title: Disparities in treatment rates of paediatric end-stage renal disease across Europe: insights from the ESPN/ERA-EDTA registry.
abstract: BACKGROUND
  Considerable disparities exist in the provision of paediatric renal replacement therapy (RRT) across Europe. This study aims to determine whether these disparities arise from geographical differences in the occurrence of renal disease, or whether country-level access-to-care factors may be responsible.
  
  
  METHODS
  Incidence was defined as the number of new patients aged 0-14 years starting RRT per year, between 2007 and 2011, per million children (pmc), and was extracted from the ESPN/ERA-EDTA registry database for 35 European countries. Country-level indicators on macroeconomics, perinatal care and physical access to treatment were collected through an online survey and from the World Bank database. The estimated effect is presented per 1SD increase for each indicator.
  
  
  RESULTS
  The incidence of paediatric RRT in Europe was 5.4 cases pmc. Incidence decreased from Western to Eastern Europe (-1.91 pmc/1321 km, P < 0.0001), and increased from Southern to Northern Europe (0.93 pmc/838 km, P = 0.002). Regional differences in the occurrence of specific renal diseases were marginal. Higher RRT treatment rates were found in wealthier countries (2.47 pmc/€10 378 GDP per capita, P < 0.0001), among those that tend to spend more on healthcare (1.45 pmc/1.7% public health expenditure, P < 0.0001), and among countries where patients pay less out-of-pocket for healthcare (-1.29 pmc/11.7% out-of-pocket health expenditure, P < 0.0001). Country neonatal mortality was inversely related with incidence in the youngest patients (ages 0-4, -1.1 pmc/2.1 deaths per 1000 births, P = 0.10). Countries with a higher incidence had a lower average age at RRT start, which was fully explained by country GDP per capita.
  
  
  CONCLUSIONS
  Inequalities exist in the provision of paediatric RRT throughout Europe, most of which are explained by differences in country macroeconomics, which limit the provision of treatment particularly in the youngest patients. This poses a challenge for healthcare policy makers in their aim to ensure universal and equal access to high-quality healthcare services across Europe.
authors.affiliation: ESPN/ERA-EDTA Registry and ERA-EDTA Registry, Amsterdam, Netherlands.
authors.forename: Nicholas C
authors.initials: NC
authors.lastname: Chesnaye
authors.affiliation: Division of Paediatric Nephrology, University of Heidelberg Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany.
authors.forename: Franz
authors.initials: F
authors.lastname: Schaefer
authors.affiliation: Department of Pediatric Nephrology, Emma Children's Hospital AMC, Amsterdam, Netherlands.
authors.forename: Jaap W
authors.initials: JW
authors.lastname: Groothoff
authors.affiliation: Richard Bright Renal Unit, Bristol, UK.
authors.forename: Fergus J
authors.initials: FJ
authors.lastname: Caskey
authors.affiliation: Department of Nephrology, University of Copenhagen, Herlev, Denmark.
authors.forename: James G
authors.initials: JG
authors.lastname: Heaf
authors.affiliation: Department of Pediatric Nephrology, University of Kiev, Kyiv, Ukraine.
authors.forename: Stella
authors.initials: S
authors.lastname: Kushnirenko
authors.affiliation: Manchester Children's Hospital, Manchester, UK.
authors.forename: Malcolm
authors.initials: M
authors.lastname: Lewis
authors.affiliation: Department of Pediatric Nephrology, University of Gent, Gent, Belgium.
authors.forename: Reiner
authors.initials: R
authors.lastname: Mauel
authors.affiliation: Institute of Social and Preventive Medicine, Bern, Switzerland.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Maurer
authors.affiliation: Department of Pediatric Nephrology and Transplantation, University of Helsinki, Helsinki, Finland.
authors.forename: Jussi
authors.initials: J
authors.lastname: Merenmies
authors.affiliation: Department of Pediatrics Nephrology Unit, University Hospital Centre 'Mother Tereza', Tirana, Albania.
authors.forename: Diamant
authors.initials: D
authors.lastname: Shtiza
authors.affiliation: Department of Pediatric Nephrology, Hacettepe University, Ankara, Turkey.
authors.forename: Rezan
authors.initials: R
authors.lastname: Topaloglu
authors.affiliation: Institute of Mother and Child Care, Chisinau, Moldova.
authors.forename: Natalia
authors.initials: N
authors.lastname: Zaicova
authors.affiliation: Department of Pediatric Nephrology, 'A. and P. Kyriakou' Children's Hospital, Athens, Greece.
authors.forename: Argyroula
authors.initials: A
authors.lastname: Zampetoglou
authors.affiliation: ESPN/ERA-EDTA Registry and ERA-EDTA Registry, Amsterdam, Netherlands.
authors.forename: Kitty J
authors.initials: KJ
authors.lastname: Jager
authors.affiliation: ESPN/ERA-EDTA Registry and ERA-EDTA Registry, Amsterdam, Netherlands.
authors.forename: Karlijn J
authors.initials: KJ
authors.lastname: van Stralen
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005060:Europe / Q000453:epidemiology; D005260:Female; D005843:Geography; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D054625:Healthcare Disparities; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000628:therapy*; D016030:Kidney Transplantation / Q000401:mortality / Q000706:statistics & numerical data*; D008297:Male; D012042:Registries; D017582:Renal Replacement Therapy / Q000401:mortality / Q000706:statistics & numerical data*; D015996:Survival Rate
keywords: disparities; paediatric nephrology; public health; renal replacement therapy