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Kidney Week

Abstract: PO1122

Clinician Perspectives on Access to Kidney Replacement Therapy in Rural Communities

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Scholes-Robertson, Nicole Jane, The University of Sydney School of Medicine, Sydney, New South Wales, Australia
  • Gutman, Talia M., Centre for Kidney Research, Westmead, New South Wales, Australia
  • Tong, Allison, Centre for Kidney Research, Westmead, New South Wales, Australia

Group or Team Name

  • Centre for Kidney Research
Background

Patients with chronic kidney disease (CKD) requiring kidney replacement therapy in rural communities are at higher risk of mortality compared with patients in urban areas, and encounter many barriers in accessing care. We aimed to describe clinicians’ perspectives of patient access to dialysis and kidney transplantation in rural communities.

Methods

We conducted 28 semi- structured interviews with clinicians (nephrologists, nurses, transplant co-ordinators and social workers) from Australia. Transcripts were thematically analyzed.

Results

We identified five major themes: the tyranny of distance (overwhelming burden of travel, minimizing relocation distress, scarcity of transportation options, concerns for patient safety), supporting navigating of health systems (reliance on local champions, negotiating variability of literacy, providing flexible pathways, frustrating presence of gatekeepers), disrupted care and lacking services (without continuity of care, scarcity of specialist services, fluctuating capacity for dialysis), pervasive financial distress (crippling out of pocket expenditure, widespread socio-economic disadvantage), and awareness of rurality (lacking availability of safe and sustainable resources for dialysis, sensitivity to local needs, dependence on social support, limited options available). Selected quotations are provided in Table 1.

Conclusion

Clinicians felt hampered and frustrated for patients living in rural communities who had limited access to quality care because of geography, financial burden, and complexity and rigidity of the health system. Increased use of telehealth, increased specialist outreach clinics in rural locations and improving flexibility of pathways were suggested to improve access.

Table 1. Selected illustrative quotations
Overwhelming burden of travelEven when I went to the bush (rural), I still had people traveling an hour, two hours to get to me.
I know they're going to have to travel for another six hours to get there (transplant hospital).
Minimizing relocation distressThe problem with that is that still from PD catheter insertion to going home still works out to be about at least three months (with patients living away from home).
Hopefully for those people that have got the tyranny of distance, more equality with them having actual designated accommodation, designated assistance (will make relocation easier).
Reliance on local championsWe're doing everything by telemedicine (Urban Doctor) and without Nurse on the ground up there (rural location) it would be impossible.
Fluctuating capacity for dialysisThey can’t actually have it in their home town. They actually have to travel to somewhere else, look at a home therapy or something else. It's not the way dialysis is set up. It's like a hospital when it goes on bed block, when the dialysis unit in the local town is overwhelmed.
I think about a chap [patient] that I was wanting to start on dialysis who was blind and, in a wheelchair, and our nearest chair was going to be over an hour away.
Crippling out of pocket expenditureI've got one complicated patient who's had a lot of surgical complications post-transplant. And he told me the other day and it actually made me gasp that him and his wife, both on the Pension $20,000 in the red over the last two and a half years.
I need a root canal and I don't have X number of thousands of dollars; therefore, I can't have my transplant because I cannot get my dental clearance.
Dependence on social supportIf someone doesn't have the support net that is actually a very serious barrier to transplant.
It's difficult for these patients who live alone, and don’t have a lot of support, so they're the ones who really find it difficult.”

Funding

  • Government Support - Non-U.S.