Quality of care and mortality are worse in chronic kidney disease patients living in remote areas

Abstract

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 m² 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.

Documentation and Management of CKD in Rural Primary Care

“…Studies show reduced access to kidney transplantation, home dialysis training, and renal replacement therapy in lesspopulated areas of the United States (14,15). Although limited nephrology care has been shown in Canadian remote dwellers with CKD (16), little research evaluating predialysis care in US rural communities has been performed.…”

La atención a la enfermedad renal en Uruguay: la perspectiva de individuos con trasplante renal

“…A la vez, han enfrentado múltiples desafíos en esos países, particularmente en aquellos en vías de desarrollo. Por ejemplo, se estima que dos tercios de los países de bajos ingresos no tienen acceso a tales terapias 4 ; su financiamiento, costo y cobertura difiere en países con un sistema de sanidad público respecto a aquellos con uno mixto o privado 5 y las personas con ERC que viven en áreas remotas reciben menos atención de médicos especialistas, estudios de laboratorio y medicamentos, respecto a quienes habitan en centros urbanos 6 .…”

Adding Specialized Clinics for Remote-Dwellers with Chronic Kidney Disease

“…Adding a clinic in Grand Prairie would shift 876 patients with CKD from a .120-minute drive to a #120-minute drive. Driving distance was categorized as #30, 30.1-60, 60.1-120, and .120 minutes, as in our previous work (10). The distribution of the 876 stage 3b-4 CKD patients in the respective distance categories would shift from 0%, 0%, 0%, and 100% to 40%, 12%, 48%, and 0%, respectively.…”

“…3b-4 CKD patients residing in Alberta (10). From all Albertan patients who had an outpatient serum creatinine measured in 2005, we selected those with estimated GFR ,45 ml/min per 1.73 m 2 , after excluding those requiring renal replacement (RRT) at baseline.…”