Rural patients face gaps in hospice access and care intensity compared to their urban counterparts, according to a new study published in JAMA. The research indicates that older adults living in isolated rural areas are less likely to receive hospice care or higher-intensity services than those in urban settings.
Disparities exist in Medicare hospice use.
The study examined data from 2013 to 2022, analyzing 21 million Medicare decedents. Unadjusted rates of hospice use were highest in urban areas and lowest in isolated rural regions. While the gap between urban and rural hospice use narrowed over the decade, the disparity remains statistically significant. They noted that rural residents are more likely to die in nursing homes and rely on unpaid family caregivers rather than paid support.
The type of care delivered also varies by location. Most hospice care is provided at the routine level, but higher-intensity services are less common in rural areas. Patients in isolated rural regions were less likely to receive general inpatient or continuous home care compared to urban patients. These differences suggest that rural patients may not receive the same level of symptom management and support during their final months, which can impact their quality of life and treatment options.
Staffing and facility differences contribute to disparities.
The researchers found that while rural hospice patients received more frequent nurse visits, they had fewer visits from home health aides. Social worker visits did not differ between the two groups. The location of care also shifted based on geography. Patients in isolated rural areas were more likely to receive care in private homes or nursing homes, while urban patients were more likely to be in assisted living facilities or inpatient hospice settings. The company behind the study suggests that these variations may be due to differences in resource availability.
It is essential to identify the drivers of these disparities.
Despite these variations, the study did not formally analyze patient characteristics that might explain the differences. The authors suggested future research should identify the drivers of these disparities, including financial factors and the consequences of limited access to higher-intensity hospice care. They propose that understanding these factors can help address the disparities and improve care for rural patients.
The researchers utilized a full dataset, including the 2013 to 2022 Master Beneficiary Summary File, to identify eligible decedents and assess hospice use and outcomes across different communities. By linking each decedent’s zip code to a Rural-Urban Commuting Area code, the researchers were able to categorize rurality and examine how hospice care varies across the rural-urban continuum. This approach allowed for a subtle understanding of the differences in hospice care delivery and intensity.
The study’s findings highlight the importance of considering the rural-urban continuum when examining hospice care. The results show that patients in isolated rural areas had a shorter mean length of stay in hospice care compared to those in urban areas, with a mean length of stay of 59 days versus 61.6 days. Additionally, the last location of hospice care differed between isolated rural and urban areas, with patients in isolated rural areas more likely to receive care in private homes or nursing homes.
The differences in staffing and facility utilization also have significant implications for rural patients. The more frequent nurse visits in isolated rural areas may be due to the need for more intensive symptom management, while the fewer aide visits may indicate a lack of resources or support for patients with complex needs. The fact that social worker visits did not differ between groups suggests that social support services may be more evenly distributed across the rural-urban continuum.
Further research is needed to fully understand the drivers of these disparities and to develop targeted interventions to address them. The authors suggest that future studies should examine the financial drivers of differences in care across the rural-urban continuum, as well as the consequences of limited access to higher-intensity care. By exploring these factors, researchers can gain a deeper understanding of the complex issues surrounding rural-urban disparities in hospice care and develop effective strategies to improve care for rural patients.
The study’s limitations, including the lack of formal analysis of patient characteristics, highlight the need for further research in this area. The authors acknowledge that patient characteristics, such as age, diagnosis, and socioeconomic status, may influence differences in hospice use and outcomes. Future studies should strive to include a more full analysis of patient characteristics to better understand the factors contributing to rural-urban disparities in hospice care.
The implications of this study are far-reaching, with significant consequences for healthcare policy and practice. The findings suggest that policymakers and healthcare providers must prioritize addressing the disparities in hospice care across the rural-urban continuum. By developing targeted interventions and allocating resources to support rural patients, healthcare providers can work to ensure that all patients, regardless of location, receive high-quality, patient-centered care.
