title: Effects of health service geographic accessibility in patients with treated end stage kidney disease: Cohort study 2000-2010.
abstract: OBJECTIVE
  Patients in rural areas experience poor access to health services. There are limited data on patterns of health service utilization in rural patients treated with renal replacement therapy (RRT).
  
  
  METHODS
  All prevalent patients over the age of 18 and resident in New South Wales who were receiving RRT on 01/07/2000 and incident patients who started RRT between 01/07/2000 up until 31/07/2010 were included in the study. The Accessibility Remoteness Index of Australia was used to measure rurality and to categorize participant postcode of residence at the time of their first use of a New South Wales healthcare facility after the start of RRT. We assessed (1) rates of hospitalization, (2) rates of inter-hospital transfer (IHT), (3) length of hospital stay (LOS) and (4) survival. Day-only and dialysis admissions were excluded. Negative binomial regression was used to calculate incidence rate ratios (IRR) for hospitalizations, IHT and LOS. Cox proportional hazards was used to calculate hazard ratios (HR) for survival.
  
  
  RESULTS
  Of the 10 505 patients included in the analysis, 1527 (15%) were rural residents while 8978 (85%) resided in urban areas. Median follow up time from start of RRT/study to end of study/death was 4.2 years (IQR 2.0 to 8.2). After allowing for differences in baseline characteristics, rural residence increased the rates of hospitalization by 8% (IRR 1.08: 95% CI 1.01-1.15; P = 0.02), rates of IHT by 176% (IRR 2.76: 95% CI 2.44-3.13; P < 0.001) and the hazard of death by 14% (HR 1.14 95% CI: 1.05-1.24; P = 0.003) LOS was similar (Median 4.0; P = 0.07).
  
  
  CONCLUSIONS
  Rural residents receiving RRT have higher hospitalization rates, markedly higher rates of IHT and higher long-term mortality compared with their urban counterparts.
authors: The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia.
authors: Sradha
authors: S
authors: Kotwal
authors: The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia.|Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia.
authors: Martin
authors: M
authors: Gallagher
authors: Menzies School of Health Research, Charles Darwin University, Darwin, New South Wales, Australia.
authors: Alan
authors: A
authors: Cass
authors: Centre for Transplant and Renal Research, Westmead Hospital|, Westmead, New South Wales, Australia.|Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.
authors: Angela
authors: http://orcid.org/0000-0001-7509-0512
authors: A
authors: Webster
mesh_terms: D000368:Aged; D015331:Cohort Studies; D005260:Female; D006297:Health Services Accessibility; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer; D016016:Proportional Hazards Models; D012424:Rural Population
keywords: cohort studies; hospitalization; mortality; renal replacement therapy; rural population