Urban palliative care

A Comprehensive Insight into Geographic Disparities Affecting Terminal Care

Geographical accessibility to health care services is a widely recognized determinant of where people receive care, particularly towards the end of life. A groundbreaking study published in the International Journal of Health Geographics (DOI: 10.1186/s12942-019-0172-1) illuminates the influence of geographic access on the place of death in England, highlighting stark differences between urban and rural areas.

The research conducted by Emeka Chukwusa and colleagues from the Department of Palliative Care, Policy and Rehabilitation at King’s College London, meticulously combined 430,467 individual-level death data points in England from 2014 with the Office for National Statistics death registry. It employed drive times to the nearest inpatient palliative and end-of-life care (PEoLC) facilities as a pragmatic gauge of accessibility.

Study Overview

Chukwusa et al.’s work draws on the hypothesis that geographic proximity to inpatient PEoLC facilities significantly influences the place of final repose. This intriguing study unfolded over several methodical stages, utilizing a modified Poisson regression to account for various socio-demographic and clinical characteristics of patients. The process yielded two exploratory models:

1. Model 1: Focused on access to hospices, contrasting hospice and home deaths.
2. Model 2: Oriented towards hospital access, comparing hospital with home deaths.

Adjusting for confounding variables, the study distilled its findings into adjusted prevalence ratios (APRs), thereby quantifying the association between accessibility and the place of death.

Findings and Implications

The research discovered a noticeable inverse relationship between the drive time to the nearest hospice and hospice deaths; the longer the drive time, the lesser the likelihood of dying in a hospice. This correlation exhibited a dose-response effect, where a ten-minute increment in driving time was associated with a progressively reduced probability of hospice death. The APRs shed light on an undeniable disparity:

1. In rural areas, the APR ranged from 0.49 to 0.80 for Model 1 and 0.79 to 0.98 for Model 2.
2. Urban dwellers exhibited a narrower APR range of 0.50 to 0.83 for Model 1 and an almost negligible difference with 0.98 to 0.99 for Model 2.

These results signify that rural inhabitants experiencing more extended travel times are substantially less likely to end their lives in a hospice or hospital setting compared to those living in urban locales. This phenomenon indicates a larger rural-urban chasm in PEoLC facility utilization.

Policy Implications and Recommendations

This groundbreaking work by Chukwusa and colleagues requires policymakers to reassess established healthcare frameworks, particularly in rural settings. As geographic access emerges as a formidable factor governing the end-of-life venue, there is a pressing need for tailored policies that mitigate these disparities. While the context of the study is England, the implications transcend national boundaries, making a robust case for the overhaul of end-of-life care policies globally.

The study accentuates the urgency of strategically situating PEoLC facilities, offering transportation services to remote locales, or potentially shifting towards home-based end-of-life care models. Indeed, the evidence posits that spatial inequalities can propagate inequitable health outcomes — a situation no health system should sanction.

References

1. Chukwusa E, et al. Urban and rural differences in geographical accessibility to inpatient palliative and end-of-life (PEoLC) facilities and place of death: a national population-based study in England, UK. Int J Health Geogr. 2019;18(1):8. doi: 10.1186/s12942-019-0172-1.

2. Gao W, et al. A population-based conceptual framework for evaluating the role of healthcare services in place of death. Healthcare (Basel). 2018;6(3):107. doi: 10.3390/healthcare6030107.

3. Higginson IJ, et al. Which patients with advanced respiratory disease die in hospital? A 14-year population-based study of trends and associated factors. BMC Med. 2017;15:19. doi: 10.1186/s12916-016-0776-2.

4. WHO. Strengthening of palliative care as a component of comprehensive care throughout the life course. 2014.

5. Virnig BA, et al. Geographic variation in hospice use prior to death. J Am Geriatr Soc. 2000;48(9):1117–1125. doi: 10.1111/j.1532-5415.2000.tb04789.x.

Keywords

1. Geographic Access to Palliative Care
2. End-of-Life Care Disparities
3. Rural Hospice Accessibility
4. Urban Palliative Care
5. Place of Death Study England

In summary, this examination shines a light on critical but often overlooked nuances of healthcare delivery at the end of life. The dissonance in accessibility across urban and rural demographics demands a conscious intervention targeting equitable healthcare across all geographies. As this study resonates with the global health community, it underscores the crucial juncture healthcare systems are at, to recalibrate and realign services with an equitable compass, ensuring that everyone, irrespective of where they live, has dignified access to end-of-life care.