title: Quality of end-of-life care among rural Medicare beneficiaries with colorectal cancer.
abstract: BACKGROUND
  Although previous research has documented rural disparities in hospice use, limited data exist on the roles of geographic access in different types of end-of-life indicators among cancer survivors.
  
  
  METHODS
  Medicare claims data were used to identify beneficiaries with colorectal cancer who died in 2008 (N = 34,975). We evaluated rural-urban differences in ER visits 90 days before death, inpatient hospital admissions ≤90 days before death, intensive care unit (ICU) use ≤90 days before death, hospice care use at any time, and hospice enrollment <3 days before death.
  
  
  RESULTS
  About 60% of beneficiaries in rural areas lived in counties with the 2 lowest socioecomonic levels compared to only 5.3% of beneficiaries in metropolitan areas. After adjusting for demographic factors and comorbidities, beneficiaries in rural counties had a lower number of ICU days (RR = 0.65) and were less likely to ever use hospice (OR = 0.78) compared to those in metropolitan counties. Beneficiaries from racial/ethnic minority groups, those with lower socioeconomic status, and those with a higher comorbidity index were less likely to ever use hospice but they tended to use ER, inpatient care, and ICU.
  
  
  CONCLUSIONS
  Evidence for disparities due to geographic access and socioeconomic factors warrant increased efforts to remove systemic and structural barriers. Future research should focus on exploring and evaluating potential policy and practice interventions to improve the quality of life among elderly cancer survivors living in rural communities and those from socioeconomically disadvantaged backgrounds.
authors.affiliation: Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska.
authors.forename: Shinobu
authors.initials: S
authors.lastname: Watanabe-Galloway
authors.forename: Wanqing
authors.initials: W
authors.lastname: Zhang
authors.forename: Kate
authors.initials: K
authors.lastname: Watkins
authors.forename: K M
authors.initials: KM
authors.lastname: Islam
authors.forename: Preethy
authors.initials: P
authors.lastname: Nayar
authors.forename: Eugene
authors.initials: E
authors.lastname: Boilesen
authors.forename: Lina
authors.initials: L
authors.lastname: Lander
authors.forename: Hongmei
authors.initials: H
authors.lastname: Wang
authors.forename: Fang
authors.initials: F
authors.lastname: Qiu
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015179:Colorectal Neoplasms / Q000628:therapy*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D006278:Medicare; D011787:Quality of Health Care; D012424:Rural Population; D013727:Terminal Care / Q000592:standards*; D014481:United States
keywords: Medicare; access to care; geography; quality; utilization of health services