Variation in renal service provision in the UK

Introduction: There is variation in both the incidence of renal replacement therapy (RRT) and the proportion of patients using home as opposed to hospital based treatments for their renal disease. The determinants of this variation have not been fully elucidated and this work seeks to explain this variation by looking at socio-demographic, health status, access to healthcare and renal centre practice pattern factors. Methods: The determinants of RRT incidence were examined using an ecological approach. Multilevel Poisson regression models using local health' area rate of RRT incidence per year as the outcome variable were constructed. Publically available information about the socio-demographic, health status and healthcare access of each local health area were then included in these models as explanatory variables. A national renal centre survey was purposely designed to determine the practice patterns in use in each renal centre. The contents of this survey were determined by using a two stage modified Delphi consensus generating process with a group of renal stakeholders. The survey results were then added to these models to further explain variation in RRT incidence. The determinants of home dialysis uptake were examined using individual patient level logistic regression models with the percentage of patients using home dialysis in that centre as the outcome variable and individual patient characteristics as the explanatory variables. The survey responses were then added to these models to further explain variation. Results: Population socio-demographic, health status and access to healthcare markers were all associated with RRT incidence. Renal centre capacity, rates of treatment in older persons, use of variable price contracts with private dialysis companies and the number of out-patient appointments provided were all practice patterns associated with RRT incidence. Age, distance lived from a renal unit, socio-economic deprivation score, ethnic group and primary renal disease were all associated with use of home dialysis. There were higher rates of home dialysis in centres with physician enthusiasm for the modality, home visits for education, home visits for troubleshooting problems once on home therapy and centres with a responsive access service.