D JEGATHEESAN1,2, R KRISHNASAMY2,3, P LAWTON4, N GRAY2,3
1Princess Alexandra Hospital, Woolloongabba, Australia, 2University of Queensland, Brisbane, Australia, 3Sunshine Coast University Hospital, Birtinya, Australia, 4Menzies School of Research, , Australia
Background: Recipients of dialysis in Australia living outside major cities have increased mortality. It is not known whether quality of care (QOC) varies by remoteness to possibly explain the poorer rural outcomes.
Methods: We included all adults commencing haemodialysis (HD) or peritoneal dialysis (PD) registered with Australia and New Zealand Dialysis and Transplant Registry between 2002 and 2012. Postcode at dialysis start and the Accessibility/Remoteness Index of Australia was used to classify patients by remoteness. QOC measures included pre-dialysis phosphate, calcium, haemoglobin, transferrin saturation and ferritin; HD-specific measures: urea reduction ratio, dialysis hours/week, and arteriovenous fistula/graft rates; PD-specific measures: weekly Kt/V and technique failure. Indigenous and non-Indigenous patients were analysed separately. Association between remoteness and attainment of QOC indicators (as per guidelines) at 6-18 and 18-30 months after dialysis commencement was assessed using logistic regression models.
Results: A total 21690 commenced dialysis with median age 61.0 ± 15.1 years, 77.2% Caucasian, and 66.7% resident in cities. Overall there were few consistent differences in QOC by remoteness. Compared with those in major cities, patients in remote/very remote regions were more likely to have serum ferritin > 200 mcg/L at 6-18 months (Indigenous: OR 2.66 (1.82-3.88), p < 0.001; non-Indigenous: OR 1.73 (1.19-2.50), p=0.004), remaining significant at 18-30 months in the Indigenous group (OR 3.27 (2.05-5.20), p < 0.001). No significant differences were noted between groups for achieving target haemoglobin or phosphate levels at both time-points following dialysis commencement.
Conclusion: Dialysis QOC is similar regardless of patient location. Higher ferritin levels remotely require explanation. Other factors such as pre-dialysis care, individual patient factors such as health-related behaviours, lifestyle and literacy, and environment may explain poorer rural outcomes.
Dev Jegatheesan (BSc, MBBS, FRACP) is currently completing his renal transplant fellowship at the Princess Alexandra Hospital, Brisbane. Research interests include cardiovascular risk and lifestyle modification, patient-centred care and quality of care in patients with kidney disease.