Grace et al. in a review of ANZDATA listed patients starting dialysis between 2000 and 2010 found only 7% of postcodes outside of major Saracatinib cities were in the most advantaged quartile, compared with 54% of postcodes within major cities[9] Gray et al. in a similar review of non-indigenous patients on dialysis on found significant differences in disease burden between major capitals (MC), inner remote (IM), outer remote (OM) and very remote (VR) areas – Figure 2.[10] Patients want to be treated close to where they reside to avoid the cost of travel and dislocation involved in visiting metropolitan based clinics.

The implementation of renal palliative/supportive care services in rural areas requires a different model to metropolitan areas if these patients are to have the same standard of care as those in metropolitan areas. General practitioners and renal physicians tend to refer on the basis of previous personal exposure. Providing specialist renal palliative/supportive

care services will need to involve some on the ground outreach services to gain the trust and respect of the local physicians. Any model will need to enhance contact between palliative care services and local physicians. A ‘move aside while we show you how it is done in the city’ approach is unlikely to be successful. The knowledge base for renal palliative this website care will need to be outsourced to the local physicians, GPs, and palliative care nurses to enhance patient care. Given that it is unlikely that rural units will have specialist renal palliative /supportive expertise on site the DNT committee supports the concept of a hub and spoke model of care to provide equity of service in all rural and remote areas.

This implies that metropolitan palliative care services will have a responsibility to provide outreach services and will need adequate resources. The same model is used to provide transplant services successfully in rural areas and not only allows rural patients to access these services locally but provides up skilling of the local workforce. Developments in information technology such as telemedicine are possible solutions to some of the problems associated with distance and isolation. The current Medicare also rebate for consultations by videoconferencing should promote and compensate set up costs. This can be easily performed with currently available technology including Skype. There is a potential role for web based on going education for rural renal physicians and palliative care physicians in renal supportive care. This could potentially involve cased based scenarios in a chat room environment. A model currently working in the New England Area involves having a local supportive care nurse who is experienced in dialysis assess all patients referred to the service. Referrals can be from nursing colleagues, GPs, allied health workers and renal physicians.