Toxicology Program, Department of Biological Sciences, North Carolina State University, Raleigh, North Carolina, United States of America.
Bioinformatics Research Center, North Carolina State University, Raleigh, North Carolina, United States of America.
PLoS One. 2019 Mar 21;14(3):e0214094. doi: 10.1371/journal.pone.0214094. eCollection 2019.
Prevalence of end-stage renal disease (ESRD) in the US increased by 74% from 2000 to 2013. To investigate the role of the broader environment on ESRD survival time, we evaluated average distance to the nearest hospital by county (as a surrogate for access to healthcare) and the Environmental Quality Index (EQI), an aggregate measure of ambient environmental quality composed of five domains (air, water, land, built, and sociodemographic), at the county level across the US. Associations between average hospital distance, EQI, and survival time for 1,092,281 people diagnosed with ESRD between 2000 and 2013 (age 18+, without changes in county residence) from the US Renal Data System were evaluated using proportional-hazards models adjusting for gender, race, age at first ESRD service date, BMI, alcohol and tobacco use, and rurality. The models compared the average distance to the nearest hospital (<10, 10-20, >20 miles) and overall EQI percentiles [0-5), [5-20), [20-40), [40-60), [60-80), [80-95), and [95-100], where lower percentiles are interpreted as better EQI. In the full, non-stratified model with both distance and EQI, there was increased survival for patients over 20 miles from a hospital compared to those under 10 miles from a hospital (hazard ratio = 1.14, 95% confidence interval = 1.12-1.15) and no consistent direction of association across EQI strata. In the full model stratified by average hospital distance, under 10 miles from a hospital had increased survival in the worst EQI strata (median survival 3.0 vs. 3.5 years for best vs. worst EQI, respectively), however for people over 20 miles from a hospital, median survival was higher in the best (4.2 years) vs worst (3.4 years) EQI. This association held across different rural/urban categories and age groups. These results demonstrate the importance of considering multiple factors when studying ESRD survival and future efforts should consider additional components of the broader environment.
美国 2000 年至 2013 年期间，终末期肾病（ESRD）的发病率增长了 74%。为了探究更广泛的环境因素对 ESRD 患者存活时间的影响，我们评估了各县的医院平均距离（作为获得医疗保健服务的替代指标）和环境质量指数（EQI），这是一个由五个领域（空气、水、土地、建筑和社会人口统计学）组成的综合环境质量指标。使用比例风险模型，我们评估了美国肾脏数据系统中 2000 年至 2013 年间诊断为 ESRD 的 1092281 人（年龄在 18 岁以上，无县居住变更）的平均医院距离、EQI 与存活时间之间的关联，该模型对性别、种族、首次 ESRD 服务日期年龄、BMI、酒精和烟草使用以及农村/城市情况进行了调整。模型比较了到最近医院的平均距离（<10、10-20、>20 英里）和总体 EQI 百分位数[0-5）、[5-20）、[20-40）、[40-60）、[60-80）、[80-95）和[95-100），其中较低的百分位数表示更好的 EQI。在包含距离和 EQI 的完整非分层模型中，与距离 10 英里以内的患者相比，距离 20 英里以上的患者的存活率更高（风险比=1.14，95%置信区间=1.12-1.15），且 EQI 分层之间没有一致的关联方向。在按平均医院距离分层的完整模型中，距离医院 10 英里以内的患者在 EQI 最差的分层中存活时间增加（中位数存活时间分别为 3.0 年和 3.5 年），然而，对于距离医院 20 英里以上的患者，最佳（4.2 年）与最差（3.4 年）EQI 的中位数存活时间更高。该关联在不同的农村/城市类别和年龄组中均成立。这些结果表明，在研究 ESRD 患者的存活时间时，考虑多个因素非常重要，未来的研究应考虑更广泛的环境的其他组成部分。
