Association between proximity to the attending nephrologist and mortality among patients receiving hemodialysis (original) (raw)
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Mortality of Canadians treated by peritoneal dialysis in remote locations
Kidney International, 2007
Patients residing in remote locations may be more likely to initiate peritoneal dialysis when starting renal replacement therapy to avoid relocation. These patients may have reduced access to medical care, however. To examine the hypothesis that patients residing some distance from their nephrologists would be more likely to select peritoneal dialysis but have an increased risk of mortality, we used prospectively collected data in a random sample of 26 775 patients initiating dialysis in Canada between 1990 and 2000. The distance between the patient's residence at dialysis inception and the practice location of their nephrologists was calculated. We used Cox proportional hazard models to determine the adjusted relation between this distance and clinical outcomes over a mean follow-up period of 2.5 years up to 14 years. Remote-dwelling patients were more likely than urban dwellers to commence peritoneal dialysis in distances ranging from 50 to greater than 300 km than those residing within 50 km. The adjusted rates of death and the adjusted hazard ratio among patients initiating peritoneal dialysis was significantly higher in those living further from the nephrologists than those living within 50 km. Further study into the quality of care delivered to remote-dwelling patients on peritoneal dialysis is needed.
The association between geographic proximity to a dialysis facility and use of dialysis catheters
BMC nephrology, 2014
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.
2015
Background. To provide better dialysis care to rural communities, the Ministry of Health chose to build satellite haemodialysis (HD) units, which are affili-ated with, but are distant to, a main renal centre. We considered whether constructing such units in rural regions of Ontario, Canada, alleviated under-service of rates of renal replacement therapy (RRT) locally, decreased patient travel distance and decreased local peritoneal dialysis (PD) utilization. Methods. We compared two groups of rural regions at two time points (years 1995 and 2002) in a before and after cross-sectional study. These regions were either already serviced by a satellite unit in 1995 (control group, 10 communities), or had new satellite units built between the years 1995 and 2002 (exposure group, 24 communities). Results. The exposure group had a slightly greater increase in prevalent rate of RRT over time, but this did not reach statistical significance (control group increased 401 per million, exposure gr...
Quality of care and mortality are worse in chronic kidney disease patients living in remote areas
Kidney International, 2011
Many patients with non-dialysis dependent chronic kidney disease (CKD) live far from the closest nephrologist; although reversible, this might constitute a barrier to optimal care. In order to evaluate outcomes, we selected 31,452 outpatients older than 18 years with an estimated glomerular filtration rate (eGFR) less than 45 ml/min per 1.73 m 2 who had serum creatinine measured at least once during 2005 in Alberta, Canada. We then used logistic regression to examine the association between outcomes of 6545 patients who lived more than 50 km from the nearest nephrologist. Over a median follow-up of 27 months, 7684 participants died and 15,075 were hospitalized at least once. Compared with those living within 50 km, those further away were significantly less likely to visit a nephrologist or a multidisciplinary CKD clinic within 18 months of the index measurement of the eGFR. Similarly, remote dwellers with diabetes were significantly less likely to have hemoglobin A1c evaluated within 1 year of the index eGFR measurement, to have urinary albumin assessed biannually, or to receive an angiotensin converting enzyme inhibitor or receptor blocker in the setting of diabetes or proteinuria. Remote-dwelling participants were also significantly more likely to die or be hospitalized during follow-up than those living closer. Thus, among people with CKD, remote dwellers were less likely to receive specialist care, recommended laboratory testing, and appropriate medications, and were more likely to die or be hospitalized compared with those living closer to a nephrologist.
Comparative hospitalization of hemodialysis and peritoneal dialysis patients in Canada
Kidney International, 2000
on each treatment modality, PD was associated with a higher Comparative hospitalization of hemodialysis and peritoneal rate of hospitalization when analyzed according to the type of dialysis patients in Canada. dialysis in use at baseline (RR 1.10, 95% CI, 1.07 to 1.13, P Ͻ Background. Most comparisons of hemodialysis (HD) and 0.001) and according to the type of dialysis in use three months peritoneal dialysis (PD) have used mortality as an outcome. after study entry (RR 1.26, 95% CI, 1.23 to 1.30, P Ͻ 0.001). Relatively few studies have directly compared the hospitaliza-Conclusions. Conclusions regarding comparative hospitaltion rates, an outcome of perhaps equal importance, of patients ization rates are heavily dependent on the analytic starting using these different dialysis modalities. point and on whether intention-to-treat or treatment-received Methods. Eight hundred twenty-two consecutive patients at analyses are used. When early treatment switches are ac-11 Canadian institutions with irreversible renal failure had an counted for, HD is associated with a lower rate of hospitalizaextensive assessment of comorbid illness and initial mode of tion than PD, but the effect is modest. dialysis collected prospectively immediately prior to starting dialysis therapy. The cohort was assembled between March 1993 and November 1994. The mean follow-up was 24 months. Admission data were used to compare hospitalization rates in The two major modes of dialysis used in clinical practice HD and PD. today, hemodialysis (HD) and peritoneal dialysis (PD), Results. Thirty-four percent of patients at baseline and 50% are very different in terms of technique and physiology. at three months used PD. Twenty-five percent of HD and 32% of PD patients switched dialysis modality at least once after Although one modality is frequently preferable to another their first treatment (P ϭ NS). Nine percent of HD patients because of an individual patient's abilities, medical proband 30% of PD patients switched modality after three months lems, or geographic location, an individual's choice of (P Ͻ 0.001). Total comorbidity was higher in HD patients at treatment is sometimes difficult given the fact that the baseline (P Ͻ 0.001) and at three months (P ϭ 0.001). The effect of dialysis modality on patient outcome is controoverall hospitalization rate was 40.2 days per 1000 patient days after baseline and 38.0 days per 1000 patient days after three versial. Recent studies have shown that there is no differmonths. When an adjustment was made for baseline comorbid ence in mortality in these two groups of patients, particuconditions, patients on PD had a lower rate of hospitalization larly when comorbid illness and acuity of onset of renal in intention-to-treat analysis according to the type of dialysis failure are taken into consideration (abstract; Collins et in use at baseline (RR 0.85, 95% CI, 0.82 to 0.87, P Ͻ 0.001), al, J Am Soc Nephrol 9:204A, 1998) [1, 2]. In addition but a higher rate according to the type of dialysis in use three months after study entry (RR 1.31, 95% CI, 1.27 to 1.34, P Ͻ to mortality, however, patient morbidity is an important 0.001). In analyses based on the amount of time actually spent outcome that may be influenced by the type of dialysis received. Although patient morbidity clearly extends beyond Key words: dialysis modalities, hospitalization rates, patient outcome hospitalization, hospital admission data are frequently and dialysis, Canadian HD mortality, morbidity analysis, end-stage renal disease. used as an objective measure of morbidity. In addition to the obvious economic implications, it has been shown
Clinical Journal of the American Society of Nephrology, 2013
Background and objectives Geographic and other variations in medical practices lead to differences in medical costs, often without a clear link to health outcomes. This work examined variation in the frequency of physician visits to patients receiving hemodialysis to measure the relative importance of provider practice patterns (including those patterns linked to geographic region) and patient health in determining visit frequency. Design, setting, participants, & measurements This work analyzed a nationally representative 2006 database of patients receiving hemodialysis in the United States. A variation decomposition analysis of the relative importance of facility, geographic region, and patient characteristics-including demographics, socioeconomic status, and indicators of health status-in explaining physician visit frequency variation was conducted. Finally, the associations between facility, geographic and patient characteristics, and provider visit frequency were measured using multivariable regression. Results Patient characteristics accounted for only 0.9% of the total visit frequency variation. Accounting for casemix differences, patients' hemodialysis facilities explained about 24.9% of visit frequency variation, of which 9.3% was explained by geographic region. Visit frequency was more closely associated with many facility and geographic characteristics than indicators of health status. More recent dialysis initiation and recent hospitalization were associated with decreased visit frequency. Conclusions In hemodialysis, provider visit frequency depends more on geography and facility location and characteristics than patients' health status or acuity of illness. The magnitude of variation unrelated to patient health suggests that provider visit frequency practices do not reflect optimal management of patients on dialysis.
The Provision of Dialysis Services inRural and Remote Populationsin Newfoundland and Labrador
2008
The province of Newfoundland and Labrador has the highest rate in the country of newly diagnosed patients over the age of 65 years with end-stage renal (kidney) disease (ESRD). 1 Here, as elsewhere in Canada, the profile of patients undergoing dialysis has changed, with a growing number of older, and more medically frail, patients being offered dialysis. In January, 2008, there were 380 patients on dialysis in this province, 65% of whom were being treated by hemodialysis in main hospital-based dialysis units in St. John's and Corner Brook, and in Grand Falls-Windsor, a satellite of St. John's that operates much like a main unit.