Access to health care that is affordable, available and, of course, effective is an ongoing concern. For people living in rural areas — nearly 45% of the world’s total population — these conditions have been found to be worse than for those in urban areas, with fewer care facilities to choose from and longer travel times.

New research from Michigan State University, San José State University and the Nova Scotia Health Authority provides a framework for planners to use when designing rural care facilities to optimize access to care and lower travel times for patients, given the non-uniformity of rural populations. The work was a specific look at dialysis treatment facilities for people living with chronic kidney disease in Nova Scotia, Canada.

“Health care is well studied — not solved,” Vedat Verter, chairperson of the Department of Supply Chain Management at MSU’s Broad College, said. “What is studied most commonly is in urban hospital settings. What we’re trying to do in this paper is look at the rural setting and how that affects the number of options patients have and travel distances.”

The research paper, “Designing a Rural Network of Dialysis Facilities,” was published in the latest issue of the European Journal of Operational Research, a top European journal according to the Chartered Association of Business Schools in the U.K. Michael Klein, assistant professor at San José State University, and Brian Moses, M.D., zone chief of medicine for the Nova Scotia Health Authority’s Western Zone, coauthored the paper alongside Verter.

“The problem is the trade-off between in-home and facility dialysis,” Verter said. “The convenience of the former comes with a training component; it’s not a simple process.” Nonetheless, given the far distances of the rural setting, some patients aren’t opposed to the time and monetary investment of setting up in-home dialysis — especially because patients traveling longer than 60 minutes have a 20% greater risk of death compared to those traveling 15 minutes or less. Furthermore, conventional dialysis treatment requires patients to travel to a facility three times per week, with a four-hour treatment each time.

“The population of patients with end-stage renal disease is growing, and the current facilities in Nova Scotia lack capacity to absorb the number of patients who will need to be initiated on dialysis,” Moses said. “In addition, home dialysis (either hemodialysis or peritoneal dialysis) is a more cost-effective therapy in the long run. As a result of these two issues, there is a big push in Nova Scotia to encourage patients to pursue dialysis options in their own home. While this is a great option for many patients, it is not possible for some. As such, we need to look at other solutions, including expanding the network of facilities to accommodate this growing population. In doing this research, we wanted to be able to inform the decision-making process with real data on how to optimize the entire network.”

The team started by getting the current lay of the land. They tallied up the number of hospitals that are equipped with in-center dialysis facilities, finding that only five out of 39 hospitals had these facilities. In addition, there were nine existing satellite facilities that specialized in offering dialysis treatment.

They also surveyed the local population of dialysis patients to understand their care preferences, finding three subsets: some who always preferred home treatment, some who always wanted to travel to a facility for care, regardless of distance, and some who said the choice depended on the facility location and travel time. The mean travel time was found to be nearly 40 minutes in each direction.

“We know the supply in this case, which is determined by the existing main hospitals and satellite facilities,” Verter explained. “If the supply can’t meet demand, one way is to convince some people to do treatment at home or to look at building [additional] satellite facilities to fill in gaps and meet demand.”

And that’s exactly what the team studied. They used the data to create a mathematical model based on patient preferences, running different scenarios to reduce travel times overall and optimize the situation. As noted in the paper, “The objective is to maximize patient access to dialysis facilities; the longer the travel time, the more we seek to avoid it.”

“We made sure that patients were allocated in the framework based on their preferences,” Verter said. Patients were assigned to the nearest facility, as long as the facility had enough capacity for their care. The team wrote in the paper, “If an existing facility has available capacity, it is cheaper [for the administration] to allocate a patient to a facility since the facility costs have already been incurred.”

“We’re doing this all to split the undecided group of patients in a way that will benefit everyone,” Verter continued. “We’re configuring the network structure to incentivize those patients to behave in a certain way.”

Simply by optimizing the current situation within the current budget, this model could reduce travel times significantly, to a mean of 23 minutes. The authors suggest numerous network scenarios in the paper, detailing how various budget adjustments could increase the number of satellite facilities and motivate the undecided patients to access facility care, improving travel times and capacity across the board.

“Essentially, our research shows how health care administrators can channel their activities to do the best thing in a balanced sense,” Verter said. “We’re trying to make sure they’re sustainable and not operated by purely short-term concerns.”

Verter is optimistic that this research will inform the health care situation in Michigan; he says the geography of Nova Scotia is not too different from the Great Lakes State’s. “My perception is that the health system, at least in the greater Lansing area, is very distributed, much like the case in Canada,” he said. “I hope our work can inform dialysis care network design issues that rural Michiganders face as well.”