Variation in dialysis patient mortality by Health Authority

Background: Maintenance dialysis is a relatively low prevalence, highly specialized, and labour-intensive treatment, which is usually delivered at regional centres serving many different health authorities. It is unknown whether a patient's health authority, in many ways an accident of birth, influences long-term dialysis outcomes. Aim: To study survival patterns in patients starting maintenance dialysis therapy in the north-west of England between 1990 and 1999. Design: Retrospective analysis. Methods: We analysed data from quarterly returns submitted to the West Pennine Health Authority from 10 dialysis centres, including health authority, dialysis centre, age, gender, mode of dialysis therapy, postal code and diabetic status. Postal codes were used to compute the distance from residence to dialysis centre and Carstairs index. Results: There were 2458 patients from 18 health authorities. Survival on dialysis therapy differed by health authority (p<0.0001). Health authorities were then grouped into socioeconomic families, using The Office of National Statistics health authority classification system (ONS1). ONS1 profiles at inception of dialysis therapy were also associated with disparities in survival, with subjects from Urban and Rural health authorities having longer survival than those from Mining and Industrial, Mature or Prospering health authorities (P<0.0001). Discussion: Survival on dialysis varies significantly by health authority. The interface between highly specialized, centralized, medical services and the health authorities they serve may be a major outcome determinant.