Access to Palliative Care for Cancer Patients Living in a Northern and Rural Environment in Ontario, Canada: The Effects of Geographic Region and Rurality on End-of-Life Care in a Population-Based Decedent Cancer Cohort

Abstract

Background:Access to palliative care has been associated with improving quality of life and reducing the use of potentially aggressive end-of-life care. However, many challenges and barriers exist in providing palliative care to residents in northern and rural settings in Ontario, Canada.Aim:The purpose of this study was to examine access to palliative care and associations with the use of end-of-life care in a decedent cohort of northern and southern, rural and urban, residents.Design:Using linked administrative databases, residents were classified into geographic and rural categories. Regression methods were used to define use and associations of palliative and end-of-life care and death in acute care hospital.Setting/Participants:A decedent cancer cohort of Ontario residents (2007-2012).Results:Northern rural residents were less likely to receive palliative care (adjusted odds ratio [OR] = 0.90, 95% confidence interval [CI]: 0.83-0.97). Those not receiving palliative care were more likely to receive potentially aggressive end-of-life care and die in an acute care hospital (adjusted OR = 1.20, 95% CI: 1.02-1.41).Conclusions:Palliative care was significantly associated with reduced use of aggressive end-of-life care; however, disparities exist in rural locations, especially those in the north. Higher usage of emergency department (ED) and hospital resources at end of life in rural locations also reflects differing roles of rural community hospitals compared with urban hospitals. Improving access to palliative care in rural and northern locations is an important care issue and may reduce use of potentially aggressive end-of-life care.

End-of-Life Cancer Care Resource Utilisation in Rural Versus Urban Settings: A Systematic Review

“…Another study also found rural residency to increase the rate ratio of the total number of ED visits after controlling for patient characteristics and the effect of continuity of care with a family physician (OR 1.29, 95% CI, 1.21–1.37) [ 10 ]. Similar results were found in four studies where higher rates of ED visits were reported in the last 30 days of life [ 29 , 35 ] among cancer decedents living in rural areas compared to urban areas with rates reducing with narrower time periods to death [ 35 ] such as the last two weeks of life [ 9 , 27 ].…”

“…The most common index used to measure rurality was objective measures of population concentration derived from 2006 Canadian Census of the Populations and the Registered Persons Database (RPD). This was assessed in four studies (17%) [ 9 , 11 , 28 , 29 ].…”

“…Seven studies assessed the utilisation of chemotherapy [ 9 , 11 , 12 , 13 , 29 , 35 , 36 ], 10 studies assessed the number of ED visits [ 9 , 10 , 11 , 12 , 27 , 28 , 29 , 33 , 35 , 36 ], eight assessed hospital admissions [ 11 , 12 , 13 , 15 , 29 , 35 , 36 ] and six studies assessed the number of ICU admissions [ 9 , 11 , 12 , 29 , 35 , 36 ] in relation to rurality ( Table 1 ). Among entire death cohorts who received chemotherapy in the last 14 days of life in a hospital setting, irrespective of rurality, the rates of chemotherapy usage varied from 2–4.5%.…”

“…Among entire death cohorts who received chemotherapy in the last 14 days of life in a hospital setting, irrespective of rurality, the rates of chemotherapy usage varied from 2–4.5%. When assessed as an independent variable and in relation to rurality, four studies found no difference in the odds of receiving chemotherapy in the last 14 days of life according to rural region of residency ( p > 0.05) [ 9 , 13 , 29 , 35 ].…”

End‐of‐life care in rural and regional Australia: Patients’, carers’ and general practitioners’ expectations of the role of general practice, and the degree to which they were met

“…Of concern for collaborating health professionals, consumers and policy makers is how well rural GPs are providing palliative and EOL care, and what can be done to maximise the effectiveness of their care for people at the EOL and their informal carers in Australia (Ding, Saunders, Cook, & Johnson, 2019) and other countries (Chukwusa et al., 2019; Conlon et al., 2019; Isaacson & Lynch, 2017; Leng, Jing, Nicholas, & Wang, 2019; Warraich et al., 2019). Prior to the development of interventions to support GPs and consumers, it is necessary to identify the attributes of EOL care and current gaps in service delivery within rural settings.…”