Determining the Costs and Benefits of Dialysis Services in Urban, Rural and Remote Settings

: Does Place Matter?

Abstract

Background
The Northern Territory has the highest rates of kidney disease in Australia with Aboriginal people from remote areas suffering the heaviest burden. Despite this, dialysis services are largely centralised in urban areas requiring many people to relocate for treatment. Long term relocation has significant psychosocial and economic ramifications for the individual, but logistical and financial challenges also exist for the provision of services to remote areas. Few dialysis cost studies have examined how a patient’s preference for services closer to home affects treatment adherence, health service utilisation and health outcomes. Even fewer studies have determined the value for money of a service from multiple stakeholder perspectives.

Aims
To determine the costs and benefits of dialysis services in urban, rural and remote locations using a mixed methods approach incorporating multi-stakeholder perspectives and world views.

Methods
Clinical and administrative data (including financial records) for maintenance dialysis patients was analysed by the type and location of dialysis service. The patient perspective was drawn from historical and contemporary interviews. A value for money framework incorporating the quantitative, qualitative and economic data was developed with all stakeholders.

Results
Observed and modelled activity and costs demonstrated a strong association between dialysis attendance, model of dialysis service and downstream health service utilisation. Although the recurrent maintenance dialysis costs of remote services were higher than urban services, relocated people attending urban services had significantly lower dialysis attendance and higher other health service usage. This resulted in substantially higher tertiary service costs, and when combined with the maintenance dialysis costs by model of care, the incremental differences between models were minimal. In a participatory co-design process, policy makers, clinicians and patients agreed on six criteria expressing value for money, spanning the qualitative, quantitative and economic data.

Conclusion
This mixed methods analysis demonstrates the importance of using multiple data sources and incorporating all stakeholder perspectives when considering the value for money of a service model. Given the geographical mismatch between demand and service provision, a narrow focus that fails to take into account these different perspectives may mis-inform policy makers attempting to allocate scarce resources.

Date of Award	30 Sept 2021
Original language	English
Supervisor	Alan Cass (Supervisor) & Joan Cunningham (Supervisor)