To compare the likelihood of Indigenous and non-Indigenous Australians being placed on the waiting list for transplantation of a kidney from a deceased donor; to compare the subsequent likelihood of ...transplantation.
Observational cohort study; analysis of data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry for patients aged 18-60 years at the start of renal replacement therapy, who commenced renal replacement therapy in Australia between 28 June 2006 and 31 December 2016.
Time to wait-listing; time to kidney transplantation after wait-listing.
10 839 patients met the inclusion criteria, of whom 2039 (19%) were Indigenous Australians; 217 Indigenous and 3829 non-Indigenous patients were active on the waiting list at least once during the study period. The hazard ratio (HR) for wait-listing (Indigenous v non-Indigenous patients, adjusted for patient- and disease-related factors) in the first year of renal replacement therapy varied with age and remoteness (range, 0.11 95% CI, 0.07-0.15 to 0.36 95% CI, 0.16-0.56); in subsequent years the adjusted HR was 0.90 (95% CI, 0.50-1.6). The adjusted HR for transplantation during the first year of wait-listing did not differ significantly from 1.0; for subsequent years of wait-listing, however, the adjusted HR was 0.40 (95% CI, 0.29-0.55).
Disparities between Indigenous and non-Indigenous patients with end-stage kidney disease in access to kidney transplantation are not explained by patient- or disease-related factors. Changes in policy and practice are needed to reduce these differences.
Summary Planning for programme sustainability is a key contributor to health and development, especially in low-income and middle-income countries. A consensus evidence-based operational framework ...would facilitate policy and research advances in understanding, measuring, and improving programme sustainability. We did a systematic review of both conceptual frameworks and empirical studies about health-programme sustainability. On the basis of the review, we propose that sustainable health programmes are regarded as complex systems that encompass programmes, health problems targeted by programmes, and programmes' drivers or key stakeholders, all of which interact dynamically within any given context. We show the usefulness of this approach with case studies drawn from the authors' experience.
The factors affecting the outcomes among Indigenous kidney transplant recipients is not fully understood. We conducted a retrospective case control study to identify risk factors beyond those ...explained by the ANZDATA registry.
To identify the risk factors for loss of kidney transplant function or death among Indigenous kidney transplant recipients.
Cases were defined as all Indigenous Australian kidney transplant recipients from 1 January 2005 to 31 December 2015 from the major hospitals in the Northern Territory (NT) and South Australia (SA) who experienced graft loss (including patient death) up to 2-years post-transplant. Controls (matched 4:1) were defined as all indigenous kidney transplant recipients during the same period with functioning transplants at 2-years post-transplant operation. Matching was done on gender and diabetes status. Regression analysis adjusted for age was used for comparing cases and controls.
There were 17 cases and 68 matched controls. Among cases, the odds ratio for more than one hospital admission episode (compared with ≤1 episode) in the 2-year pretransplant period was 6.2 (95% confidence interval, 1.2-32.5). However, there were no significant differences in the frequency of comorbidities at renal replacement therapy start, cardiovascular intervention pretransplant, pretransplant infection screening, age and gender of the donors, frequency of admission episodes where an infection was documented, the total length of inpatient stay or admission to intensive care unit during pretransplant hospital admission between cases and controls.
Early graft loss was associated with a higher frequency of hospital admissions in the 2-years pretransplant period. In contrast, other measured factors in the pretransplant period did not predict these adverse outcomes.
Abstract
Background
Rates of end-stage kidney disease in Australia are highest in the Northern Territory (NT), with the burden of disease heaviest in remote areas. However, the high cost of ...delivering dialysis services in remote areas has resulted in centralisation, requiring many people to relocate for treatment. Patients argue that treatment closer to home improves health outcomes and reduces downstream healthcare use. Existing dialysis cost studies have not compared total health care costs associated with treatment in different locations.
Objective
To estimate and compare, from a payer perspective, the observed health service costs (all cause hospital admissions, emergency department presentations and maintenance dialysis) associated with different dialysis models in urban, rural and remote locations.
Methods
Using cost weights attributed to diagnostic codes in the NT Department of Health’s hospital admission data set (2008–2014), we calculated the mean (SD) total annual health service costs by dialysis model for 995 dialysis patients. Generalized linear modeling with bootstrapping tested the marginal cost differences between different explanatory variables to estimate ‘best casemix’/‘worst casemix’ cost scenarios.
Results
The mean annual patient hospital expenditure was highest for urban models at $97 928 (SD $21 261) and $43 440 (SD $5 048) and lowest for remote at $19 584 (SD $4 394). When combined with the observed maintenance dialysis costs, expenditure was the highest for urban models at $148 510 (SD $19 774). The incremental cost increase of dialysing in an urban area, compared with a rural area, for a relocated person from a remote area, was $5 648 more and increased further for those from remote and very remote areas to $10 785 and $15 118 respectively.
Conclusions
This study demonstrates that dialysis treatment in urban areas for relocated people has health and cost implications that maybe greater than the cost of remote service delivery. The study emphasises the importance of considering all health service costs and cost consequences of service delivery models.
Key points for decision makers
Relocation for dialysis treatment has serious health and economic consequences. Relocated people have low dialysis attendance and high hospital costs in urban areas. While remote dialysis service models are more expensive than urban models, the comparative cost differences are significantly reduced when all health service costs are included. The delivery of equitable and accessible dialysis service models requires a holistic approach that incorporates the needs of the patient; hence dialysis cost studies must consider the full range of cost impacts beyond the dialysis treatments alone.
Aims/hypothesis
The aim of this work was to investigate the risk of developing chronic kidney disease (CKD) or end-stage kidney disease (ESKD) following a pregnancy complicated by gestational ...diabetes mellitus (GDM) or pre-existing diabetes among Aboriginal women in the Northern Territory (NT), Australia.
Methods
We undertook a longitudinal study of linked healthcare datasets. All Aboriginal women who gave birth between 2000 and 2016 were eligible for inclusion. Diabetes status in the index pregnancy was as recorded in the NT Perinatal Data Collection. Outcomes included any stage of CKD and ESKD as defined by ICD-10 coding in the NT Hospital Inpatient Activity dataset between 2000 and 2018. Risk was compared using Cox proportional hazards regression.
Results
Among 10,508 Aboriginal women, the mean age was 23.1 (SD 6.1) years; 731 (7.0%) had GDM and 239 (2.3%) had pre-existing diabetes in pregnancy. Median follow-up was 12.1 years. Compared with women with no diabetes during pregnancy, women with GDM had increased risk of CKD (9.2% vs 2.2%, adjusted HR 5.2 95% CI 3.9, 7.1) and ESKD (2.4% vs 0.4%, adjusted HR 10.8 95% CI 5.6, 20.8). Among women with pre-existing diabetes in pregnancy, 29.1% developed CKD (adjusted HR 10.9 95% CI 7.7, 15.4) and 9.9% developed ESKD (adjusted HR 28.0 95% CI 13.4, 58.6).
Conclusions/interpretation
Aboriginal women in the NT with GDM or pre-existing diabetes during pregnancy are at high risk of developing CKD and ESKD. Pregnancy presents an important opportunity to identify kidney disease risk. Strategies to prevent kidney disease and address the social determinants of health are needed.
Graphical abstract
To examine the association between delay in planned diabetes care and quality of outcomes.
A retrospective analysis of primary care and inpatient records for 2567 Aboriginal patients, with diabetes, ...living in 49 remote communities in the Northern Territory of Australia. Poisson regression was used to estimate the association between delay from diagnosis to documented diabetes care plan and three outcome measures: mean HbA1c level, most recent blood pressure and number of diabetes-related hospital admissions.
Compared with no delay (< 60 days), patients with delay had increased risk of elevated mean HbA1c: 60 days to < 2 years, incidence rate ratio (IRR), 1.2 (95% CI:1.07-1.39); 2 years to < 4 years, incidence rate ratio (IRR), 1.2 (95% CI:1.04-1.45); 4 years and over, incidence rate ratio (IRR), 1.3 (95% CI:1.12-1.52). There was no evidence of association between delay and optimal blood pressure control. Risk of diabetes-related admission increased with increased delay. Compared with no delay the IRRs for delay were: 60 days to < 2 years, 1.2 (95% CI:1.07-1.42); 2 to < 4 years, 1.3 (95% CI: 1.15-1.58): and 4 years and over, 2.6 (95% CI,2.28-3.08).
The study found that a timely diabetes care plan was associated with better short-term blood glucose control and fewer diabetes-related admissions but not with improved blood pressure control. Delays may be a result of both patient and service-related factors.
To examine the variation of chronic disease mortality by remoteness areas of Australia, including states and territories.
Australian Bureau of Statistics (ABS) death registration data, by Statistical ...Local Area (SLA), were used to identify chronic disease mortality by remoteness category for states and territories and Australia. The analysis used multiple cause of death for six common chronic diseases: diabetes, ischaemic heart disease, stroke, hypertension, chronic obstructive pulmonary disease and renal disease. ABS correspondence files were used to adjust the SLA level death records and population.
The chronic disease mortality rate for Australian residents living in a very remote area (512 per 100,000 persons) was respectively 1.3, 1.4, 1.5, and 1.6 times higher than Remote, Outer Regional, Inner Regional and Major Cities categories. This pattern was consistent for the two age groups of 35–64 years and 65 years and over, all six chronic diseases and all states and territories except Victoria.
This study shows that chronic disease mortality increases with increasing relative remoteness. The results highlight the importance and opportunity to redress poorer health outcomes for rural and remote area populations. The study is limited by absence of reliable Indigenous identification in national death data.
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