title: Impact of remote location on quality care delivery and relationships to adverse health outcomes in patients with diabetes and chronic kidney disease.
abstract: BACKGROUND
  To investigate the relation of residence location, markers of good quality healthcare and adverse clinical outcomes in patients with diabetes and chronic kidney disease (CKD).
  
  
  METHODS
  We identified 31 337 individuals with diabetes and estimated glomerular filtration rate (eGFR) 15-59 mL/min/1.73 m(2) from a population-based cohort (n= 1 278 375) of adults with serum creatinine measured at least once during 2005 or 2006 in Alberta, Canada. The study population was classified into categories based on travel distance by road from residence location to the closest nephrologist: (0-50, 50.1-100, 100.1-200 and >200 km).
  
  
  RESULTS
  At follow-up, compared with those living within 50 km, remote dwellers were less likely to visit a nephrologist, less likely to have hemoglobin A1c and urinary albumin measured within 1 year of the index eGFR, and less likely to receive an angiotensin converting enzyme inhibitor, angiotensin receptor blocker or statin (all P < 0.0001). In adjusted models, compared with those with CKD (Stage 3 or 4) living within 50 km, the adjusted likelihood of all-cause hospitalization was [1.4 (95% confidence interval, CI, 1.3-1.6)], [1.3 (95% CI, 1.1-1.6)] and [1.3 (95% CI, 1.2-1.5)]-fold higher for patients living 50.1-100, 100.1-200 and >200 km away from a nephrologist, respectively (P < 0.0001). The hazard ratio of all-cause mortality increased with increasing distance: [1.07 (95% CI, 0.9-1.2)], [1.1 (95% CI, 0.9-1.2)] and [1.2 (95% CI, 1.0-1.4)], respectively (P < 0.0001).
  
  
  CONCLUSIONS
  Compared with those living closer to a nephrologist, remote dwellers with diabetes and CKD were less likely to receive recommended quality care, and more likely to experience adverse health outcomes.
authors: Department of Medicine and Public Health Sciences, University of Alberta, Edmonton, AB, Canada.
authors: Aminu K
authors: AK
authors: Bello
authors: Brenda
authors: B
authors: Hemmelgarn
authors: Meng
authors: M
authors: Lin
authors: Braden
authors: B
authors: Manns
authors: Scott
authors: S
authors: Klarenbach
authors: Stephanie
authors: S
authors: Thompson
authors: Matthew
authors: M
authors: James
authors: Marcello
authors: M
authors: Tonelli
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000416:Alberta; D015331:Cohort Studies; D003695:Delivery of Health Care; D003928:Diabetic Nephropathies / Q000628:therapy*; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009398:Nephrology; D011365:Professional Practice Location; D011787:Quality of Health Care; D051436:Renal Insufficiency, Chronic / Q000628:therapy*; D017582:Renal Replacement Therapy; D012424:Rural Population