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      Associations between access to healthcare, environmental quality, and end-stage renal disease survival time: Proportional-hazards models of over 1,000,000 people over 14 years

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          Abstract

          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.

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          Neighborhoods and health.

          Features of neighborhoods or residential environments may affect health and contribute to social and race/ethnic inequalities in health. The study of neighborhood health effects has grown exponentially over the past 15 years. This chapter summarizes key work in this area with a particular focus on chronic disease outcomes (specifically obesity and related risk factors) and mental health (specifically depression and depressive symptoms). Empirical work is classified into two main eras: studies that use census proxies and studies that directly measure neighborhood attributes using a variety of approaches. Key conceptual and methodological challenges in studying neighborhood health effects are reviewed. Existing gaps in knowledge and promising new directions in the field are highlighted.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: Writing – original draft
                Role: ConceptualizationRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Writing – review & editing
                Role: ConceptualizationRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                21 March 2019
                2019
                : 14
                : 3
                : e0214094
                Affiliations
                [1 ] Toxicology Program, Department of Biological Sciences, North Carolina State University, Raleigh, North Carolina, United States of America
                [2 ] Bioinformatics Research Center, North Carolina State University, Raleigh, North Carolina, United States of America
                [3 ] Center for Human Health and the Environment, North Carolina State University, Raleigh, North Carolina, United States of America
                [4 ] National Health and Environmental Effects Research Lab, U.S. EPA, Chapel Hill, North Carolina, United States of America
                [5 ] Population Wellbeing and Environment Research Lab, School of Health and Society, Faculty of Social Sciences, University of Wollongong, Wollongong, New South Wales, Australia
                [6 ] Menzies Centre for Health Policy, University of Sydney, Sydney, New South Wales, Australia
                [7 ] School of Public Health, Peking Union Medical College and The Chinese Academy of Medical Sciences, Beijing, China
                [8 ] ICF, Fairfax, Virginia, United States of America
                University of Mississippi Medical Center, UNITED STATES
                Author notes

                Competing Interests: The authors declare that they have no conflicts of interest. The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the U.S. government. The views expressed in this manuscript are those of the authors and do not necessarily reflect the views or policies of the US Environmental Protection Agency. Mention of trade names or commercial products does not constitute endorsement or recommendation for use. The commercial affiliation of author JDH does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0002-2609-5816
                http://orcid.org/0000-0001-8456-0969
                Article
                PONE-D-18-31589
                10.1371/journal.pone.0214094
                6428249
                30897121
                4ace51ba-3422-461e-8976-60df2ff8de10

                This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

                History
                : 1 November 2018
                : 6 March 2019
                Page count
                Figures: 2, Tables: 4, Pages: 17
                Funding
                This work was supported by the University Global Partnership Network Research Collaboration Fund, “An International Alliance for Population, Wellbeing and Environment Research” (PI: Astell-Burt), National Institutes of Health [P30 ES025128, T32 ES007046], and the US Environmental Protection Agency [STAR R83502]. Author JDH was employed by a commercial company, ICF, during this study. The funder provided support in the form of salary for author JDH, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific role of this author is articulated in the “author contributions” section.
                Categories
                Research Article
                Medicine and Health Sciences
                Nephrology
                Chronic Kidney Disease
                Medicine and Health Sciences
                Health Care
                Socioeconomic Aspects of Health
                Medicine and Health Sciences
                Public and Occupational Health
                Socioeconomic Aspects of Health
                People and places
                Population groupings
                Ethnicities
                Native American people
                Biology and Life Sciences
                Physiology
                Physiological Parameters
                Body Weight
                Body Mass Index
                Medicine and Health Sciences
                Physiology
                Physiological Parameters
                Body Weight
                Body Mass Index
                Biology and Life Sciences
                Psychology
                Addiction
                Alcoholism
                Social Sciences
                Psychology
                Addiction
                Alcoholism
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Substance-Related Disorders
                Alcoholism
                Medicine and Health Sciences
                Public and Occupational Health
                Substance-Related Disorders
                Alcoholism
                Computer and Information Sciences
                Geoinformatics
                Geographic Information Systems
                Earth Sciences
                Geography
                Geoinformatics
                Geographic Information Systems
                Ecology and Environmental Sciences
                Terrestrial Environments
                Urban Environments
                People and Places
                Population Groupings
                Age Groups
                Custom metadata
                Data cannot be shared publicly because of US Renal Data System data requirements. The data underlying the results presented in this study are available: Patient data is available for researchers who meet the criteria for access from the US Renal Data System ( http://www.usrds.org). Environmental Quality Index data is available from the US EPA ( https://edg.epa.gov/data/Public/ORD/NHEERL/EQI). Hospital location information is available from Medicare ( https://data.medicare.gov/Hospital-Compare/Hospital-General-Information/xubh-q36u).

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                Uncategorized

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