Urban and rural inequities in end-stage kidney disease: a 7-year (2012–2021) random-effects panel study of health care access and catastrophic expenditure

Early Abstract:

Introduction: End-stage kidney disease (ESKD) imposes a significant financial burden due to its long-term treatment and represents a growing health issue worldwide. Health inequalities arising from urban and rural geographic disparities remain pressing global issues. Korea operates a universal and inclusive healthcare system aimed at achieving health equity, with catastrophic health expenditure (CHE) widely recognised as a key indicator for measuring the financial burden associated with diseases. This study aims to assess health equity between urban and rural ESKD subjects by identifying health status, health services accessibility, household finances, financial burden, and CHE factors.
Methods: This study utilised longitudinal data comprising 421 observations of ESKD from 105 subjects in the 7-year dataset of the Korean Health Panel (2012–2018). Nonparametric statistics were used for cross-sectional analyses to determine subject characteristics at baseline, and mixed-effects panel logistic regression and linear regression for longitudinal studies accounting for time-varying effects. Additionally, population-weighted analyses were conducted to address potential sampling bias in panel data.
Results: Among ESKD subjects, 34.3% resided in rural place. Over a 7-year period, the cumulative prevalence of CHE was 24.6% in urban place, 30.6% in rural place, and 26.7% overall. Over the 7-year panel data, no significant differences in health status or household financial indicators were identified between urban and rural place. However, regarding health services accessibility, the adjusted odds ratio (AOR) for inpatient utilisation in rural place compared to urban place was 2.72 (95% CI 1.41–5.24). Conversely, the AOR for outpatient use was 0.14 (95% CI 0.02–0.80). After applying population weighted, the prevalence of CHE (AOR 1.40, 95% CI 1.39–1.42) and the prevalence of impoverishment (AOR 1.56, 95% CI 1.54–1.57) were significantly elevated in rural place compared to urban place. Factors associated with higher CHE prevalence included women (AOR 1.83, 95% CI 1.02–3.16), lowest household income (AOR 6.55, 95% CI 1.67–25.72), inpatient utilisation (AOR 5.36, 95% CI 2.86–10.03), and 65 years of age or older (AOR 1.71, 95% CI 0.88–3.31). In the population weighted analysis, CHE was higher in rural areas than in urban areas (AOR 1.22, 95% CI 1.20–1.23).
Conclusion: Health status and household financial equity between urban and rural ESKD subjects in Korea demonstrate positive outcomes of a universal and inclusive healthcare coverage system. Nonetheless, regarding health services accessibility, rural place exhibited lower outpatient and emergency room visits alongside higher inpatient utilisation, indicating greater challenges in CHE. Tailored adjustments to the healthcare system are needed to address the vulnerabilities of rural place.
Keywords: catastrophic health expenditure, end-stage kidney disease, health services accessibility, health status disparities, poverty, rural health, urban health.