Health Services Accessibility and Clinical Outcomes in Peritoneal Dialysis: Findings from the PDTAP Study

Background: The association between health services accessibility and clinical outcomes has been revealed in patients with chronic kidney disease, but showing inconsistent findings. The study aimed to explore the association of key factors reflecting four dimensions of health services accessibility and clinical outcomes in peritoneal dialysis (PD) patients. Methods: This is an affiliated study from the Peritoneal Dialysis Telemedicine-assisted Platform (PDTAP) dataset. Healthcare resource accessibility was evaluated by factors for four dimensions, such as hospital type and regional economic level for healthcare resource accessibility, education level and residence for socio-environmental accessibility, medical insurance and annual income for affordability, and travel distance and travel time for spatial accessibility. The primary outcome was all-cause mortality. The secondary outcomes included transfer to hemodialysis and first-episode PD-related peritonitis. Results: A total of 7416 PD patients were enrolled between June 2016 and April 2019, with the median of 29.0 (14.3, 45.0) months for follow-up. By multivariable Cox regression analyzes, university-affiliated hospitals (HR 0.881, [0.780-0.996], p < 0.001), low regional economic level (HR 1.189 [1.035, 1.366], p = 0.014), and low annual income (HR 1.210 [1.023, 1.431], p = 0.026) were independently associated with all-cause mortality. The low level of regional economy and annual income played a stronger role in predicting all-cause mortality in university-affiliated hospitals as shown in analyzes for interactive effects. After propensity-score matching, university-affiliated hospitals were still associated with all-cause mortality (HR 0.817, [0.701-0.953], p = 0.010) and transfer to hemodialysis (HR 1.265 [1.065-1.502], p = 0.007) but not associated with first-episode peritonitis. Conclusion: This study indicated real-world evidences for health services accessibility and clinical outcomes among patients on PD through a nation-level prospective cohort. Health policymakers and physicians in China should explore strategies to promote the equity in health services accessibility for the improvement of clinical outcomes in the PD population. Funding: Government Support – Non-U.S.