title: Higher mortality among remote compared to rural or urban dwelling hemodialysis patients in the United States.
abstract: Living far away from specialized care centers is a potential barrier to the delivery of quality health care and has been associated with adverse outcomes. To assess mortality as a function of distance from the closest hemodialysis unit, and as a function of rural rather than urban residence, we analyzed prospectively collected data on 726,347 adults initiating chronic hemodialysis in the United States over a 13-year period. Participants were classified into categories of 0-10 (referent), 11-25, 26-45, 46-100, and remote living over 100 miles from the closest hemodialysis unit. After a median follow-up of 2.7 years (range 0 to 12.7 years), 368,569 patients died. Compared to the referent group, the adjusted hazard ratio of death was 1.01, 0.99, 0.96, and 1.21, respectively. When residence location was classified using rural-urban commuter areas, 16.5, 66.8, and 16.7% of patients lived in urban, micropolitan, and metropolitan areas, respectively. Compared with those living in metropolitan areas, the adjusted hazard ratio of mortality among patients residing in micropolitan and rural communities was 1.02 and 1.01, respectively. Thus, remote but not rural residence was associated with increased mortality among patients initiating chronic hemodialysis treatment in the United States.
authors.affiliation: Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Thompson
authors.forename: John
authors.initials: J
authors.lastname: Gill
authors.forename: Xiaoming
authors.initials: X
authors.lastname: Wang
authors.forename: Raj
authors.initials: R
authors.lastname: Padwal
authors.forename: Rick
authors.initials: R
authors.lastname: Pelletier
authors.forename: Aminu
authors.initials: A
authors.lastname: Bello
authors.forename: Scott
authors.initials: S
authors.lastname: Klarenbach
authors.forename: Marcello
authors.initials: M
authors.lastname: Tonelli
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000554:Ambulatory Care Facilities; D003695:Delivery of Health Care; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011787:Quality of Health Care; D006435:Renal Dialysis / Q000401:mortality*; D012424:Rural Population; D014481:United States / Q000453:epidemiology; D014505:Urban Population; D055815:Young Adult