Using geographical information systems to plan dialysis facility provision

Sir,

We read Toubiana et al.s' article on geographical information systems (GIS) with interest [1]. They suggest that GIS may be used to plan healthcare delivery, and we can confirm that. In Scotland, the government provides funding for universal healthcare to 15 National Health Service (NHS) Boards, with the level of funding based on population, deprivation and rurality. These Boards are responsible both for the strategic planning and the delivery of all healthcare. The Scottish government has set a target that all patients should be able to access a haemodialysis unit within 30 minutes of their home, ‘within the constraints of population density and geography’ [2]. Previous research has confirmed that travelling times in excess of 37 minutes impact on take-on rates and thus presumably patient survival [3]. Furthermore, a Scottish Renal Association patient survey identified travelling time as the single greatest concern for patients (B.J.R. Junor, personal communication). Scotland has one of the most challenging geographical situations in Europe for the provision of dialysis, with a low population density of 65 people/km2 (ranging from 8 to 1560 people/km2 in the fifteen NHS Boards), and 99 638 people (2% of the population) living on 55 islands [4], with frequently difficult weather conditions.

NHS Dumfries and Galloway is one of the more rural NHS Boards with a population of 147 210 and a population density of 23 people/km2 [4]. Currently, there is only one dialysis unit, in the main town of Dumfries. As a result the Board fails the government target badly, with 45% of renal replacement therapy (RRT) patients living >30 minutes from a dialysis facility (compared to a Scottish average of 10%). A previous study showed that 19% of Dumfries patients travelled in excess of 100 miles per dialysis day (15 000 miles per year) solely for the purpose of dialysis, compared to 2% elsewhere in Scotland (P<0.001) [5]. The Board plan to open a satellite dialysis unit to solve this problem. We used ArcGIS 8.3 and ProTerritory 1.0.591 with Bartholomew's 100 m road grid, to analyse the travelling time to the current and proposed dialysis facilities, for all RRT patients resident in the health board. We included all patients started on RRT between 1982 and 2002; all RRT patients potentially require hospital-based dialysis at some point in their life; a 21 year period was used to average out the likely requirements in low population areas. The software identifies the position of the dialysis facility and each individual patient using their postcodes (routinely collected by the Scottish Renal Registry), and calculates the estimated travelling time between the two points using an electronic map of the road network and estimated average speeds on each type of road. Postcode units in Scotland contain an average of 13 (range 1–100) delivery addresses. Using this software we generated maps of the current dialysis provision, and the relative impact of opening a satellite dialysis unit at two proposed sites (Table 1 and Figure 1). The impact on the neighbouring NHS board was also taken into account. Further details of our approach are available on the Scottish Renal Registry website (http://www.show.scot.nhs.uk/srr/Publications/DGNHSB_Time_Travel_Report.pdf). As a result of this work, the NHS Board agreed to situate the new satellite unit in the far west of the region, in Stranraer (labelled Garrick Hospital in Figure 1 and Table 1).


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Table 1. Patient travelling time to the closest dialysis facility: impact of two proposed sites for a new satellite dialysis unit

 


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Fig. 1. Patient travelling time to the dialysis unit. Shaded areas represent 30 min isochrones around existing and proposed dialysis units. Bars represent the number of patients exceeding 30 minutes travelling time in each postcode sector (postcode unit data are amalgamated into sectors in the map to protect patient anonymity). (A) Impact of opening unit at Newton Stewart Hospital. (B) Impact of opening unit at Garrick Hospital.

 
We believe this approach allows evidence-based planning of the provision of healthcare facilities, and is also useful in identifying gaps in provision. It is likely that such an approach would still be of value in countries with other funding and organizational structures, as long as complete data on the location of dialysis patients and facilities were freely available. We are currently applying the same approach on a whole-country basis, and our preliminary data are available on the same website (http://www.show.scot.nhs.uk/srr/Publications/Travelling_Time__Preliminary_Report.pdf). Areas of under-provision are clearly identified, according to government targets. Our experience suggests that this approach should be used routinely in healthcare planning.

Conflict of interest statement. None declared.

Mark S. MacGregor1, Jillian Campbell2, Marion Bain2, Chris G. Isles, Keith Simpson4 on behalf of the Scottish Renal Registry

1 The John Stevenson Lynch Renal Unit Crosshouse Hospital Kilmarnock KA2 0BE UK2 Information Services NHS National Services Scotland Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB UK3 Renal Unit Dumfries and Galloway Royal Infirmary Dumfries DG1 4AP UK4 Scottish Renal Registry Walton Building Glasgow Royal Infirmary Glasgow G4 0SF Email: Mark.MacGregor{at}aaaht.scot.nhs.uk

References

  1. Toubiana L, Richard J-B, Landais P. Geographical information system for end-stage renal disease: SIGNe, an aid to public health decision making. Nephrol Dial Transplant 2005; 20: 273–277[Free Full Text]
  2. Clinical Standards Board for Scotland. Clinical Standards: Adult Renal Services. NHS Scotland, Edinburgh: 2002 (available online at: http://www.nhshealthquality.org/nhsqis/files/Adult%20Renal%20Services.pdf)
  3. Roderick P, Clements S, Stone N, Martin D, Diamond I. What determines geographical variation in rates of acceptance onto renal replacement therapy in England? J Health Serv Res Policy 1999; 4: 139–146[Medline]
  4. General Register Office for Scotland. Land area and population density, by administrative area; 30 June 2003. http://www.gro-scotland.gov.uk/files/03mid-year-estimates-table6.xls. Accessed February 2005
  5. Brammah A, Young G, Allan A, Robertson S, Norrie J, Isles C. Haemodialysis in a rural area: a demanding form of treatment. Health Bulletin 2001; 59: 294–299[Medline]




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