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

Abstract

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.

Keywords: cohort studies; hospitalization; mortality; renal replacement therapy; rural population.