Abstract
BackgroundThe strong geographic variations in the incidence rates of renal replacement therapy (RRT) for end-stage renal disease are not solely related to variations in the population's needs, such as the prevalence of diabetes or the deprivation level. Inequitable geographic access to health services has been involved in different countries but never in France, a country with a generous supply of health services and where the effect of the variability of medical practices was highlighted in an analysis conducted at the geographic scale of districts. Our ecological study, performed at the finer scale of townships in a French area of 8,370,616 inhabitants, investigated the association between RRT incidence rates, socioeconomic environment and geographic accessibility to healthcare while adjusting for morbidity level and medical practice patterns.MethodsUsing data from the Renal Epidemiology and Information Network registry, we estimated age-adjusted RRT incidence rates during 2010–2014 for the 282 townships of the area. A hierarchical Bayesian Poisson model was used to examine the association between incidence rates and 18 contextual variables describing population health status, socioeconomic level and health services characteristics. Relative risks (RRs) and 95% credible intervals (95% CrIs) for each variable were estimated for a 1-SD increase in incidence rate.ResultsDuring 2010–2014, 6,835 new patients ≥18 years old (4231 men, 2604 women) living in the study area started RRT; the RRT incidence rates by townships ranged from 21 to 499 per million inhabitants. In multivariate analysis, rates were related to the prevalence of diabetes [RR (95% CrI): 1.05 (1.04–1.11)], the median estimated glomerular filtration rate at dialysis initiation [1.14 (1.08–1.20)], and the proportion of incident patients ≥ 85 years old [1.08 (1.03–1.14)]. After adjusting for these factors, rates in townships increased with increasing French deprivation index [1.05 (1.01–1.08)] and decreased with increasing mean travel time to reach the closest nephrologist [0.92 (0.89–0.95]).ConclusionThese data confirm the influence of deprivation level, the prevalence of diabetes and medical practices on RRT incidence rates across a large French area. For the first time, an association was found with the distance to nephrology services. These data suggest possible inequitable geographic access to RRT within the French health system.
Highlights
Variations in incidence rates of renal replacement therapy (RRT) for end-stage renal disease (ESRD) between and within countries are well documented [1,2], but the respective roles of the underlying factors involved are difficult to disentangle [3,4]
Our approach was based on a conceptual model inspired by the Caskey et al framework [5], in which the incidence of RRT is related to the burden of chronic kidney disease in the population, socioeconomic environment, accessibility to primary and secondary care and medical practices in dialysis
This study suggests possible inequitable geographic access to RRT in France
Summary
Variations in incidence rates of renal replacement therapy (RRT) for end-stage renal disease (ESRD) between and within countries are well documented [1,2], but the respective roles of the underlying factors involved are difficult to disentangle [3,4]. A first ecological study, performed at the relatively broad geographical scale of the district (French départements), showed that in addition to the prevalence of diabetes, several contextual socioeconomic factors and medical practice patterns were involved in the incidence disparities between 85 metropolitan districts during 2008–2009 [4] These results raise the question of possible social and territorial discrepancies in dialysis access at a time when French health authorities are launching a national health strategy to tackle healthcare inequalities [9]. Our ecological study, performed at the finer scale of townships in a French area of 8,370,616 inhabitants, investigated the association between RRT incidence rates, socioeconomic environment and geographic accessibility to healthcare while adjusting for morbidity level and medical practice patterns
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