Processes of care prior to dialysis initiation: role of rural clinics

Access to care may affect preparation for kidney replacement therapy (KRT). We evaluated the impact of the rural outreach program dedicated to chronic kidney disease (CKD) care on processes of care before KRT initiation in West Virginia.

Data for this retrospective study were collected from the United States Renal Data System (USRDS). West Virginia residents at KRT initiation and non-West Virginia residents living within 30 miles of the West Virginia border between 2001 and 2020 were included. Patients receiving preemptive transplantation and those living more than 3 hours from the nearest rural clinic were excluded.

Over 19 years, 16 rural outreach clinics were started in north-central West Virginia. Of 15 001 dialysis patients, 3282 (21.9%) resided in counties served by rural CKD clinics. Compared with patients from other counties, those from clinic-served counties were more likely to receive dialysis at a rural unit (68% vs 15%; P < .001), start dialysis with an arteriovenous fistula or graft (21.6% vs 18.4%, P < .001), and initiate dialysis in an outpatient setting (Odds Ratio [OR] 1.27, 95% Confidence Interval [CI] 1.13-1.44, P < .001). Among patients starting with catheters, after adjusting for age, sex, year of KRT, heart failure, and pre-KRT nephrology care, those from clinic-served counties had higher odds of a maturing arteriovenous access (OR 1.20, 95% CI 1.02-1.40,P = .02) and of receiving erythropoiesis-stimulating-agents before KRT start (OR 1.68, 95% CI 1.47-1.90, P < .001).

Regional outreach clinics for CKD had a positive impact on pre-dialysis care processes and may reduce disparities in access to kidney care among rural patients.