Rural/Urban differences in health care utilization and place of death for persons with respiratory illness in the last year of life

College of Nursing, University of Saskatchewan, Saskatoon, SK, Canada.
Rural and remote health (Impact Factor: 0.88). 04/2010; 10(2):1349.
Source: PubMed


Respiratory illness is a leading cause of death worldwide, with rates that will continue to escalate into the foreseeable future. Rural residents have an increased risk of dying from some forms of respiratory disease, although little is known about the healthcare utilization or location of death for persons with advanced respiratory illness in rural settings. The purpose of this study was to examine rural-urban differences in healthcare utilization and location of death for residents of Saskatchewan, Canada, with chronic obstructive pulmonary disease (COPD) or lung cancer in the last 12 months of life.
A retrospective cohort study was undertaken of 1098 patients who died in 2004 with a cause of death recorded as COPD or lung cancer in administrative health data from Saskatchewan Health. Decedents were classified as residents of rural/remote (< or =9,999 population size), small urban (10 000-99 999) or urban (> or =100 000) locations and analysis conducted using this primary variable of interest. Comparisons were made between the three groups in terms of demographic characteristics, healthcare utilization (physician visits, length of stay, hospitalizations, institutional care, home care, transitions between care settings) and location of death (hospital, long-term care [LTC] or home).
The study population was 57% male with a mean age of 77 years (SD=11). Demographic characteristics, underlying cause of death and number of comorbid conditions were similar between urban, small urban and rural/remote groups. After adjustment for area of residence, underlying cause of death (UCOD), age group, sex, marital status, and comorbidity, urban, small urban and rural/remote residents were comparable in terms of the likelihood of: any hospitalizations, having had 5 or more transfers between settings, and dying in hospital. The proportion of home deaths in rural settings was 15.4%, and was comparable to the rate in urban settings (16.3%). Urban residents were more likely to have had 24 or more physician visits in the last year of life compared with small urban (OR=0.52, 95% CI=.37-.74) or rural/remote residents (OR=0.52, 95% CI=.40-.69), while rural/remote residents were more likely to have received any institutional LTC (OR=1.40, 95% CI=1.03-1.90) than the other groups. Hospital as a location of death was more likely for those with a UCOD of cardiovascular disease (OR=1.84, 95% CI=1.24-2.71), but was less likely for those aged 80-85 years (OR=0.46, 95% CI=.31-.69), those aged more than 85 years (OR=0.28, 95% CI=.19-.42) and those who had never married (OR=0.48, 95% CI=.29-.78). Residents of rural/remote areas were significantly less likely than those in urban or small urban settings to receive any home care (OR=0.74, 95% CI=.56-.97), any home palliative care (OR=0.29, 95% CI=.19-.45) or home physiotherapy services (OR=0.09, 95% CI=.03-.25). Rural/remote residents were, however, much more likely to receive home supportive care (OR=1.60, 95% CI=1.17-2.19) and home meal preparation (OR=2.51, 95% CI=1.44-4.39).
While the healthcare needs of persons with respiratory illness in the last year of life were likely to be similar between locations, rural-urban differences were apparent in the number of primary care physician visits and in access to and the nature of home care services provided. Significantly fewer physician visits were made by residents of small urban or rural remote locations compared with those in urban settings, although additional research is needed to determine the reasons for this discrepancy. The likelihood of receiving home care services and professional home care services such as palliative care and physiotherapy was significantly lower for persons in rural/remote locations. The challenges experienced by rural remote regions with supporting patients in the community may have led to the increased likelihood of admission to institutional LTC noted for this group compared with residents of urban and small urban settings. The low home death rates is both urban and rural settings may pose particular hardship for rural families who may need to travel extensively or temporarily relocate to be closer to the hospital where their loved one is dying. Further investigation of issues related to differences in quality of care and unmet health care needs between rural and non-rural settings will strengthen the evidence base to allow equitable care at the end of life.

Full-text preview

Available from:
  • Source
    • "Owing to geographic and socioeconomic factors, rural residents have usually less satisfactory access to various kinds of health care services than urban counterparts. In the past, many investigations into urban-rural disparity had been devoted to aspects of hospitalizations [1, 2], surgical procedures [3], dental care [4], specialist care [5], emergency services [6, 7], preventive services [8, 9], nursing home care [10, 11], terminal care [12–15], complementary and alternative medicine use [16], and treatment outcomes [17]. The majority of these studies were related to undersupply of not easily transportable facilities and specialists in rural areas. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The aim of the current study was to investigate the urban-rural disparity of prescribing generics, which were usually cheaper than branded drugs, within the universal health insurance system in Taiwan. Data sources were the cohort datasets of National Health Insurance Research Database with claims data in 2010. The generic prescribing ratios of dihydropyridine (DHP) derivatives (the proportion of DHP prescribed as generics to all prescribed DHP) of medical facilities were examined against the urbanization levels of the clinic location. Among the total 21,606,914 defined daily doses of DHP, 35.7% belonged to generics. The aggregate generic prescribing ratio rose from 6.7% at academic medical centers to 15.3% at regional hospitals, 29.4% at community hospital, and 66.1% at physician clinics. Among physician clinics, the generic prescribing ratio in urban areas was 63.9 ± 41.0% (mean ± standard deviation), lower than that in suburban (69.6 ± 38.7%) and in rural (74.1% ± 35.3%). After adjusting the related factors in the linear regression model, generic prescribing ratios of suburban and rural clinics were significantly higher than those of urban clinics ( β = 0.043 and 0.077; P = 0.024 and 0.008, resp.). The generic prescribing ratio of the most popular antihypertensive agents at a clinic was reversely associated with the urbanization level.
    Full-text · Article · Feb 2014 · The Scientific World Journal
  • Source
    • "Social isolation and living in remote areas is common in COPD patients, with up to 28% of Veterans with COPD residing in rural and isolated areas [29]. Living in rural or isolated areas is associated with a lower probability of receiving home health services and less frequent visits to physicians [30]. Finally, a systematic review identified lack of support and program-specific barriers as factors limiting participation in rehabilitation, while belief in personal benefits and setting goals are enablers for participation [31]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Low levels of physical activity are common in patients with chronic obstructive pulmonary disease (COPD), and a sedentary lifestyle is associated with poor outcomes including increased mortality, frequent hospitalizations, and poor health-related quality of life. Internet-mediated physical activity interventions may increase physical activity and improve health outcomes in persons with COPD. This manuscript describes the design and rationale of a randomized controlled trial that tests the effectiveness of Taking Healthy Steps, an Internet-mediated walking program for Veterans with COPD. Taking Healthy Steps includes an uploading pedometer, a website, and an online community. Eligible and consented patients wear a pedometer to obtain one week of baseline data and then are randomized on a 2:1 ratio to Taking Healthy Steps or to a wait list control. The intervention arm receives iterative step-count feedback; individualized step-count goals, motivational and informational messages, and access to an online community. Wait list controls are notified that they are enrolled, but that their intervention will start in one year; however, they keep the pedometer and have access to a static webpage. Participants include 239 Veterans (mean age 66.7 years, 93.7% male) with 155 randomized to Taking Healthy Steps and 84 to the wait list control arm; rural-living (45.2%); ever-smokers (93.3%); and current smokers (25.1%). Baseline mean St. George's Respiratory Questionnaire Total Score was 46.0; 30.5% reported severe dyspnea; and the average number of comorbid conditions was 4.9. Mean baseline daily step counts was 3497 (+/- 2220).Veterans with COPD can be recruited to participate in an online walking program. We successfully recruited a cohort of older Veterans with a significant level of disability including Veterans who live in rural areas using a remote national recruitment strategy.Trial registration: Clinical NCT01102777.
    Full-text · Article · Feb 2014 · BMC Pulmonary Medicine
  • Source
    • "Besides examining the location of death and health expenditures, regional variations as well as health care settings at the end of life have also been used to reflect inappropriate care settings as individuals are approaching death. Studies of health care utilization in end-of-life care differ between regional areas and have yielded interesting results [30-34] such as differing utilization pattern depending on available health service resources in rural versus urban areas. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background There is a growing interest in examining the current state of care and identifying opportunities for improving care and reducing costs at the end of life. The aim of this study is to examine patterns of health care use at the end of life and place of death and to describe the basic characteristics of the decedents in the last six months of their life. Methods The empirical analysis is based on data from 58,732 Swiss residents who died between 2007 and 2011. All decedents had mandatory health insurance with Helsana Group, the largest health insurer in Switzerland. Descriptive statistical techniques were used to provide a general profile of the study population and determinants of the outcome for place of death were analyzed with an econometric approach. Results There were substantial and significant differences in health care utilization in the last six months of life between places of death. The mean numbers of consultations with a general practitioner or a specialist physician as well as the number of different medications and the number of hospital days was consistently highest for the decedents who died in a hospital. We found death occurred in Switzerland most frequently in hospitals (38.4% of all cases) followed by nursing homes (35.1%) and dying at home (26.6%). The econometric analysis indicated that the place of death is significantly associated with age, sex, region and multiple chronic conditions. Conclusions The importance of nursing homes and patients’ own homes as place of death will continue to grow in the future. Knowing the determinants of place of death and patterns of health care utilization of decedents can help decision makers on the allocation of these needed health care services in Switzerland.
    Full-text · Article · Mar 2013 · BMC Health Services Research
Show more