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High Cost of Dialysis Transportation in the United States: Exploring Approaches to a More Cost-Effective Delivery System

Authors:
  • Prima Health Analytics

Abstract and Figures

Background: The costs of transporting end-stage renal disease (ESRD) patients to dialysis centers are high and growing rapidly. Research has suggested that substantial cost savings could be achieved if medically appropriate transport was made available and covered by Medicare. Objectives: To estimate US dialysis transportation costs from a purchaser’s perspective, and to estimate cost savings that could be achieved if less expensive means of transport were utilized. Methods: Costs were estimated using an actuarial model. Travel distance estimates were calculated using GIS software from patient ZIP codes and dialysis facility addresses. Cost and utilization estimates were derived from fee schedules, government reports, transportation websites and peer-reviewed literature. Results: The estimated annual cost of dialysis transportation in the United States is $3.0 billion, half of which is for ambulances. Most other costs are due to transport via ambulettes, wheelchair vans and taxis. Approximately 5% of costs incurred are for private vehicle or public transportation use. If ambulance use dropped to 1% of trips from the current 5%, costs could be reduced by one-third. Conclusions: Decision-makers should consider policies to reduce ambulance use, while providing appropriate levels of care.
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Copyright © 2013 A2 Publications
134
Journal of Health Economics and Outcomes Research
High Costs of Dialysis Transportation in the United States:
Exploring Approaches to a More Cost-effective Delivery
System
J. Mark Stephens1*, Samuel Brotherton1, Stephan C. Dunning2, Larry C. Emerson3,
David T. Gilbertson2, Matthew Gitlin4, Ann C. McClellan5, William M. McClellan5,
Sanatan Shreay4
Abstract
Background: The costs of transporting end-stage renal disease (ESRD) patients to dialysis centers are high
and growing rapidly. Research has suggested that substantial cost savings could be achieved if medically
appropriate transport was made available and covered by Medicare.
Objectives: To estimate US dialysis transportation costs from a purchaser’s perspective, and to estimate
cost savings that could be achieved if less expensive means of transport were utilized.
Methods: Costs were estimated using an actuarial model. Travel distance estimates were calculated using
GIS software from patient ZIP codes and dialysis facility addresses. Cost and utilization estimates were
derived from fee schedules, government reports, transportation websites and peer-reviewed literature.
Results: The estimated annual cost of dialysis transportation in the United States is $3.0 billion, half of
which is for ambulances. Most other costs are due to transport via ambulettes, wheelchair vans and taxis.
Approximately 5% of costs incurred are for private vehicle or public transportation use. If ambulance use
dropped to 1% of trips from the current 5%, costs could be reduced by one-third.
Conclusions: Decision-makers should consider policies to reduce ambulance use, while providing
appropriate levels of care.
1Prima Health Analytics, Boston, MA; 2Chronic Disease Research Group, Minneapolis, MN; 3Dialysis Center of Lincoln, Lincoln, NE; 4Amgen
Inc., Thousand Oaks, CA; 5Emory University, Atlanta, GA *Corresponding author jmarkstephens@gmail.com
Keywords: dialysis, transportation, costs, cost-effective, end-stage renal disease
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1. Background
Among the chronically ill, travel for medical care can be burdensome from both a time and cost perspective,
and may be an important factor in treatment decisions and patient outcomes.1–3 Travel costs may be
especially high for people with end-stage renal disease (ESRD) who receive hemodialysis, as these patients
typically have to travel for outpatient treatment three times per week, every week of the year, generally for
the remainder of their lives. The high cost of transport for hemodialysis patients is not only due to the
frequency of travel, but also driven by the physical assistance needs of this population. Dialysis patients
have an average of 3.2 comorbidities,4 51% are over age 65,5 over one-third use a wheelchair or a walker and
half require some type of mobility device.6
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Due to the high prevalence of diabetes in this population, many are amputees. At least half are transportation
dependent, meaning they cannot drive themselves and are unable to take public transit.6
The costs of transporting this very ill, elderly and largely non-ambulatory population for medical care are
high and growing rapidly. In 2009, Medicare spent $930 million on ambulance transports alone for ESRD
patients;7 a 60% increase over 2005 expenditures. Patients or secondary insurers paid an additional 25%
or another $230 million, for a total cost of nearly $1.2 billion in 2009. Medicare’s recent cost containment
efforts in the ESRD program have largely focused on outpatient dialysis and injectable drugs. However,
total expenditures for these services increased by only about 4% per year between 2005 and 2010.5 During
this same period, the cost of ambulance transports for ESRD patients rose at an average annual rate of
15%.7
Medicare does not pay for any transportation services except ambulances, which are only covered when
deemed medically necessary. Therefore, while cost containment efforts have focused primarily on services
with low growth trends, the issue of the use of ambulances for transport to routine dialysis has been
identied, but not adequately addressed, for at least the past two decades. As early as 1994, the Ofce
of the Inspector General (OIG) was charged with investigating the medical necessity of, and payment
practices related to ambulance transportation of dialysis patients. The OIG found that less than 2% of
ESRD beneciaries accounted for 75% of total ESRD ambulance payments.8 The high expense for so
few people was related to the routine use of ambulances for trips to dialysis facilities. OIG also found
that 70% of dialysis-related ambulance claims examined did not meet Medicare coverage guidelines for
medical necessity because beneciaries did not have conditions that contraindicated use of another type of
transport.9 A subsequent General Accounting Ofce (GAO) report showed that more than 50% of rural
Medicare ambulance trips were of a non-emergency nature.10
Other research has suggested that substantial cost savings could be achieved if medically appropriate
transport was made available and covered by Medicare. Burkhardt11 demonstrated that Medicare’s
transportation policy was not cost-effective, with Medicare often paying for ambulance trips when less
expensive, alternative transportation could have been used. Further, Medicare could have saved 96% of
what it paid for ambulance transports that were subsequently determined to be non-emergencies. The paper
noted that cost was not the only burden that would be relieved if Medicare paid for appropriate types of
non-emergency medical transportation (NEMT), as this would greatly simplify the logistics for patients,
state programs and health providers. Finally, a 2012 report by the Medicare Payment Advisory Committee
(MedPAC) showed that reducing ambulance use for dialysis transport in high-use states to the national
median would save $400 million per year.12 However, these ndings and the previous reports from the
OIG and GAO did not lead to new legislation that would address the fundamental problem of the lack of
Medicare coverage for less expensive alternative transportation.
Given the high costs and rapid growth in the costs of dialysis transportation and the well-documented
problems in managing these costs in the Medicare program, the paucity of recent research examining the
extent and nature of such costs and their policy implications needs to be addressed. The total annual costs
of dialysis transportation in the United States are difcult to estimate. To our knowledge, no comprehensive
studies or estimates have been published to date. While estimates are available reporting Medicare costs
for ambulance transportation for dialysis patients, as are annual NEMT costs (of which some substantial
portion is for dialysis patient transport), transportation costs for other public assistance programs available
to dialysis patients and those borne by private insurers and patients and their families are more difcult to
estimate, and may be higher than the payments made by Medicare or Medicaid.
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Therefore, the objectives of this study were (1) to estimate US dialysis transportation costs from a purchaser’s
perspective, in total, by transport and payer type and by state and region, and (2) to estimate potential cost
savings that could be achieved if less expensive means of transport were utilized.
2. Methods
Data Sources and Approach
This was a retrospective modeling study of dialysis patient travel estimates and the costs of travel, using
publicly available data on U.S. dialysis patients and facilities in 2012. Using an actuarial model, the total costs
of transportation were estimated for about 360,000 patients for travel to routine in-center dialysis. Per trip
travel distance estimates were calculated from patient ZIP codes and dialysis facility addresses. Costs were
estimated from a purchaser’s perspective, where costs were dened as the total direct nancial costs of all
types of dialysis transportation incurred by the purchaser(s) of the service. This was either payments made
by insurers, patients or other third parties to the transport provider for the actual services used, or, where no
transport provider was paid for the transportation service, (i.e., patients drove themselves by private auto),
a direct cost was calculated based on standard mileage rates.
Transit service to a dialysis facility is provided by a variety of modes, dened by the type of vehicle used,
operating characteristics of the service provided, and the travel needs of the riding public for which
they are designed. The transportation categories used in the model are dened in Table 1. Utilization by
transport type used to travel to dialysis and costs of each transport type were estimated from fee schedules,
government reports, transportation websites and peer-reviewed literature. The primary data sources and
assumptions used in the model are summarized in Table 2.
Model Design
The model used was an actuarial-type deterministic model, where all inputs were pre-dened, with pre-
determined application of formulae to the inputs to produce output. Costs were estimated for all in-center
dialysis patients in the 50 US states, the District of Columbia and Puerto Rico. The base year for estimates
was 2012. Costs were projected forward to 2014 using transportation cost ination trends13 and dialysis
patient growth trends.7
Costs were estimated using the following input variables:
• Number of patients;
• Average number of treatments per patient per year (PPPY);
• Distance traveled per treatment; and
• Cost of travel per mile/treatment.
Input variables were detailed by the following dimensions:
• Insurance category (e.g., Medicare, Medicaid, commercial, no insurance);
• Transport type (e.g., ambulance, wheelchair van, private auto);
• Patient location (e.g., state, urban versus rural); and
• Calendar year.
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Table 1. Denitions for Transport Service Categories Used in the Model
Model outputs were:
• Number of patients,
• Number of treatments,
• Distance traveled,
• Costs of travel, and
• Sums and averages of the above: US total, PPPY, per treatment.
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Table 2. Summary of Data Sources and Assumptions Used for Estimating Transport Costs
ESRD=end-stage renal disease; IRS=internal revenue service; PPPY=per patient per year; USRDS=United States renal data
system
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Output variables were developed in detail by:
• Insurance category,
• Transport type,
• Patient location,
• Calendar year, and
• Payer (e.g., Medicare, Medicaid, private insurance, patient/other).
The full matrix of detailed cost estimates across all model dimensions included thousands of data points.
Each data point was estimated using actuarial techniques through a combination of detailed estimates and
higher level adjustment factors. For example, an average cost per trip for ambulettes was modied by an
insurance-type factor to differentiate what Medicaid would pay versus what a patient would pay out-of-
pocket. Detailed utilization estimates (i.e., treatments, transport miles) by transport type and insurance
category were also calculated by applying utilization proportions to the detailed estimates of patients, miles,
and visits that were derived from the distance calculations. The output from distance calculations was miles
per treatment and patient counts by ZIP code.
Each detailed estimate was then broken down by insurance category and transport type based on higher
level estimates for the general population. A further delineation of each cost estimate was made by applying
payment allocation factors to each insurance category-by-transport type, reecting the insurance benets
for each transport type in each insurance category. For example, Medicare pays 80% of the allowable
costs of ambulance services. The remainder is paid by third parties such as Medicaid (for dual eligible
beneciaries), private insurance or the patients themselves.
Patient Travel Estimates (distance calculations)
To estimate patient travel distances for dialysis, two data points were estimated: (1) patient residence and (2)
dialysis treatment destination. These data points were mapped to latitude and longitude coordinates using
Microsoft MapPoint 2011 and GPS Visualizer software. Driving distances and times were calculated using
custom software developed in MapPoint and Wolfram Mathematica 8. Patient address data were limited to
ZIP code of residence. Patients were assigned to residential locations within their ZIP code, weighted by
population density. For example, an urban center within a ZIP code received a higher allocation of patients
than a rural area of the same size within the same ZIP code.
Data on each patient’s actual facility were not obtained. It was assumed that the facility location closest
to the patient residence was the one utilized. This assumption is commonly used in studies of dialysis
access.14–16 However, initial modeling of patient assignments to their nearest facility revealed that such an
assumption produced unrealistic patient counts at many facilities. Many facilities would be heavily over-
or under-allocated, relative to the actual number of patients served by these facilities. To address this
problem, the model’s initial patient assignment results were compared with reported patient census counts
from Medicare Cost Reports17,18 and Dialysis Facility Reports,4 and the model-assigned patient counts were
“corrected” by randomly selecting patients from over-allocated facilities and re-assigning them to other
nearby facilities so that the number of patients assigned to each facility in the model achieved a 90%
correlation with the actual patient counts reported by facilities.
Comparisons with point estimates found in recent literature on U.S. patient travel for dialysis services19–21
were made to validate the estimates of patient travel distance and time to dialysis facilities made for this
study.
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Statistical Analysis
Study Outcomes
Transportation costs, trips and miles were estimated nationally, by state, census region and ESRD network
for urban, rural and super-rural subgroups, by transport type and payer. Rates were calculated for average
costs per patient, per round-trip and per mile. Costs were cumulated over 3 years —2012 through 2014.
Reliability and Validity
Three sets of comparisons were made between model estimates and other cost estimates from the literature:
(1) total national costs of dialysis transportation, (2) Medicare payments for ambulances, and (3) NEMT
costs per trip. In general, the estimates from this study were conservative by comparison to the other
estimates available from the literature. Model estimates were 7% to 12% lower than the comparison gures.
For example, the model estimate of 2012 Medicare ambulance payments per patient for routine dialysis
transportation was approximately 8% lower than those calculated from the 2009 actual Medicare ambulance
payments (trended for ination).
Cost Saving Scenarios
In addition to the baseline estimates, cost estimates and potential cost savings were calculated for three
scenarios in which utilization of higher cost means of transport was shifted to less expensive transport
types. The three scenarios tested were:
Scenario 1: Reduce ambulance utilization to 1% of trips. In the baseline model, seven states had
ambulance use below 1% of total trips. This scenario calculated the savings that would result if all
states had ambulance utilization of 1% of trips, and excess ambulance trips were proportionally
allocated to all other modes except self-transport.
Scenario 2: Change the mix of non-ambulance commercial NEMT transports (i.e., ambulettes,
wheelchair vans, taxis and public transit) to a lower cost mix based on local “best practices”. In
the baseline estimates, the national average mix of transports within these four categories was 7%,
54%, 29%, and 10%, respectively. The mix used in this scenario was 5%, 25%, 60%, and 10%,
respectively. It was assumed that public transit use could not be higher than the national average, due
to limited availability in rural areas and access problems for most dialysis patients. Reducing ambulette
and wheelchair van use to 30% of this total from the national average of 61% may be aggressive
when compared to current practices. It was assumed that some ambulette trips could be shifted to
wheelchair vans, and most wheelchair van trips could be shifted to taxis.
Scenario 3: Combine the utilization shifts from Scenarios 1 and 2, rst shifting excess ambulance use
proportionally to all other modes except self-transport, and then shifting the mix within commercial
NEMT to the proportions in Scenario 2.
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Sensitivity Analysis
A series of one-way sensitivity analyses were conducted for the 3-year (2012-2014) projected costs of
dialysis transportation for in-center dialysis patients, to determine the key cost drivers estimated in the
model. Eight variables expected to show sensitivity in the results to changes in their values were identied
in the model. The effects of changes from the baseline assumption for each single variable in the analysis
were isolated in the model by holding all other factors constant (at baseline estimates) and then modifying
the test variable through a range of reasonable alternate assumptions. Model results for total (cumulative)
costs under these alternate assumptions were compared to the baseline result. Plausible ranges of values
were developed from the literature and/or from sub-analyses to bound the one-way sensitivity analyses.
Sources and rationales for the assumptions used are given in Table 3.
Table 3. Sensitivity Analysis: Plausible Ranges of Values, Sources and Rationales
NEMT=non-emergency medical transportation
aRange based on U.S. regions with the least intensive (West) and most intensive (Northeast) mix of transportation services
utilized in the model.
bFew NEMT cost estimates per trip were found in the literature. A range of ±20% around the baseline estimate was
used.
cLow end: Commercial NEMT discounts same as Medicaid, ambulance fees at Medicare fee schedule for commercial and
Medicaid. High end: no discounts, Medicaid or Commercial.
dLow end estimate: Baseline model, which was the lowest estimate found. High end estimate: MedPAC 2011 Report to the
Congress, which examined travel for new Fee for Service beneciaries in 2008.19
eLow estimate from average of 2009 Renal Cost Reports17 for in-center hemodialysis + peritoneal dialysis. High estimate
from USRDS 2011 Annual Data Report7 Table J.8 for 2009 (including hospitals). Base estimate was the average of 2009-2010
hemodialysis-only from all cost reports (includes hospital non-maintenance sessions).
fLow estimate: All miles at Internal Revenue Service (IRS) 2012 Medical Rate (variable costs only). High estimate: All miles at IRS
2012 full mileage rate (all costs included).39
gBased on economic scenarios of poor economy = more Medicaid/more uninsured/less commercially-insured, and good economy
= less Medicaid/less uninsured, more commercially-insured. Assume Medicare eligible patients stay about the same.
hUsed the high and low annual percentage ination of the last 5 years of the CPI-U Transportation Index13 and the high and low
annual percentage growth in dialysis patient year-end point prevalence of the most recent 5 years available (2004 to 2009).7 The
baseline assumption was 6.8% annual growth, which was the average of the past 3 years.
3. Results
The study cohort used in the model included 360,579 in-center dialysis patients assigned to 5,405 dialysis
centers (Table 4).
Table 4. Study Cohort of Patients and Facilities
ESRD=end stage renal disease
aNational Patient Prevalence Report32
bCenters for Medicare & Medicaid Services (CMS) Dialysis Facility Compare File34
cThese patients could not be assigned to a dialysis facility, since the model allocated them to geographically inaccessible areas (e.g.
wilderness areas and bodies of water).
d61 facilities had no patients assigned as the closest facility.
The estimated annual cost of transportation to dialysis in the United States for 2012 was $3.0 billion,
approximately half of which was for ambulance transport. Most of the remaining costs were for use of
commercial transport via ambulettes, wheelchair vans and taxi services. Only about 5% of costs were
related to use of private vehicles or public transportation. Costs were expected to grow to $3.4 billion by
2014 (Table 5).
Table 5. Estimated National Costs of Dialysis Transportation from 2012 to 2014, by Transport Type ($
Millions)
We estimated that in-center dialysis patients would travel almost 744 million miles to dialysis in 2012, an
average of 14.5 miles per round-trip. Collectively, they would make an estimated 51.2 million round-trips
for dialysis in 1 year, an average of 142 round-trips per patient (Table 6). Ambulance services account for
48% of all costs, but only 5% of transports. Patients who drive themselves account for 25% of all trips,
but only 1% of costs.
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Table 6. 2012 National Utilization Statistics - Transportation to In-Center Dialysis
Costs PPPY were estimated at over $8,300. About one-third of these costs would not be covered by
patients’ primary or secondary insurance (Medicare, Medicaid, or Employer Group Health Plans) and
would therefore be the responsibility of the patient or other third parties (Table 7). The costs to Medicare
for ambulances alone was expected to exceed $1.0 billion in 2012, not including emergency ambulance
services for these patients.
Table 7. 2012 Costs ($ Millions) and Percent of Costs by Transport Type, by Payer
Per patient dialysis transportation costs vary tremendously from state to state, ranging from $3,951 PPPY
in Utah to $30,516 PPPY in Puerto Rico. As at the national level, costs by state were driven by ambulance
utilization. The percentage of trips via ambulance in Utah was less than 1%, while it was 47% in Puerto
Rico (Figure 1).
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Figure 1. Dialysis Transportation Cost PPPY and Percent of Trips by Ambulance, by State
The correlation was calculated from state-level observations, using the percent of total trips that were via ambulance correlated with total costs
PPPY.
There was also high regional variation, with PPPY costs of $7,119 in the Midwest versus $9,780 in the
Northeast (Figure 2). The percentage of costs attributed to ambulances was 39% in the Midwest and 56%
in the Northeast.
Figure 2. Dialysis Transportation Costs PPPY and Percent of Costs Attributable to Ambulance Trips, by
Census Region
Sensitivity Analysis
Figure 3 shows the results of the one-way sensitivity analysis. The largest effects on the model cost estimates
resulted from the assumptions of utilization mix by type of transport. The range of results varied from
16% below baseline to 20% above baseline when the utilization patterns of individual US regions were
substituted for the overall US average pattern. The average cost per trip for NEMT services, the level
of insurer discounts from charges, and the average miles driven per trip also showed large effects. Other
variables had very small effects by comparison.
Figure 3. Sensitivity Analysis: Key Factors Inuencing Cumulative Dialysis Transportation Costs from 2012
to 2014
Black bars represent outcomes based on minimum plausible values. Gray bars represent outcomes based on maximum plausible
values. Numbers in square brackets to the right of the labels denote the range of values used.
Savings Estimates
Potential cost savings that may be achieved over 3 years under various scenarios of changes in service
utilization mix are shown in Table 8. Changing the mix of services within the four non-ambulance
commercial transport categories (ambulettes, wheelchair vans, taxis and public transit) to a lower cost mix
of 5% ambulettes, 25% wheelchair vans, 60% taxi and 10% public transit would save nearly $1 billion, or
10% of total costs over 3 years, versus the baseline utilization mix in the model. Shifting patients from
costly ambulance transport to less expensive modes of transport offers the potential for dramatic savings.
If ambulance use dropped to 1% of trips from the current 5% of trips, the savings would be over $3.2
billion, or one-third of total costs, over the 3-year period. Combining the utilization shifting strategies of
the rst two scenarios could save $4.2 billion, or 44% of total costs over 3 years.
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Table 8. Cost Savings Scenarios ($ Billions)
NEMT=non-emergency medical transportation
4. Discussion
This study estimated that the costs of transport to routine dialysis for US patients are approximatley $3.0
billion annually and growing rapidly, especially Medicare ambulance costs. The study further showed that
if regional or state-level “best practices” were implemented nationally, costs could be cut by one-third or
more, saving billions of dollars over 3 years. Despite the apparent high costs of dialysis transportation, this
cost segment has received very little attention relative to its overall impact on ESRD costs. For example,
concern over the high costs of dialysis drugs arguably led to an entire re-design of Medicare’s payment
system for dialysis.22 Yet the costs of ambulances for ESRD patients were rising at a much faster rate than
dialysis drug costs and rapidly approached $1 billion per year by 2009 (Table 9).
Table 9. Total Medicare Payments ($ Millions) for ESRD Patients: by Select Claim Type7
In response to the 2012 MedPAC report on Medicare payment for ambulance services,12 Congress took
action in the American Taxpayer Relief Act of 2012 (the so-called “Fiscal Cliff ” act) to attempt to restrain
the use of ambulances for dialysis transport. The new law cut fee schedule payments for non-emergency
basic life support services involving transport of an individual with ESRD to a dialysis facility by 10%,
effective October 1, 2013.23
Reduced payments should be a disincentive to ambulance providers to transport dialysis patients, but
coverage of any alternative means of transport was not addressed. A major policy issue that should be
addressed is to determine how to reduce transportation costs without shifting the cost burden to the patient,
to the dialysis provider, or to tax-funded public transportation programs. There is already a heavy burden of
costs borne by patients, their families and public transit services. This study estimated that approximately
one-third of total costs are not covered by patients’ primary or secondary insurance. Patients who do not
have access to public transportation assistance programs may face a large nancial burden due to transport
to and from dialysis three times per week. Access to needed services may be reduced or eliminated for some
patients, purely based on costs.
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Citing budget constraints and the growing demand for dialysis transport, some community transportation
services are already turning away dialysis patients.24 Not only is the prevalent dialysis patient population
growing, but also there is growing evidence for the health benets of short daily hemodialysis versus
traditional three-times weekly treatment.25–28 Added to this is a trend toward more off-hours appointment
times, especially at the centers run by the largest dialysis organizations. These factors, taken together, could
precipitate more service cutbacks or shortfalls for budget-constrained county and municipal paratransit
services. The transportation that many dialysis patients rely on may no longer be available. Concern in some
states over this pending crisis of increasing demand in the face of shrinking budgets is high enough that
congressmen are taking action to address the problem. At least two bills were introduced in 2012 (H.R.
6011 and S. 2163) to address barriers in accessing quality care for people with kidney failure, including
transportation issues.29
Policy issues, such as Medicare’s limited transportation benets, and budget cuts to state Medicaid programs
and county and municipal transit services, may combine to create a serious crisis in care for dialysis patients.
One opportunity to address the issue is through the Dual Eligible demonstration projects funded by the
Affordable Care Act. With at least half of the 50 states expected to participate, the ability to coordinate
transportation benets between Medicare and Medicaid for dialysis patients could save a lot of money, and
more importantly, protect vital access to medical services for dialysis patients. Another opportunity may
result from the ESRD demonstration projects that are under consideration by the Centers for Medicare and
Medicaid Services (CMS). In a recent Open Door Forum held by CMS on ESRD demonstration projects,
several participants commented on the need to address transportation services.30
This study was primarily limited by the lack of quality and the incompleteness of the data used to generate
estimates. We are unaware of any systematic reporting on dialysis transportation costs in the United States.
There are unreported costs, such as data on the number of patient-driven miles; and information on
transportation type used by dialysis patients is very limited. The cost estimates in this study appear to be
conservative, when compared with other available literature, and may have underestimated the actual costs
by 10% or more. Some model assumptions were generalized across geographic regions, where variation may
exist. This limits the reliability of the detailed estimates at the state or region level.
Few studies have been published that attempt to examine overall US dialysis transportation costs and
utilization across all transport types and payers. This study begins to explore the range of probable costs
and associated policy issues in dialysis transportation. However, higher quality data are needed to more
thoroughly address this largely ignored but growing segment of ESRD costs. There are signicant savings
opportunities that will improve quality of care and protect patient access. Study of these opportunities
deserves more attention from policy-makers, especially in the current environment of tightening federal,
state, and local budgets that fund much of this care.
Acknowledgements
The authors wish to thank Holly Tomlin (employee and stockholder, Amgen Inc.) and Mandy Suggitt on
behalf of Amgen Inc. for their medical writing, editing and journal formatting assistance.
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Conict of Interest Declaration
Amgen Inc. provided funding for this study, and the manuscript was provided for legal, medical and
biostatistical review prior to submission. All content decisions were made at the discretion of the authors.
Employees of Amgen Inc. participated in the study design and interpretation of the data, and in reviewing,
revising and providing nal approval of this manuscript.
JMS has received consulting, travel reimbursement, research, and data collection/analysis fees from Amgen
Inc. SB received funds from Prima Health Analytics. SCD has received consulting fees from Amgen Inc and
fees from Amgen Inc., NxStage, DaVita, Takeda, Gilead, and Ortho-McNeil. LCE has received consulting
fees and travel reimbursement fees from Amgen Inc. DTG has received consultancy fees from Amgen Inc.
and research funding from Amgen Inc., NxStage, DaVita, Takeda, and Gilead. ACM has received consulting
fees from Amgen Inc. and Abor Research Collaborative for Health.
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... The estimated annual cost of dialysis transportation in the United States approximates US$3.0 billion, about 6-7% of total dialysis patient costs. 2 Ambulance services account for 46% of all costs. 2 Approximately 5% of cost represent private vehicle or public transportation use, and the remainder for ambulettes, wheelchair vans, and taxis. 2 The US Bipartisan Budget Act of 2018 reduced funding for nonemergency ambulance transportation services by 13%. 1 Advocating home dialysis and using telehealth to conduct two of three monthly visits will aid in reducing nonemergency dialysis transportation cost. ...
... The estimated annual cost of dialysis transportation in the United States approximates US$3.0 billion, about 6-7% of total dialysis patient costs. 2 Ambulance services account for 46% of all costs. 2 Approximately 5% of cost represent private vehicle or public transportation use, and the remainder for ambulettes, wheelchair vans, and taxis. 2 The US Bipartisan Budget Act of 2018 reduced funding for nonemergency ambulance transportation services by 13%. 1 Advocating home dialysis and using telehealth to conduct two of three monthly visits will aid in reducing nonemergency dialysis transportation cost. ...
... The estimated annual cost of dialysis transportation in the United States approximates US$3.0 billion, about 6-7% of total dialysis patient costs. 2 Ambulance services account for 46% of all costs. 2 Approximately 5% of cost represent private vehicle or public transportation use, and the remainder for ambulettes, wheelchair vans, and taxis. 2 The US Bipartisan Budget Act of 2018 reduced funding for nonemergency ambulance transportation services by 13%. 1 Advocating home dialysis and using telehealth to conduct two of three monthly visits will aid in reducing nonemergency dialysis transportation cost. ...
Article
The 2018 Bipartisan Budget Act in the United States extended telehealth access to Medicare beneficiaries who receive home dialysis in which two of three monthly visits in a quarter may be performed by telehealth after three initial face-to-face monthly visits. The originating site (where the patient is located) can be a dialysis unit or the patient’s home and without geographic restriction. Patient awareness and interest in this new telehealth benefit in urban patients has not been well characterized. Patients receiving peritoneal dialysis (PD) treatment located in an urban facility completed a survey to ascertain knowledge of telehealth and readiness and willingness to participate in telehealth for their monthly visit. A total of 30 patients participated: 37% who completed the survey had heard of telehealth and 40% were able to define telehealth in words and correctly identify an example of telehealth. None of the patients were aware of the 2018 US Bipartisan Budget Act which extended telehealth assess to Medicare beneficiaries. Almost everyone had a mobile phone (83%), owned a computer (50%), and had access to Internet services (90%). The majority of patients (73%) were willing to use telehealth services for their monthly visit with the physician. PD patients living in an urban setting appear to be ready and interested in using telehealth to perform their monthly visit with the physician.
... Given that ADPKD is a life-long and progressive disorder, a substantial economic burden over the course of the disease is expected, including a variety of treatmentrelated and other costs [6][7][8][9][10][11][12][13]. Few studies to date have estimated direct and indirect costs among patients with ADPKD. ...
... Costs of matching donors and recipients for kidney transplant among individuals with ADPKD were based on the Organ Procurement and Transplantation Network (OPTN) fees and the United Network for Organ Sharing (UNOS) fees multiplied by the number of individuals waiting for a kidney transplant due to ADPKD [16,[33][34][35]. Costs of transportation to and from dialysis centers among individuals with ADPKD in the US were based on the average transportation costs for individuals using in-center dialysis multiplied by the number of individuals with ADPKD using in-center dialysis in the US [12,16]. The number of individuals with ADPKD using in-center dialysis in the US was computed as the number of individuals with ESRD-RRT requiring dialysis due to cystic kidney disease in the US multiplied by the proportion of individuals with ESRD-RRT due to ADPKD among individuals with cystic kidney disease and the proportion of individuals requiring incenter dialysis among individuals requiring dialysis due to cystic kidney disease [16]. ...
Article
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Background: Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common inherited kidney diseases characterized by progressive development of renal cysts and numerous extra-renal manifestations, eventually leading to kidney failure. Given its chronic and progressive nature, ADPKD is expected to carry a substantial economic burden over the course of the disease. However, there is a paucity of evidence on the impact of ADPKD from a societal perspective. This study aimed to estimate the direct and indirect costs associated with ADPKD in the United States (US). Methods: A prevalence-based approach using data from scientific literature, and governmental and non-governmental organizations was employed to estimate direct healthcare costs (i.e., medical services, prescription drugs), direct non-healthcare costs (i.e., research and advocacy, donors/recipients matching for kidney transplants, transportation to/from dialysis centers), and indirect costs (i.e., patient productivity loss from unemployment, reduced work productivity, and premature mortality, caregivers' productivity loss and healthcare costs). The incremental costs associated with ADPKD were calculated as the difference between costs incurred over a one-year period by individuals with ADPKD and the US population. Sensitivity analyses using different sources and assumptions were performed to assess robustness of estimates and account for variability in published estimates. Results: The estimated total annual costs attributed to ADPKD in 2018 ranged from $7.3 to $9.6 billion in sensitivity analyses, equivalent to $51,970 to $68,091 per individual with ADPKD. In the base scenario, direct healthcare costs accounted for $5.7 billion (78.6%) of the total $7.3 billion costs, mostly driven by patients requiring renal replacement therapy ($3.2 billion; 43.3%). Indirect costs accounted for $1.4 billion (19.7%), mostly driven by productivity loss due to unemployment ($784 million; 10.7%) and reduced productivity at work ($390 million; 5.3%). Total excess direct non-healthcare costs were estimated at $125 million (1.7%). Conclusions: ADPKD carries a considerable economic burden, predominantly attributed to direct healthcare costs, the majority of which are incurred by public and private healthcare payers. Effective and timely interventions to slow down the progression of ADPKD could substantially reduce the economic burden of ADPKD.
... The CMS revised nursing home regulations as of August 2018, simplifying the process whereby permanent residents could receive the benefits of more frequent HD and avoid transportation to and from the dialysis clinic. 50 Financial incentives to hospitals (for each patient receiving inhospital education on home modalities and being discharged to an HHD program) and to nursing homes (additional monies for treatments beyond three times weekly) may make these scenarios more likely. ...
Article
The Advancing American Kidney Health Initiative has set an aggressive target for home dialysis growth in the United States, and expanding both peritoneal dialysis and home hemodialysis (HHD) will be required. While there has been a growth in HHD across the United States in the last decade, its value in controlling specific risk factors has been underappreciated and as such its appropriate utilization has lagged. Repositioning how nephrologists incorporate HHD as a critical renal replacement therapy will require overcoming a number of barriers. Advancing education of both nephrology trainees and nephrologists in practice, along with increasing patient and family education on the benefits and requirements for HHD, is essential. Implementation of a transitional care unit design coupled with an intensive patient curriculum will increase patient awareness and comfort for HHD; patients on peritoneal dialysis reaching a modality transition point will benefit from Experience the Difference programs acclimating them to HHD. In addition, the potential link between HHD program size and patient outcomes will necessitate an increase in the size of the average HHD program to more consistently deliver quality dialysis results. Addressing the implications of the nursing shortage and need for designing in scope staffing models are necessary to safeguard HHD growth. Seemingly, certain government payment policy changes and physician documentation requirements deserve further examination. Future HHD innovations must result in decreasing the burden of care for HHD patients, optimize the level of device and biometric data flow, facilitate a more functional centralized patient management care approach, and leverage computerized clinical decision support for modality assignment.
... 18 Significant cost savings may also be realized by reducing transportation costs to in-center facilities by enabling patients in nursing facilities or with significant disabilities to perform PD who would otherwise not have that option. 42 RPM may provide a way for these patients to safely dialyze at home without the added need of transportation. Finally, in many areas of the world, there are limited health care providers to care for large populations of patients. ...
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Remote patient management (RPM) offers renal health care providers and patients with end-stage kidney disease opportunities to embrace home dialysis therapies with greater confidence and the potential to obtain better clinical outcomes. Barriers and evidence required to increase adoption of RPM by the nephrology community need to be clearly defined. Ten health care providers from specialties including nephrology, cardiology, pediatrics, epidemiology, nursing, and health informatics with experience in home dialysis and the use of RPM systems gathered in Vienna, Austria to discuss opportunities for, barriers to, and system requirements of RPM as it applies to the home dialysis patient. Although improved outcomes and cost-effectiveness of RPM have been demonstrated in patients with diabetes mellitus and heart disease, only observational data on RPM have been gathered in patients on dialysis. The current review focused on RPM systems currently in use, on how RPM should be integrated into future care, and on the evidence needed for optimized implementation to improve clinical and economic outcomes. Randomized controlled trials and/or large observational studies could inform the most effective and economical use of RPM in home dialysis. These studies are needed to establish the value of existing and/or future RPM models among patients, policy makers, and health care providers.
... In order to guide future reimbursement decisions, there is great need for studies that assess an endpoint of overall resource utilization including reduction in nonemergent transportation costs. For the latter, it has been estimated that annually almost $3 billion is spent on this for patients receiving dialysis (48). Furthermore, studies evaluating clinical outcomes and economic analyses associated with reduction in hospitalizations and rehospitalizations, technique failure, and peritonitis rates should also be undertaken to guide reimbursement. ...
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Telehealth and remote monitoring of a patient's health status has become more commonplace in the last decade and has been applied to conditions such as heart failure, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Conversely, uptake of these technologies to help engender and support home RRTs has lagged. Although studies have looked at the role of telehealth in RRT, they are small and single-centered, and both outcome and cost-effectiveness data are needed to inform future decision making. Furthermore, alignment of payer and government (federal and state) regulations with telehealth procedures is needed along with a better understanding of the viewpoints of the various stakeholders in this process (patients, caregivers, clinicians, payers, dialysis organizations, and government regulators). Despite these barriers, telehealth has great potential to increase the acceptance of home dialysis, and improve outcomes and patient satisfaction while potentially decreasing costs. The Kidney Health Initiative convened a multidisciplinary workgroup to examine the current state of telehealth use in home RRTs as well as outline potential benefits and drawbacks, impediments to implementation, and key unanswered questions.
... Second, In the U.S., transportation costs for travel to dialysis facilities has been estimated at more than $3 billion [33]. A study of health expenditure data determined that NEMT for chronic conditions that can lead to more serious conditions (i.e., NEMT for diabetes and hypertension) were determined to be cost saving to highly cost-effective. ...
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Background: Older adults in rural areas have unique transportation barriers to accessing medical care, which include a lack of mass transit options and considerable distances to health-related services. This study contrasts non-emergency medical transportation (NEMT) service utilization patterns and associated costs for Medicaid middle-aged and older adults in rural versus urban areas. Methods: Data were analyzed from 39,194 NEMT users of LogistiCare-brokered services in Delaware residing in rural (68.3%) and urban (30.9%) areas. Multivariable logistic analyses compared trip characteristics by rurality designation. Results: Rural (37.2%) and urban (41.2%) participants used services more frequently for dialysis than for any other medical concern. Older age and personal accompaniment were more common and wheel chair use was less common for rural trips. The mean cost per trip was greater for rural users (difference of $2910 per trip), which was attributed to the greater distance per trip in rural areas. Conclusions: Among a sample who were eligible for subsidized NEMT and who utilized this service, rural trips tended to be longer and, therefore, higher in cost. Over 50% of trips were made for dialysis highlighting the need to address prevention and, potentially, health service improvements for rural dialysis patients.
Article
Introduction New personal hemodialysis systems, such as the quanta SC+, are being developed; these systems are smaller and simpler to use while providing the clearances of conventional systems. Increasing the uptake of lower-intensity assistance and full self-care dialysis may provide economic benefits to the public health payer. In the United Kingdom, most hemodialysis patients currently receive facility-based dialysis costing more than £36,350 per year including patient transport. As such, we aimed to describe the annual costs of using the SC+ hemodialysis system in the United Kingdom for 3×-weekly and 3.5×-weekly dialysis regimens, for self-care hemodialysis provided both in-center and at home. Methods We applied a cost minimization approach. Costs for human resources, equipment, and consumables were sourced from the dialysis machine developer (Quanta Dialysis Technologies) based upon discussions with dialysis providers. Facility overhead expenses and transport costs were taken from a review of the literature. Findings Annual costs associated with the use of the SC+ hemodialysis system were estimated to be £26,642 for hemodialysis provided 3× weekly as home self-care; £30,235 for hemodialysis provided 3× weekly as self-care in-center; £29,866 for hemodialysis provided 3.5× weekly as home self-care; and £36,185 for hemodialysis provided 3.5× weekly as self-care in-center. Discussion We found that the SC+ hemodialysis system offers improved cost-effectiveness for both 3×-weekly and 3.5×-weekly self-care dialysis performed at home or as self-care in-center versus fully assisted dialysis provided 3× weekly with conventional machines in facilities.
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Background Transportation costs can be a barrier to healthcare services, especially for low-income, disabled, elderly, and geographically isolated populations. This study aimed to estimate the transportation costs of healthcare service utilization and related influencing factors in Korea in 2016. Methods Transportation costs were calculated using data from the 2016 Korea Health Panel Study. A total of 14,845 participants were included (males, 45.07%; females, 54.93%), among which 2,148 participants used inpatient and 14,787 used outpatient care services. Transportation costs were estimated by healthcare types, transportation modes, and all disease and injury groups that caused healthcare service utilization. The influencing factors of higher transportation costs were analyzed using multivariable regression analysis. Results In 2016, the average transportation costs were United States dollars (USD) 43.70 (purchasing power parity [PPP], USD 32.35) per year and USD 27.67 (PPP, USD 20.48) per visit for inpatient care; for outpatient case, costs were USD 41.43 (PPP, USD 30.67) per year and USD 2.09 (PPP, USD 1.55) per visit. Among disease and injury groups, those with neoplasms incurred the highest transportation costs of USD 9.73 (PPP, USD 7.20). Both inpatient and outpatient annual transportation costs were higher among severely disabled individuals (inpatient, +USD 44.71; outpatient, +USD 23.73) and rural residents (inpatient, +USD 20.40; outpatient, +USD 28.66). Transportation costs per healthcare visit were influenced by healthcare coverage and residential area. Sex, age, and income were influencing factors of higher transportation costs for outpatient care. Conclusion Transportation cost burden was especially high among those with major non-communicable diseases (e.g., cancer) or living in rural areas, as well as elderly, severely disabled, and low-income populations. Thus, there is a need to address the socioeconomic disparities related to healthcare transportation costs in Korea by implementing targeted interventions in populations with restricted access to healthcare.
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Geographic and socioeconomic barriers may pose a significant difficulty in delivering home dialysis care to remote underserved populations leading to low utilization rates and poor outcomes. Telehealth may serve as a solution to overcome geographic barriers in delivering home dialysis care. Although technologic advances in telehealth have progressed rapidly making it accessible and inexpensive, it has been underused by nephrologists. Components of a regular face-to-face visit that can be successfully accomplished remotely using telehealth techniques include physician-patient communication, physical examination, laboratory and treatment data monitoring, nursing and nutrition education. Regulatory and reimbursement-related policies continue to present barriers that need to be overcome in operationalizing telehealth and widespread adoption of telehealth solutions. Although more quality evidence is needed to study the impact of telehealth on home dialysis outcomes and uptake, telehealth holds the promise of increasing access to care, improving quality of life, and improving quality of care for current and would be home dialysis patients.
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Living far away from specialized care centers is a potential barrier to the delivery of quality health care and has been associated with adverse outcomes. To assess mortality as a function of distance from the closest hemodialysis unit, and as a function of rural rather than urban residence, we analyzed prospectively collected data on 726,347 adults initiating chronic hemodialysis in the United States over a 13-year period. Participants were classified into categories of 0-10 (referent), 11-25, 26-45, 46-100, and remote living over 100 miles from the closest hemodialysis unit. After a median follow-up of 2.7 years (range 0 to 12.7 years), 368,569 patients died. Compared to the referent group, the adjusted hazard ratio of death was 1.01, 0.99, 0.96, and 1.21, respectively. When residence location was classified using rural-urban commuter areas, 16.5, 66.8, and 16.7% of patients lived in urban, micropolitan, and metropolitan areas, respectively. Compared with those living in metropolitan areas, the adjusted hazard ratio of mortality among patients residing in micropolitan and rural communities was 1.02 and 1.01, respectively. Thus, remote but not rural residence was associated with increased mortality among patients initiating chronic hemodialysis treatment in the United States.
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Micropolitan and rural patients face challenges when initiating dialysis, including healthcare access. Previous studies have shown little association of nonurban residence with dialysis outcomes but have not examined the association of dialysis modality with residence location. This retrospective cohort study used data from the U.S. Renal Data System. Adults who initiated maintenance dialysis between January 1, 2006, and December 31, 2007, were classified as rural, micropolitan, or urban. Early and long-term mortality and kidney transplantation were examined with Cox regression stratified by dialysis modality. Of 204,463 patients, 80% were urban; 10.2%, micropolitan; and 9.8%, rural. Micropolitan and rural patients were older, were less racially diverse, had more comorbid conditions, and were more likely to start peritoneal dialysis (PD). Median follow-up was 2.0 years. Early mortality or long-term hemodialysis (HD) mortality did not significantly differ by geographic residence. After adjustment, micropolitan and rural PD patients had higher risk for long-term mortality (hazard ratio [HR], 1.21 [95% confidence interval (CI), 1.09-1.35] and 1.12 [95% CI, 1.01-1.24], respectively) than urban PD patients. After adjustment, kidney transplantation was more likely in micropolitan and rural HD patients (HR, 1.19 [95% CI, 1.11-1.28] and 1.30 [CI, 1.21-1.40]) than urban HD patients, and micropolitan PD patients (HR, 1.31 [95%, CI 1.13-1.51]) than urban PD patients. Micropolitan and rural residence is associated with higher mortality in PD patients and similar or higher likelihood of kidney transplantation among HD and PD patients. Studies examining the underlying mechanisms of these associations are warranted.
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In this randomized clinical trial, we aimed to determine whether increasing the frequency of in-center hemodialysis would result in beneficial changes in left ventricular mass, self-reported physical health, and other intermediate outcomes among patients undergoing maintenance hemodialysis. Patients were randomly assigned to undergo hemodialysis six times per week (frequent hemodialysis, 125 patients) or three times per week (conventional hemodialysis, 120 patients) for 12 months. The two coprimary composite outcomes were death or change (from baseline to 12 months) in left ventricular mass, as assessed by cardiac magnetic resonance imaging, and death or change in the physical-health composite score of the RAND 36-item health survey. Secondary outcomes included cognitive performance; self-reported depression; laboratory markers of nutrition, mineral metabolism, and anemia; blood pressure; and rates of hospitalization and of interventions related to vascular access. Patients in the frequent-hemodialysis group averaged 5.2 sessions per week; the weekly standard Kt/V(urea) (the product of the urea clearance and the duration of the dialysis session normalized to the volume of distribution of urea) was significantly higher in the frequent-hemodialysis group than in the conventional-hemodialysis group (3.54±0.56 vs. 2.49±0.27). Frequent hemodialysis was associated with significant benefits with respect to both coprimary composite outcomes (hazard ratio for death or increase in left ventricular mass, 0.61; 95% confidence interval [CI], 0.46 to 0.82; hazard ratio for death or a decrease in the physical-health composite score, 0.70; 95% CI, 0.53 to 0.92). Patients randomly assigned to frequent hemodialysis were more likely to undergo interventions related to vascular access than were patients assigned to conventional hemodialysis (hazard ratio, 1.71; 95% CI, 1.08 to 2.73). Frequent hemodialysis was associated with improved control of hypertension and hyperphosphatemia. There were no significant effects of frequent hemodialysis on cognitive performance, self-reported depression, serum albumin concentration, or use of erythropoiesis-stimulating agents. Frequent hemodialysis, as compared with conventional hemodialysis, was associated with favorable results with respect to the composite outcomes of death or change in left ventricular mass and death or change in a physical-health composite score but prompted more frequent interventions related to vascular access. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; ClinicalTrials.gov number, NCT00264758.).
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Patients' end-stage renal disease (ESRD) characteristics are changing. Improving the quality of care requires a steady adaptation of treatment modalities together with equity of access to dialysis facilities. We explored the ability of the health system to cope with the demand of ESRD care. An analysis of a 5-year follow-up cohort of ESRD patients in the Limousin region, France, was performed. Data were entered in the Multi-Source Information System of the Renal Epidemiology and Information Network (REIN). The participation rate of centres was complete. We analysed patient characteristics, therapeutic options and driving time to reach dialysis facilities. We investigated geographic accessibility by defining areas within 45 minutes from dialysis units. We constructed scenarios to assess the impact of health care reorganization. In-centre haemodialysis units represented 73% of treatment modalities. One quarter of patients lived at more than 45 minutes of their dialysis unit. Based on a scenario of creating an additional In-centre unit, the number of patients living far from their centre would decrease by 31%. This study emphasizes important issues related to ESRD epidemiology, comorbidity and health care planning. It stimulates the development of new scenarios allowing the assessment of equity in accessing health care facilities.
Article
6030 Background: Post-mastectomy radiation therapy (PMRT) has been shown to improve survival in patients at high risk for local or regional recurrence. However, radiation therapy necessitates daily travel to treatment centers for several weeks. We sought to study the effect of distance to the nearest radiation treatment facility on receipt of PMRT in elderly women. Methods: Using the linked Surveillance, Epidemiology, and End Results-Medicare (SEER-Medicare) database, we analyzed 19,787 women with Stage I or II breast cancer who received mastectomy as definitive surgery between 1991 and 1999. Multivariable logistic regression was used to investigate the association of travel distance with receipt of PMRT after adjusting for clinical and sociodemographic factors. Results: Overall, 2,075 (10.5%) patients treated with mastectomy received PMRT. In addition to cancer and patient characteristics, increasing distance from the nearest radiation treatment facility was independently associated with a decreased likelihood of receiving PMRT, (OR = 0.996 per additional mile, p = 0.01). The decline in PMRT use appeared at distances greater than 25 miles and was statistically significant for those patients living greater than 75 miles from the nearest radiation facility (odds of receiving PMRT of 0.58 [95% CI: 0.34–0.99] versus those living within 25 miles of such a facility). In secondary analyses, the effect of distance was only significant in women aged 75–80 years (OR = 0.992 per additional mile, p = 0.03), and those above the age of 80 (OR = 0.989, p = 0.02). When analyses were conducted separately by geographic region, the effect of distance was only significant in the Midwest (OR = 0.992, p = 0.014). The effect of distance was not significant (OR = 1.00, p = 0.87) among women with positive nodes, but was significant in women with no positive nodes (OR = 0.992, p = 0.013). Conclusions: Oncologists must be cognizant of the potential barrier to quality care that is posed by travel distance, especially for elderly patients. Mechanisms to ameliorate the effect of distance on receipt of radiation therapy by assisting individuals with transportation limitations or policies to decrease the centralization of RT services, may help to remove barriers to potentially life-saving treatment. No significant financial relationships to disclose.
Article
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