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

Vision loss and diabetic retinopathy prevalence and risk among a cohort of Indigenous and non-Indigenous Australians with type 2 diabetes receiving renal haemodialysis treatment: The retinopathy in people currently on renal dialysis (RiPCORD) study

AIMS

Diabetic nephropathy, vision loss and diabetic retinopathy (DR) are frequent comorbidities among individuals with type 2 diabetes (T2D). The Retinopathy in People Currently On Renal Dialysis (RiPCORD) study sought to examine the epidemiology and risk of vision impairment (VI) and DR among a cohort of Indigenous and non-Indigenous Australians with T2D currently receiving haemodialysis for end-stage renal failure (ESRF).

METHODS

A total of 106 Indigenous and 109 non-Indigenous Australians were recruited in RiPCORD across five haemodialysis centres in urban and remote settings. Clinical assessments, questionnaires and medical record data determined the rates of ocular complications and risk factor profiles.

RESULTS

Prevalence rates include unilateral VI, 23.5 %; bilateral VI, 11.7 %; unilateral blindness, 14.2 %; and bilateral blindness, 3.7 %, with no significant differences between sub-cohorts (p=0.30). DR prevalence rates were 78.0 % among non-Indigenous Australians and 93.1 % among Indigenous Australians (p=<0.001). Non-Indigenous ethnicity (OR: 0.28) and pre-dialysis diastolic blood pressure (OR: 0.84 per 10-mmHg) were protective, while peripheral vascular disease (OR: 2.79) increased DR risk.

CONCLUSIONS

Ocular complications among individuals with T2D and ESRF are disproportionately high, especially for Indigenous Australians, and beyond what can be accounted for by risk factor variation. Findings suggest a need to improve screening and preventative efforts within this high-risk population group.

Hotspots of kidney failure: Analysing Australian metropolitan dialysis demand for service planning

OBJECTIVE

To locate incident hotspots of dialysis demand in Australian capital cities and measure association with prevalent dialysis demand and socioeconomic disadvantage.

METHODS

A retrospective cohort study used Australia and New Zealand Dialysis and Transplant Registry data on people commencing dialysis for kidney failure (KF) resident in an Australian capital city, 1 January 2001 - 31 December 2021. Age-sex-standardised dialysis incidence was estimated by Statistical Area Level 3 (SA3) and dialysis prevalence by SA2.

RESULTS

A total of 32,391 people commencing dialysis were referenced to SA3s within city metropolitan areas based on residential postcode. Incident hotspots were located in Western Sydney. The highest average annual change of standardised incidence was 8.3 per million people (false discovery rate-corrected 95% CI 1.0,15.7) in Mount Druitt, reflecting a 263% increase in absolute demand from 2001-3 to 2019-21. Incident dialysis for diabetic kidney disease contributed substantially to total growth. Incident hotspots were co-located with areas where prevalent dialysis demand was associated with socioeconomic deprivation.

CONCLUSIONS

Novel spatial analyses of geo-referenced registry data located hotspots of kidney failure and associated socio-demographic and comorbid states.

IMPLICATIONS FOR PUBLIC HEALTH

These analyses advance current abilities to plan dialysis capacity at a local level. Hotspots can be targeted for prevention and slowing the progression of kidney disease.

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.

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.