation coefficients (ICCs) and range odds ratios (rORs).

Results

We observed the highest quality indicator achievement rate for withholding non-steroidal anti-inflammatory drug prescription in patients with CKD staged G2–3b within 12 months of follow-up (82.6%), the lowest for albuminuria assessment within 18 months of follow-up (18.1%). Highest physician-level variation was found for renal function assessment during 18 months of follow-up in patients with predisposing conditions (diabetes: ICC 0.31, rOR 26.5; cardiovascular disease: ICC 0.28, rOR 17.4; hypertension: ICC 0.24, rOR 17.2).

Conclusion

This study suggests potentially unwarranted variation in general practice concerning RF assessment in patients affected by conditions predisposing for CKD. We further identified potential gaps in quality of CKD monitoring as well as lower quality of CKD care for female patients and patients not affected by comorbidities.

Renal Health Benefits of Rural City Planning in Japan

Progression of chronic kidney disease (CKD) is a substantial threat because it is associated with reduced healthy life expectancy and quality of life, and increase in economic burden. Research indicates people with nondialysis CKD often have lower physical functioning and that improvement of physical activity may contribute to maintaining renal health. Another issue with the current treatment of CKD is that the synergistic effects of rural depopulation due to aging and uncontrolled rural city sprawling will increase the number of under-served healthcare areas. To ensure the quality of renal health care, hospital integration is desirable, under the condition of reconstruction of the public transport system for physically and socially vulnerable people. Recently, medical and non-medical scientists advocate the challenge of city planning for population health. The links between city design and health such as cardiovascular disease, obesity, type 2 diabetes and mental disorders, have been widely studied, except for renal health. Based on our experience in a Kidney and Lifestyle-related Disease Center, we propose the idea that city planning be prioritized to improve renal health through two main streams: 1) Improve physical status by use of public and active transportation including daily walking and cycling; and 2) Equal accessibility to renal health services. Many countries, including Japan, have enacted plans and public policy initiatives that encourage increased levels of physical activity. We should focus on the impact of such movement on renal as well as general health.

Patients’ Perspectives on Access to Dialysis and Kidney Transplantation in Rural Communities in Australia

Introduction

This study aimed to describe the perspectives of patients from rural communities on access to all forms of kidney replacement therapy to inform strategies to address such inequity.

Methods

Semistructured interviews were conducted. Transcripts were thematically analyzed.

Results

There were 28 participants, of whom, 14 (50%) were female and 5 (17%) Aboriginal or Torres Strait Islander. The mean distance to a nephrologist was 107 km, and transplant center was 447 km. We identified the following 5 themes: encumbered by transportation hardship (burdening of family and friends, frustration at lack of transportation options, heightened vulnerability to road trauma, unrelenting financial strain); deprived of treatment and care (isolated from centralized services, unresolved psychological distress, vulnerable without care, disadvantaged by limited options); confused by multiple information sources (despair at fragmented care, fear of unfamiliar health settings and treatments); compounding economic consequences (depletion of income/leave, coping with unexpected expenses); and the looming threat of relocation (devastated by displacement, resigned to periods of separation, uncertainty in sourcing appropriate accommodation).

Conclusion

Patients with chronic kidney disease (CKD) in rural communities face profound economic, logistical, and psychological obstacles to accessing dialysis and transplant, leaving them feeling vulnerable and confused. To achieve equity of access and improved health outcomes for rural patients with CKD, barriers to dialysis, transplantation, and psychological services in this population require addressing through policy and alternate models of health service delivery, in consultation with rural communities and those families affected by CKD.

Clinicians' perspectives on equity of access to dialysis and kidney transplantation for rural people in Australia: a semistructured interview study

OBJECTIVES

People with chronic kidney disease requiring dialysis or kidney transplantation in rural areas have worse outcomes, including an increased risk of hospitalisation and mortality and encounter many barriers to accessing kidney replacement therapy. We aim to describe clinicians' perspectives of equity of access to dialysis and kidney transplantation in rural areas.

DESIGN

Qualitative study with semistructured interviews.

SETTING AND PARTICIPANTS

Twenty eight nephrologists, nurses and social workers from 19 centres across seven states in Australia.

RESULTS

We identified five themes: the tyranny of distance (with subthemes of overwhelming burden of travel, minimising relocation distress, limited transportation options and concerns for patient safety on the roads); supporting navigation of health systems (reliance on local champions, variability of health literacy, providing flexible models of care and frustrated by gatekeepers); disrupted care (without continuity of care, scarcity of specialist services and fluctuating capacity for dialysis); pervasive financial distress (crippling out of pocket expenditure and widespread socioeconomic disadvantage) and understanding local variability (lacking availability of safe and sustainable resources for dialysis, sensitivity to local needs and dependence on social support).

CONCLUSIONS

Clinicians identified geographical barriers, dislocation from homes and financial hardship to be major challenges for patients in accessing kidney replacement therapy. Strategies such as telehealth, outreach services, increased service provision and patient navigators were suggested to improve access.

Telemonitoring and Case Management for Hypertensive and Remote-Dwelling Patients With Chronic Kidney Disease—The Telemonitoring for Improved Kidney Outcomes Study (TIKO): A Clinical Research Protocol

Background:

Hypertension, together with poorly controlled blood pressure (BP) are known risk factors for kidney disease and progression to kidney failure as well as increased cardiovascular (CV) morbidity and mortality. Several studies in patients without kidney disease have demonstrated the efficacy of home BP telemonitoring (HBPT) for BP control.

Objective:

The primary aim of this study is to assess the mean difference in systolic BP (SBP) at 12 months, from baseline in remote dwelling patients with hypertension and chronic kidney disease (CKD) in Northern Alberta, Canada, comparing HBPT + usual care versus HBPT + a case manager. Other secondary objectives, including cost-effectiveness and acceptability of HBPT as well as occurrence of adverse events will also be assessed.

Methods

Design:

This study is designed as a pragmatic randomized controlled trial (RCT) of HBPT plus clinical case management compared to HBPT with usual care.

Setting:

Peace River region in Northern Alberta Region, Canada.

Patients:

Primary care patients with CKD and hypertension.

Measurements:

Eligible patients will be randomized 1:1 to HBPT + BP case management versus HBPT + usual care. In the intervention arm, BP will be measured 4 times daily for 1 week, with medications titrated up or down by the study case manager until guideline targets (systolic BP [SBP]: <130 mmHg) are achieved. Once BP is controlled, (ie, to guideline-concordant targets), this 1-week protocol will be repeated every 3 months for 1 year. Patients in the control arm will also follow the same BP measurement protocol; however, there will be no interactions with the case manager; they will share their BP readings with their primary care physicians or nurse practitioners at scheduled visits.

Limitations:

Potential limitations of this study include the relatively short duration of follow-up, possible technological pitfalls, and need for patients to own a smartphone and have access to the internet to participate.

Conclusions:

As this study will focus on a high-risk population that has been characterized by a large care gap, it will generate important evidence that would allow targeted and effective population-level strategies to be implemented to improve health outcomes for high-risk hypertensive CKD patients in Canada’s remote communities.

Trial Registration:

www.clinicaltrials.gov (NCT number: NCT04098354)

Improving Access to the Glycated Hemoglobin Test in Rural Communities With Point-of-Care Devices: An Application Study

Background: Living in a rural or remote area is frequently associated with impaired access to health services, which directly affects the possibility of early diagnosis and appropriate monitoring of diseases, mainly non-communicable ones, because of their asymptomatic onset and evolution. Point-of-care devices have emerged as useful technologies for improving access to several laboratory tests closely patients' beds or homes, which makes it possible to eliminate the distance barrier.

Objective: To evaluate the application of point-of-care technology for glycated hemoglobin (HbA1c) estimation in the assessment of glycemic control and identification of new diagnoses of diabetes in primary care among rural communities in a Brazilian municipality.

Materials and Methods: We included individuals aged 18 years or older among rural communities in a Brazilian municipality. From September 2019 to February 2020, participants were assessed for anthropometrics, blood pressure, and capillary glycemia during routine primary care team activities at health fairs and in patient groups. Participants previously diagnosed with diabetes but without recent HbA1c test results or those without a previous diagnosis but with random capillary glycemia higher than 140 mg/dL were considered positive and were tested for HbA1c by using a point-of-care device.

Results: At the end of the study, 913 individuals were accessed. Of these, 600 (65.7%) had no previous diagnosis of diabetes, 58/600 (9.7%) refused capillary glycemia screening and 542/600 (90.7%) were tested. Among tested individuals, 73/542 (13.5%) cases without a previous diagnosis of diabetes, were positive for capillary glycemia. Among positives, 31/73 (42.5%) had HbA1c levels that were considered indicative of prediabetes and 16/73 (21.9%) were newly diagnosed with diabetes. Among the participants, 313/913 (34.3%) were previously diagnosed with diabetes. Recent HbA1c results were unavailable for 210/313 (67.1%). These individuals were tested using point-of-care devices. Among them, 143/210 (68.1%) had HbA1c levels higher than target levels (>7% and >8% for adults and elderly individuals, respectively.

Conclusion: The application of point-of-care devices for HbA1c level measurement improved the access to this test for people living in rural or remote areas. Thus, it was possible to include this technology in the routine activities of primary health care teams, which increased the rates of new diagnoses and identification of patients with uncontrolled glycemia.

Online clinical pathway for chronic kidney disease management in primary care: a retrospective cohort study

BACKGROUND

Clinical pathways aim to improve patient care. We sought to determine whether an online chronic kidney disease (CKD) clinical pathway was associated with improvements in CKD management.

METHODS

We conducted a retrospective pre/post population-based cohort study using linked health data from Alberta, Canada. We included adults 18 years or older with mean estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2. The primary outcome was measurement of an outpatient urine albumin creatinine ratio (ACR) in a 28-day period, among people without a test in the prior year. Secondary outcomes included use of guideline-recommended drug therapies (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statins).

RESULTS

The study period spanned October 2010 to March 2017. There were 84 independent 28-day periods (53 pre, 31 post pathway implementation) including 345,058 adults. The population was predominantly female (56%) with median age 77 years; most had category 3A CKD (67%) and hypertension (82%). In adjusted segmented regression models, the increase in the rate of change of ACR testing was greatest in Calgary zone (adjusted OR 1.19 per year, 95% CI 1.16-1.21), where dissemination of the pathway was strongest; this increase was more pronounced in those without diabetes (adjusted OR 1.25 per year, 95% CI 1.21-1.29). Small improvements in guideline-concordant medication use were also observed.

CONCLUSIONS

Following implementation of an online CKD clinical pathway, improvements in ACR testing were evident in regions where the pathway was most actively used, particularly among individuals without diabetes.

Progression to unscheduled hospital admissions in people with diabetes: a qualitative interview study

BACKGROUND

People with diabetes often have difficulty maintaining optimal blood glucose levels, risking progressive complications that can lead to unscheduled care. Unscheduled care can include attending emergency departments, ambulance callouts, out-of-hours care, and non-elective hospital admissions. A large proportion of non-elective hospital admissions involve people with diabetes, with significant health and economic burden.

AIM

To identify precipitating factors influencing diabetes-related unscheduled hospital admissions, exploring potential preventive strategies to reduce admissions.

DESIGN & SETTING

Thirty-six people with type 1 (n = 11) or type 2 (n = 25) diabetes were interviewed. They were admitted to hospital for unscheduled diabetes-related care across three hospitals in Scotland, Northern Ireland, and the Republic of Ireland. Participants were admitted for peripheral limb complications (n = 17), hypoglycaemia (n = 5), hyperglycaemia (n = 6), or for comorbidities presenting with erratic blood glucose levels (n = 8).

METHOD

Factors precipitating admissions were examined using framework analysis.

RESULTS

Three aspects of care influenced unscheduled admissions: perceived inadequate knowledge of diabetes complications; restricted provision of care; and complexities in engagement with self-care and help-seeking. Limited specialist professional knowledge of diabetes by staff in primary and community care, alongside inadequate patient self-management knowledge, led to inappropriate treatment and significant delays. This was compounded by restricted provision of care, characterised by poor access to services - in time and proximity - and poor continuity of care. Complexities in patient engagement, help-seeking, and illness beliefs further complicated the progression to unscheduled admissions.

CONCLUSION

Dedicated investment in primary care is needed to enhance provision of and access to services. There should be increased promotion and earlier diabetes specialist team involvement, alongside training and use of technology and telemedicine, to enhance existing care.

Opportunities To Improve Diabetes Care in the Hemodialysis Unit: A Cohort Study in Ontario, Canada

Background

Patients with diabetes receiving chronic, in-center hemodialysis face healthcare challenges. We examined the prevalence of gaps in their diabetes care, explored regional differences, and determined predictors of care gaps.

Methods

We conducted a population-based, retrospective study between January 1, 2016 and January 1, 2018 in Ontario, Canada. We included adults with prevalent diabetes mellitus receiving in-center hemodialysis as of January 1, 2018 and examined the proportion with (1) insufficient or excessive glycemic monitoring, (2) suboptimal screening for diabetes-related complications (retinopathy and cardiovascular screening), (3) hospital encounters for hypo- or hyperglycemia, and (4) hospital encounters for hypertension in the 2 years prior (January 1, 2016 to January 1, 2018). We then identified patient, provider, and health-system factors associated with more than one care gap and used multivariable logistic regression to determine predictors. Further, we used geographic information systems to explore spatial variation in gaps.

Results

There were 4173 patients with diabetes receiving in-center hemodialysis; the mean age was 67 years, 39% were women, and the majority were of lower socioeconomic status. Approximately 42% of patients had more than one diabetes care gap, the most common being suboptimal retinopathy screening (53%). Significant predictors of more than one gap included younger age, female sex, shorter duration of diabetes, dementia, fewer specialist visits, and not seeing a physician for diabetes. There was evidence of spatial variation in care gaps across our region.

Conclusions

There are opportunities to improve diabetes care in patients receiving in-center hemodialysis, particularly screening for retinopathy. Focused efforts to bring diabetes support to high-risk individuals might improve their care and outcomes.

The Psychosocial and Somatic Effects of Relocation from Remote Canadian First Nation Communities to Urban Centres on Indigenous Peoples with Chronic Kidney Disease (CKD)

Chronic kidney disease, also referred to as end-stage renal disease (ESRD), is a prevalent and chronic condition for which treatment is necessary as a means of survival once affected individuals reach the fifth and final stage of the disease. Dialysis is a form of maintenance treatment that aids with kidney functioning once a normal kidney is damaged. There are two main types of dialysis: hemodialysis (HD) and peritoneal dialysis (PD). Each form of treatment is discussed between the patient and nephrologist and is largely dependent upon the following factors: medical condition, ability to administer treatment, supports, geographical location, access to necessary equipment/supplies, personal wishes, etc. For Indigenous Peoples who reside on remote Canadian First Nation communities, relocation is often recommended due to geographical location and limited access to both health care professionals and necessary equipment/supplies (i.e., quality of water, access to electricity/plumbing, etc.). Consequently, the objective of this paper is to determine the psychosocial and somatic effects for Indigenous Peoples with ESRD if they have to relocate from remote First Nation communities to an urban centre. A review of the literature suggests that relocation to urban centres has negative implications that are worth noting: cultural isolation, alienation from family and friends, somatic issues, psychosocial issues, loss of independence and role adjustment. As a result of relocation, it is evident that the impact is profound in terms of an individuals’ mental, emotional, physical and spiritual well-being. Ensuring that adequate social support and education are available to patients and families would aid in alleviating stressors associated with managing chronic kidney disease.

Patients' and caregivers' perspectives on access to kidney replacement therapy in rural communities: systematic review of qualitative studies

OBJECTIVE

Patients with chronic kidney disease (CKD) requiring kidney replacement therapy (KRT) in rural communities encounter many barriers in accessing equitable care and have worse outcomes compared with patients in urban areas. This study aims to describe the perspectives of patients and caregivers on access to KRT in rural communities to inform strategies to maximise access to quality care, and thereby reduce disadvantage, inequity and improve health outcomes.

SETTING

18 studies (n=593 participants) conducted across eight countries (Australia, Canada, the UK, New Zealand, Ghana, the USA, Tanzania and India).

RESULTS

We identified five themes: uncertainty in navigating healthcare services (with subthemes of struggling to absorb information, without familiarity and exposure to options, grieving former roles and yearning for cultural safety); fearing separation from family and home (anguish of homesickness, unable to fulfil family roles and preserving sense of belonging in community); intense burden of travel and cost (poverty of time, exposure to risks and hazards, and taking a financial toll); making life-changing sacrifices; guilt and worry in receiving care (shame in taking resources from others, harbouring concerns for living donor, and coping and managing in isolation).

CONCLUSION

Patients with CKD in rural areas face profound and inequitable challenges of displacement, financial burden and separation from family in accessing KRT, which can have severe consequences on their well-being and outcomes. Strategies are needed to improve access and reduce the burden of obtaining appropriate KRT in rural communities.

Screening for chronic kidney disease over hospital integration

Hospital integration among rural districts to concentrate medical resources is one of the main projects of the Japanese government. In advance of this, we experienced hospital integration and screening for chronic kidney disease as definitive risk for end-stage kidney disease and cardiovascular mortality. After that, high-risk patients have been appropriately referred from generalists to nephrologists and/or cardiologists without acute deterioration of renal function or cardiac sudden death.

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.

Changes in kidney function follow living donor nephrectomy

Better understanding of kidney function after living donor nephrectomy and how it differs by donor characteristics can inform patient selection, counselling, and follow-up care. To evaluate this, we conducted a retrospective matched cohort study of living kidney donors in Alberta, Canada between 2002-2016, using linked healthcare administrative databases. We matched 604 donors to 2,414 healthy non-donors from the general population based on age, sex, year of cohort entry, urban residence and the estimated glomerular filtration rate (eGFR) before cohort entry (nephrectomy date for donors and randomly assigned date for non-donors). The primary outcome was the rate of eGFR change over time (median follow-up seven years; maximum 15 years). The median age of the cohort was 43 years, 64% women, and the baseline (pre-donation) eGFR was 100 mL/min/1.73 m². Overall, from six weeks onwards, the eGFR increased by +0.35 mL/min/1.73 m² per year (95% confidence interval +0.21 to +0.48) in donors and significantly decreased by -0.85 mL/min/1.73 m² per year (-0.94 to -0.75) in the matched healthy non-donors. The change in eGFR between six weeks to two years, two to five years, and over five years among donors was +1.06, +0.64, and -0.06 mL/min/1.73 m² per year, respectively. In contrast to the steady age-related decline in kidney function in non-donors, post-donation kidney function on average initially increased by 1 mL/min/1.73 m² per year attributable to glomerular hyperfiltration, which began to plateau by five years post-donation. Thus, the average change in eGFR over time is significantly different between donors and non-donors.

Health Information Technology Adoption and Clinical Performance in Federally Qualified Health Centers

A national sample (N = 982) of federally qualified health centers (FQHCs) for the period 2011-2016 was examined regarding the relationship between the age and extent of health information technology (HIT) use and clinical performance. We found that each additional year of HIT use was associated with an approximate 4 percent increase in both process and outcome measures of clinical performance. Furthermore, FQHCs that fully adopted HIT had 7 percent higher clinical performance on hypertension control than those that did not adopt HIT. This study's findings can assist stakeholders to make informed decisions for improving care and sustaining a competitive advantage.

Electronic Advice Request System for Nephrology in Alberta: Pilot Results and Implementation

Background:

Residents of rural areas of Alberta face significant barriers regarding access to specialist care, resulting in delays in provision of optimal care. Electronic referral and consultation systems are promising tools for facilitating timely access to specialist care, especially for people living in rural locations.

Objective:

To report our initial experience with the launch of an electronic advice request system for ambulatory kidney care in Alberta, Canada.

Methods:

We analyzed electronic advice requests for nephrology services in Alberta after the system’s pilot launch, from October 2016 to December 2017. Data for province-wide advice request utility by primary care providers (PCPs) were extracted from Alberta Netcare for analysis.

Results:

The total number of electronic advice requests directed to nephrology was 118 (mean number of requests: 2 per week). Only 31 (26.3%) of the cases required a face-to-face clinic visit with a nephrologist. Most (87; 73.7%) cases were managed by PCPs with ongoing nephrologist support via the advice request tool. Typical nephrologist response time was 5.7 ± 0.6 (mean ± SEM) days.

Conclusion:

These preliminary data suggest that the electronic advice request program has potential to enhance timely access to specialist kidney care and minimize unnecessary nephrologist visits while reducing response time. Broad implementation of this system may have a substantial positive impact on health outcomes and improve cost-effectiveness for nephrology care in the long term, particularly in rural communities of Alberta.

Protocol: Improving Access to Specialist Nephrology Care Among Rural/Remote Dwellers of Alberta: The Role of Electronic Consultation in Improving Care for Patients With Chronic Kidney Disease

Background:

As the burden of chronic kidney disease (CKD) continues to increase, many geographically dispersed Canadians have limited access to specialist nephrology care, which tends to be centralized in major urban areas. As a result, many rural/remote-dwellers in Canada experience poor quality of care and related adverse outcomes. It is imperative to develop alternative care delivery mechanisms to ensure optimal health outcomes for all Canadians.

Objective:

To investigate the feasibility and effectiveness of electronic consultation (eConsult) as a new model for interactions between specialists and primary care providers (PCPs) to improve access to care for patients with CKD.

Design:

This is a sequential, mixed methods study that will be conducted in 3 phases.

Setting:

The study will be conducted across the entire province of Alberta, supported by Alberta Kidney Care (formerly, Northern and Southern Alberta Renal Programs [NARP/SARP]).

Patients:

Patients suffering from CKD will be included in the study.

Measurements:

We will assess the barriers and enablers of implementation and adoption of an e-consultation protocol to facilitate access to care for patients with CKD in Alberta with a focus on rural/remote-dwellers with CKD. We will also evaluate the impact of the eConsult system (eg, improved access to specialist care, reduction in care gaps), assess the feasibility of province-wide implementation, and compare eConsult with practice facilitation versus eConsult alone in terms of access to specialist care, quality of care, and related outcomes.

Methods:

The study will be conducted in 3 phases. In phase 1, we will assess the perceptions of stakeholders (ie, PCPs, nephrologists, patients, policymakers, and other care providers) to improve CKD care delivery, quality, and outcomes in Alberta with focus groups and semistructured interviews. Phase 2 will engage specific family physicians for their input on key factors and logistical issues affecting the feasibility of implementing eConsult for the care of patients with CKD. Phase 3 will provide academic detailing including practice facilitation to clinics in Alberta to assess how eConsult with practice facilitation compares with eConsult alone in terms of access to specialist care, quality of care, and related outcomes.

Results:

We will assess stakeholder perceptions about potential barriers to and enablers of a new eConsult and decision support system strategy, focusing on elements that are most important for the design of a feasible and implementable intervention. We will develop, pilot test, and assess the impact of the eConsult model in improving access to specialist nephrology care and the feasibility of province-wide implementation. The final phase of the project will address key challenges for optimal care for patients with CKD living in rural, remote, and underserved areas of Alberta, particularly timely referral and disease management as well as the cost-effective benefits of eConsult.

Limitations:

Lack of high-speed Internet in many rural and remote areas of Alberta may lead to more time spent in completing the eConsult request online versus faxing a referral the traditional way. Allied health care staff (referral coordinators, administrative staff) require training to the eConsult system, and physicians at many remote sites do not have adequate staff to handle eConsult as an added task.

Conclusions:

Implementation of eConsult can favorably influence referral patterns, access to care, care quality, patient outcomes, and health care costs for people with CKD. Results of this study will inform the optimization of care for rural/remote-dwellers with CKD and will facilitate future partnerships with policymakers and provincial renal programs in Alberta to ensure optimal kidney health for all residents.

Trial registration:

Not required.

Quality of Chronic Kidney Disease Management in Canadian Primary Care

IMPORTANCE

Although patients with chronic kidney disease (CKD) are routinely managed in primary care settings, no nationally representative study has assessed the quality of care received by these patients in Canada.

OBJECTIVE

To evaluate the current state of CKD management in Canadian primary care practices to identify care gaps to guide development and implementation of national quality improvement initiatives.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study leveraged Canadian Primary Care Sentinel Surveillance Network data from January 1, 2010, to December 31, 2015, to develop a cohort of 46 162 patients with CKD managed in primary care practices. Data analysis was performed from August 8, 2018, to July 31, 2019.

MAIN OUTCOMES AND MEASURES

The study examined the proportion of patients with CKD who met a set of 12 quality indicators in 6 domains: (1) detection and recognition of CKD, (2) testing and monitoring of kidney function, (3) use of recommended medications, (4) monitoring after initiation of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), (5) management of blood pressure, and (6) monitoring for glycemic control in those with diabetes and CKD. The study also analyzed associations of divergence from these quality indicators.

RESULTS

The cohort comprised 46 162 patients (mean [SD] age, 69.2 [14.0] years; 25 855 [56.0%] female) with stage 3 to 5 CKD. Only 4 of 12 quality indicators were met by 75% or more of the study cohort. These indicators were receipt of an outpatient serum creatinine test within 18 months after confirmation of CKD, receipt of blood pressure measurement at any time during follow-up, achieving a target blood pressure of 140/90 mm Hg or lower, and receiving a hemoglobin A1c test for monitoring diabetes during follow-up. Indicators in the domains of detection and recognition of CKD, testing and monitoring of kidney function (specifically, urine albumin to creatinine ratio testing), use of recommended medications, and appropriate monitoring after initiation of treatment with ACEIs or ARBs were not met. Only 6529 patients (18.4%) with CKD received a urine albumin test within 6 months of CKD diagnosis, and 3954 (39.4%) had a second measurement within 6 months of an abnormal baseline urine albumin level. Older age (≥85 years) and CKD stage 5 were significantly associated with not satisfying the criteria for the quality indicators across all domains. Across age categories, younger patients (aged 18-49 years) and older patients (≥75 years) were less likely to be tested for albuminuria (314 of 1689 patients aged 18-49 years [18.5%], 1983 of 11 919 patients aged 75-84 years [61.6%], and 614 of 5237 patients aged ≥85 years [11.7%] received the urine albumin to creatinine ratio test within 6 months of initial estimated glomerular filtration rate <60 mL/min per 1.73 m2; P < .001). Patients aged 18 to 49 years were less commonly prescribed recommended medications (222 of 2881 [7.7%]), whereas patients aged 75 to 84 years were prescribed ACEIs or ARBs most frequently (2328 of 5262 [44.2%]; P < .001).

CONCLUSIONS AND RELEVANCE

The findings suggest that management of CKD across primary care practices in Canada varies according to quality indicator. This study revealed potential priority areas for quality improvement initiatives in Canadian primary care practices.

Is Assisted Peritoneal Dialysis a Solution for Northern Manitoba?

Background:

End-stage kidney disease (ESKD) continues to fundamentally impact the lives of First Nations (FN) patients. Home peritoneal dialysis (PD) offers patients more mobility and flexibility, but few Manitoba FNs have availed themselves of this option.

Objective:

This paper discusses Manitoba FNs' experience of PD, to highlight enablers and barriers to expanding the use of PD in rural and remote Manitoba communities.

Methods:

We analyzed interviews of individuals living with ESKD (N = 14), family caregivers (N = 14) and healthcare providers and administrators (N = 27).

Results:

Barriers to PD uptake include medical suitability, patients' distrust of home modalities and fear in their ability to manage. Other factors include limited family support and lack of appropriate housing.

Conclusions:

Assisted peritoneal dialysis (APD) is an emerging model where PD supplies are centrally located, and where a cohort of PD patients can provide mutual support with added assistance from an APD worker. This model could mitigate existing treatment barriers.

Uptake and Scalability of a Peritoneal Dialysis Virtual Care Solution: Qualitative Study

Background

Early research in the area of virtual care solutions with peritoneal dialysis (PD) patients has focused on evaluating the outcomes and impact of these solutions. There has been less attention focused on understanding the factors influencing the uptake, usability, and scalability of virtual care for chronic kidney disease (CKD) patients receiving PD at home.

Objective

In this context, a study was undertaken to (1) assess and understand the factors influencing the uptake of a virtual care solution and (2) provide recommendations for the scalability of a virtual care solution aimed at enhancing CKD patients’ outcomes and experiences.

Methods

This study used a qualitative design with semistructured interviews and a thematic analysis approach. A total of 25 stakeholders—6 patients and 3 caregivers, 6 health care providers, 2 vendors, and 8 health system decision makers—participated in this study.

Results

The following three primary mechanisms emerged to influence the usability of the virtual care solution: (1) receiving hands-on training and ongoing communication from a supportive team, (2) adapting to meet user needs and embedding them into workflow, and (3) being influenced by patient and caregiver characteristics. Further, two overarching recommendations were developed for considerations around scalability: (1) co-design locally, embed into the daily workflow, and deploy over time and (2) share the benefits and build the case.

Conclusions

Study findings can be used by key stakeholders in their future efforts to enhance the implementation, uptake, and scalability of virtual care solutions for CKD and managing PD at home.

Improving safety and efficiency in care: multi-stakeholders' perceptions associated with a peritoneal dialysis virtual care solution

BACKGROUND

Although there is a growing body of literature on the outcomes and impacts of remote home management with peritoneal dialysis (PD) patients, less is understood how this virtual care solution impacts the quality and efficiency of the healthcare system care. In this context, a study was undertaken to understand the perceptions of patients and their caregivers, healthcare providers, health system decision makers, and vendors associated with a remote monitoring and tracking solution aimed at enhancing the outcomes and experiences of chronic kidney disease (CKD) patients receiving PD at home.

METHODS

A qualitative design using semi-structured interviews with 25 stakeholders was used in this study. Narrative data were analyzed by a thematic analysis approach.

RESULTS

The following two themes emerged from the data: (1) leveraging data to monitor and intervene to keep patients safe and (2) increasing efficiencies and having control over supplies.

DISCUSSION

Our study findings elucidated the ability of patients (and in some cases, caregivers) to monitor and trend their data and order and track directly on-line their dialysis supplies were key to their active participation in managing their CKD and keeping them safe at home. Their active participation and functionality of the virtual care solution also led to enhanced efficiencies (eg, process faster, easier, convenient, time savings) for both patients and healthcare providers.

CONCLUSION

The virtual care solution showed promising signs of a patient-centric approach and may serve as a blueprint for other virtual care solutions for chronic disease management.

Chronic Kidney Disease, Queensland (CKD.QLD) Registry: Management of CKD With Telenephrology

INTRODUCTION

Enabled by the Chronic Kidney Disease, Queensland (CKD.QLD) Registry, we aim to outline the structure, implementation, and outcomes of telenephrology clinics for the management of patients with chronic kidney disease (CKD) in rural, regional, and remote areas of the Darling Downs region in Queensland, Australia.

METHODS

This is an observational registry-based study involving adult patients with CKD, attending specialist clinics, and residing ≥50 km away from Toowoomba Hospital. The telenephrology cohort (TC) included those who had their follow-up appointments via videoconference at local Queensland Health facilities, and the standard care cohort (SCC) included those who continue to have their follow-up in Toowoomba Hospital.

RESULTS

A total of 234 patients with CKD were seen via videoconference clinics between September 1, 2011 and December 31, 2016, representing 22.2% of the CKD registry cohort from Toowoomba Hospital. The baseline characteristics and comorbid profiles of both groups were similar. The Aboriginal population was overrepresented in the TC (22.2% vs. 5.9%). As a group for each visit, the TC traveled 100,000 km less (both ways) to see a specialist physically. During follow-up, 5.1% of patients in the TC were initiated on dialysis whereas 9.9% were initiated on dialysis in the SCC (P = 0.02). There was lower mortality in the TC (11.1% vs. 18.2%; P = 0.02).

CONCLUSION

Telenephrology clinics were safe, economical, and efficient for the delivery of specialist care for patients with CKD living at a distance from the main referral hospital. Such care was comparable to standard care delivered at the main hospital but with clear benefits to the patients in terms of reduced travel distance, more independence, and similar outcomes.

Follow-up Care of Living Kidney Donors in Alberta, Canada

Background

Previous guidelines recommend that living kidney donors receive lifelong annual follow-up care to assess renal health.

Objective

To determine whether these best practice recommendations are currently being followed.

Design

Retrospective cohort study using linked health care databases.

Setting

Alberta, Canada (2002-2014).

Patients

Living kidney donors.

Measurements

We determined the proportion of donors who had annual outpatient physician visits and laboratory measurements for serum creatinine and albuminuria.

Results

There were 534 living kidney donors with a median follow-up of 7 years (maximum 13 years). The median age at the time of donation was 41 years and 62% were women. Overall, 25% of donors had all 3 markers of care (physician visit, serum creatinine, albuminuria measurement) in each year of follow-up. Adherence to physician visits was higher than serum creatinine or albuminuria measurements (67% vs 31% vs 28% of donors, respectively). Donors with guideline-concordant care were more likely to be older, reside closer to the transplant center, and receive their nephrectomy in more recent years.

Limitations

Our results may not be generalizable to other countries that do not have a similar universal health care system.

Conclusions

These findings suggest significant evidence-practice gaps, in that the majority of donors saw a physician, but the minority had measurements of kidney function or albuminuria. Future interventions should target improving follow-up care for all donors.

The Health and Health Care of Adults With Type 1 And 2 Diabetes Across the Spectrum of Estimated Glomerular Filtration Rates

OBJECTIVES

Little is known about the health and health-care patterns of patients with diabetes according to their estimated glomerular filtration rates, especially within a publicly funded health-care system.

METHODS

Using linked health-care databases in Ontario, Canada, we performed a population-based study of adults 50 years of age and older (mean age, 68 years) with prevalent diabetes on January 1, 2014. We categorized patients according to their levels of kidney function (estimated glomerular filtration rate ≥90, 60 to 89, 30 to 59, 15 to 29 or <15 mL/min/1.73 m², or the receipt of ongoing maintenance dialysis). We then followed patients for 2 years to determine: 1) their level of contact with health-care providers (i.e. visits to family doctors, specialists); 2) their use and repeated use of acute medical services (i.e. hospitalizations and emergency department encounters; 3) diabetes-related monitoring and screening (i.e. glycated hemoglobin and cholesterol tests, vision screening); 4) glycemic and lipid control; and 5) diabetes-related outcomes.

RESULTS

There were 569,384 patients in our study. Most had estimated glomerular filtration rates between 60 and 89 mL/min/1.73 m². At baseline, patients with lower kidney function had longer durations of diabetes and more comorbidities. Over 2 years of follow up, they had higher burdens of medical care, excessive diabetes monitoring and were underscreened for diabetes-related complications. Although metabolic control was reasonable across groups, patients with low kidney function had more hospital encounters and more diabetes-related complications.

CONCLUSIONS

Patients with diabetes and low kidney function are a vulnerable population that faces health system challenges and care gaps. Suggestions for policy and practice are discussed.

Implementation and Evaluation of a Risk-Based Approach to Guide Chronic Kidney Disease Care: Protocol for a Multiphase Mixed-Methods Study

Background

Risk prediction tools are used in a variety of clinical settings to guide patient care, although their use in chronic kidney disease (CKD) care is limited.

Objectives

To assess the association of a risk-based model of CKD care on patient care, satisfaction, outcomes, and cost.

Design

Mixed-methods with a pre-post design.

Setting

We will use mixed-methods and a pre-post design to evaluate use of the Kidney Failure Risk Equation (KFRE) to guide CKD care. The KFRE will be applied to patients currently followed in nephrology multidisciplinary CKD clinics in Alberta, as well as to new patients being considered for multidisciplinary care.

Patients

Patients with a 2-year risk of kidney failure ≥10% or estimated glomerular filtration rate (eGFR) ≤15 mL/min/1.73 m² will be recommended care by a multidisciplinary team coordinated by a nurse clinician and nephrologist, with access to other multidisciplinary resources including dietitians, pharmacists, and social workers as required.

Measurements/Methods

Focus groups and interviews will be conducted to qualitatively describe patient and provider perspectives of potential barriers and facilitators to implementation of the risk-based approach to CKD care. Patient and provider surveys will also be used to quantify patient and provider satisfaction before and after the intervention. Finally, administrative data will be used to evaluate the association between the risk-based approach to care and outcomes including health care resource use, frequency of testing, modality choice, and death.

Conclusions

Use of a risk-based model of care has the potential to increase use of optimal treatments such as the use of home dialysis and preemptive kidney transplantation, while reducing costs and poor outcomes related to processes of care such as unnecessary laboratory testing; however, there is also potential for unintended consequences. Our mixed-methods approach will integrate perceptions and needs from key stakeholders (including patients with CKD, their families, and their providers) to guide implementation and ensure appropriate modifications.

Patient and provider perspectives on the design and implementation of an electronic consultation system for kidney care delivery in Canada: a focus group study

OBJECTIVES

We assessed stakeholder perceptions on the use of an electronic consultation system (e-Consult) to improve the delivery of kidney care in Alberta. We aim to identify acceptability, barriers and facilitators to the use of an e-Consult system for ambulatory kidney care delivery.

METHODS

This was a qualitative focus group study using a thematic analysis design. Eight focus groups were held in four locations in the province of Alberta, Canada. In total, there were 72 participants in two broad stakeholder categories: patients (including patients' relatives) and providers (including primary care physicians, nephrologists, other care providers and policymakers).

FINDINGS

The e-Consult system was generally acceptable across all stakeholder groups. The key barriers identified were length of time required for referring physicians to complete the e-Consult due to lack of integration with current electronic medical records, and concerns that increased numbers of requests might overwhelm nephrologists and lead to a delayed response or an unsustainable system. The key facilitators identified were potential improvement of care coordination, dissemination of best practice through an educational platform, comprehensive data to make decisions without the need for face-to-face consultation, timely feedback to primary care providers, timeliness/reduced delays for patients' rapid triage and identification of cases needing urgent care and improved access to information to facilitate decision-making in patient care.

CONCLUSIONS

Stakeholder perceptions regarding the e-Consult system were favourable, and the key barriers and facilitators identified will be considered in design and implementation of an acceptable and sustainable electronic consultation system for kidney care delivery.

Targeting Access to Kidney Care Via Telehealth: The VA Experience

The Veterans Affairs (VA) is the largest integrated health care system in the United States and is responsible for the care of a population with a disproportionately high rate of CKD. As such, ensuring access to kidney health services is a VA imperative. One facet of the VA's strategy to reduce CKD is to leverage the use of teletechnology to expand the VA's outreach to Veterans with kidney disease. A wide array of teletechnology services have been deployed to both pull in Veterans and push out kidney health services to Veterans in their preferred health care venue. Teletechnology, thus, expands Veteran choice, facilitates their access to care, and furthers the goal of delivering patient-centered kidney specialty care. The VA has demonstrated the feasibility of virtual delivery of kidney specialty care services and education via synchronous and asynchronous approaches. The challenges ahead include determining the relative health care value of kidney telehealth services, identifying Veterans most likely to benefit from specific technologies and optimizing the adoption of effective kidney telehealth services by both providers and patients alike to ensure optimal and timely kidney health care delivery.

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.

Characterization of patients with diabetic foot disease presenting to an Irish Podiatry Centre: profiling suitability for entry to a clinical trial of advanced wound therapeutics

BACKGROUND

Diabetes mellitus, coined the 'Black Death of the Twenty-First Century', is associated with complications, including foot ulceration with potential loss of limb. There is a need for development of new wound therapies through completion of robust clinical trials.

AIMS

To profile demographics and wound characteristics of an Irish cohort with diabetes, forecast eligibility for entry to a clinical trial of advanced wound therapeutics, and adjust criteria to optimize eligibility for enrolment.

METHODS

A cross-sectional study of out-patients attending a Podiatry centre over 12 weeks was conducted. Information was collected through clinical assessment, including Neuropathy Disability Score and Ankle-Brachial Pressure Index. Ulcers were characterised as 'healing' or 'non-healing'; a 'healing' wound decreased by 30 % over the previous month, accomplished by retrospective analysis of files. Statistics, including binomial logistic regression and column analysis for eligibility assessment, were conducted.

RESULTS

Seventy-four participants were identified with a mean age of 67 (± 8.79) years. Non-healing DFU status correlated significantly with larger wound area (P = 0.013), infection (P = 0.009), and greater degrees of ischaemia (P = 0.015). The eligibility criteria were modelled after those proposed by the EU consortium project REDDSTAR. In this Irish population, these criteria limit eligibility to 1.4 %.

CONCLUSIONS

This research found an eligibility criterion of wound area 2-10 cm² for enrolment in a clinical trial of mesenchymal stromal cell therapy too restrictive. Extension of wound area to 1-10 cm² and the inclusion of neuro-ischaemic ulcers increased eligibility for enrolment from 1.4 to 20 %.

Mortality and treatment costs of hospitalized chronic kidney disease patients between the three major health insurance schemes in Thailand

Background

Thailand has reformed its healthcare to ensure fairness and universality. Previous reports comparing the fairness among the 3 main healthcare schemes, including the Universal Coverage Scheme (UCS), the Civil Servant Medical Benefit Scheme (CSMBS) and the Social Health Insurance (SHI) have been published. They focused mainly on provision of medication for cancers and human immunodeficiency virus infection. Since chronic kidney disease (CKD) patients have a high rate of hospitalization and high risk of death, they also require special care and need more than access to medicine. We, therefore, performed a 1-year, nationwide, evaluation on the clinical outcomes (i.e., mortality rates and complication rates) and treatment costs for hospitalized CKD patients across the 3 main health insurance schemes.

Methods

All adult in-patient CKD medical expense forms in fiscal 2010 were analyzed. The outcomes focused on were clinical outcomes, access to special care and equipment (especially dialysis), and expenses on CKD patients. Factors influencing mortality rates were evaluated by multiple logistic regression.

Results

There were 128,338 CKD patients, accounting for 236,439 admissions. The CSMBS group was older on average, had the most severe co-morbidities, and had the highest hospital charges, while the UCS group had the highest rate of complications. The mortality rates differed among the 3 insurance schemes; the crude odds ratio (OR) for mortality was highest in the CSMBS scheme. After adjustment for biological, economic, and geographic variables, the UCS group had the highest risk of in-hospital death (OR 1.13;95 % confidence interval (CI) 1.07–1.20; p < 0.001) while the SHI group had lowest mortality (OR 0.87; 95 % CI 0.76–0.99; p = 0.038). The circumscribed healthcare benefits and limited access to specialists and dialysis care in the UCS may account for less favorable comparison with the CSMBS and SHI groups.

Conclusions

Significant differences are observed in mortality rates among CKD patients from among the 3 main healthcare schemes. Improvements in equity of care might minimize the differences.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1792-9) contains supplementary material, which is available to authorized users.

Effects of health service geographic accessibility in patients with treated end stage kidney disease: Cohort study 2000-2010

AIM

Patients in rural areas experience poor access to health services. There are limited data on patterns of health service utilization in rural patients treated with renal replacement therapy (RRT).

METHODS

All prevalent patients over the age of 18 and resident in New South Wales who were receiving RRT on 01/07/2000 and incident patients who started RRT between 01/07/2000 up until 31/07/2010 were included in the study. The Accessibility Remoteness Index of Australia was used to measure rurality and to categorize participant postcode of residence at the time of their first use of a New South Wales healthcare facility after the start of RRT. We assessed (1) rates of hospitalization, (2) rates of inter-hospital transfer (IHT), (3) length of hospital stay (LOS) and (4) survival. Day-only and dialysis admissions were excluded. Negative binomial regression was used to calculate incidence rate ratios (IRR) for hospitalizations, IHT and LOS. Cox proportional hazards was used to calculate hazard ratios (HR) for survival.

RESULTS

Of the 10 505 patients included in the analysis, 1527 (15%) were rural residents while 8978 (85%) resided in urban areas. Median follow up time from start of RRT/study to end of study/death was 4.2 years (IQR 2.0 to 8.2). After allowing for differences in baseline characteristics, rural residence increased the rates of hospitalization by 8% (IRR 1.08: 95% CI 1.01-1.15; P = 0.02), rates of IHT by 176% (IRR 2.76: 95% CI 2.44-3.13; P < 0.001) and the hazard of death by 14% (HR 1.14 95% CI: 1.05-1.24; P = 0.003) LOS was similar (Median 4.0; P = 0.07).

CONCLUSIONS

Rural residents receiving RRT have higher hospitalization rates, markedly higher rates of IHT and higher long-term mortality compared with their urban counterparts.

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.

Impacts of Geographic Distance on Peritoneal Dialysis Utilization: Refining Models of Treatment Selection

OBJECTIVE

To examine the relationship between distance to dialysis provider and patient selection of dialysis modality, informed by the absolute distance from a patient's home and relative distance of alternative modalities.

DATA SOURCES

U.S. Renal Data System.

STUDY DESIGN

About 70,131 patients initiating chronic dialysis and 4,795 dialysis facilities in 2006. The primary outcome was patient utilization of peritoneal dialysis (PD). Independent variables included absolute distance between patients' home and the nearest hemodialysis (HD) facility, relative distance between patients' home and nearest PD versus nearest HD facilities, and their interaction. Logistic regression was used to model distance on PD use, controlling for patient and market characteristics.

PRINCIPAL FINDINGS

Nine percent of incident dialysis patients used PD in 2006. There was a positive, nonlinear relationship between absolute distance to HD services and PD use (p < .0001), with the magnitude of the effect increasing at greater distances. In terms of relative distance, odds of PD use increased if a PD facility was closer or the same distance as the nearest HD facility (p = .006). Interaction of distance measures to dialysis facilities was not significant.

CONCLUSIONS

Analyses of patient choice between alternative treatments should model distance to reflect all relevant dimensions of geographic access to treatment options.

An Economic Assessment Model of Rural and Remote Satellite Hemodialysis Units

BACKGROUND

Kidney Failure is epidemic in many remote communities in Canada. In-centre hemodialysis is provided within these settings in satellite hemodialysis units. The key cost drivers of this program have not been fully described. Such information is important in informing the design of programs aimed at optimizing efficiency in providing dialysis and preventative chronic kidney disease care in remote communities.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

We constructed a cost model based on data derived from 16 of Manitoba, Canada's remote satellite units. We included all costs for operation of the unit, transportation, treatment, and capital costs. All costs were presented in 2013 Canadian dollars.

RESULTS

The annual per-patient cost of providing hemodialysis in the satellite units ranged from $80,372 to $215,918 per patient, per year. The median per patient, per year cost was $99,888 (IQR $89,057-$122,640). Primary cost drivers were capital costs related to construction, human resource expenses, and expenses for return to tertiary care centres for health care. Costs related to transport considerably increased estimates in units that required plane or helicopter transfers.

CONCLUSIONS

Satellite hemodialysis units in remote areas are more expensive on a per-patient basis than hospital hemodialysis and satellite hemodialysis available in urban areas. In some rural, remote locations, better value for money may reside in local surveillance and prevention programs in addition support for home dialysis therapies over construction of new satellite hemodialysis units.

Association between medical insurance type and survival in patients undergoing peritoneal dialysis

Background

Socioeconomic characteristics may affect the outcomes of patients treated with peritoneal dialysis (PD). There are two major medical insurances in China: the New Cooperative Medical Scheme (NCMS), mainly for rural residents, and the Urban Employees’ Medical Insurance (UEMI). The aim of the present study was to assess the effect of medical insurance type on survival of patient undergoing PD.

Method

This was a prospective study in adult patients who underwent PD at the Wuhan No.1 Hospital between January 2008 and December 2013. Patients had received continuous ambulatory PD for >3 months. Patients were divided according to their medical insurance. Demographic and socioeconomic data, biochemical parameters and primary clinical outcomes including all-cause mortality, switch to hemodialysis and kidney transplantation were analyzed.

Result

There were 415 patients with UEMI and 149 with NCMS. Compared with UEMI, patients with NCMS were younger, and had shorter dialysis duration, smaller proportion of diabetic nephropathy, more severe anemia, and more frequent hyperphosphatemia and hyperuricemia. Total Kt/V, creatinine clearance and residual renal function were not different. There was no difference in technique survival (P > 0.05) between the two groups, but rural patients showed lower overall survival (P < 0.05). Multivariate analysis showed that NCMS was independently associated with lower survival (RR = 1.49; 95% CI = 1.04-2.15).

Conclusions

Medical insurance model is independently associated with PD patient survival.

The interdisciplinary team: the whole is larger than the parts

Chronic kidney disease (CKD) is an emerging global health problem. Caring for CKD patients is a medical and financial challenge currently placing a significant burden on our health-care system. This creates an impetus to explore nontraditional models of care. In this article, we explore the role of interdisciplinary care clinics in managing the complex and multifaceted aspects of CKD. By having different providers work seamlessly in a synergistic and collaborative environment, there is less risk of fragmentation of care. In this patient-centered model of care, patients are empowered and engaged to achieve therapeutic targets, make lifestyle changes, and participate in decision-making. Timely referral and education delivered by advanced practitioners are 2 of the crucial elements central to the success of the interdisciplinary model. Further studies are needed to identify other key elements that would enhance the interdisciplinary approach to ensure that guideline-based therapeutic targets are reached and to define the subset of patients that would benefit the most. Innovative information technology solutions that could enhance the implementation of interdisciplinary clinics and expand their reach should be exploited. Lastly, for the paradigm shift to occur, the integrative approach should prove to be cost-effective.

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.