title: Examining palliative care program use and place of death in rural and urban contexts: a Canadian population-based study using linked data.
abstract: BACKGROUND
  Palliative care has been both more available and more heavily researched in urban than in rural areas. This research studies factors associated with palliative care program (PCP) enrollment and place of death across the urban/rural continuum. Importantly, rather than simply comparing urban and rural areas, this article examines how the effects of demographic, geographic, and socioeconomic factors differ across service delivery settings within the Canadian province of Nova Scotia.
  
  
  METHODS
  This study linked PCP patient enrollment files from three districts to Nova Scotia vital statistics death certificate data. Postal codes of the decedents were mapped to 2006 Canadian dissemination area census data. The study examined 23 860 adult residents of three district health authorities, who died from 2003 to 2009 with a terminal illness, organ failure, or frailty and who were not nursing home residents. Demographic, geographic, and socioeconomic predictors of PCP enrollment and place of death were investigated using logistic regression across the entire study area, and stratified by district of residence. Univariate and multivariate (adjusted) odds ratios (OR) and their 95% confidence intervals (CI) are reported.
  
  
  RESULTS
  Overall, 40.3% of the study subjects were enrolled in a PCP, and 73.4% died in hospital. Odds of PCP enrollment were highest for females (OR: 1.30; 95%CI: 1.22, 1.39), persons aged 50-64 years (OR: 1.50; 95%CI: 1.35, 1.67), and persons with a terminal disease such as cancer. While in overall multivariate analysis residents of census metropolitan areas and agglomerations had higher odds of enrollment (OR: 1.51; 95%CI: 1.29, 1.77), and those at greater distance from a PCP had lower odds (OR: 0.33; 95%CI: 0.27, 0.40), stratified analysis revealed a more nuanced picture. Within each district, travel time to PCP remained a significant predictor of enrollment but the magnitude of its effect differed markedly. There was no consistent relationship with urban/rural residence, social deprivation, or economic deprivation. Enrollment in a PCP was associated with lower adjusted odds of dying in hospital (OR: 0.78; 95%CI: 0.72, 0.84), and those living at greater distance from a PCP had higher odds of hospitalization (OR: 1.52; 95%CI: 1.28, 1.81), but there was no consistent relationship for urban/rural residence or across districts.
  
  
  CONCLUSIONS
  Geographic patterns of PCP enrollment and place of death differed by district, as did the impact of economic and social deprivation. Analysis and reporting of population-based indicators of access should be grounded in an understanding of the characteristics of geographic areas and local context of health services. Although more research is needed, these findings show promise that disparities in access between urban and rural settings are not unavoidable, and positive aspects of rural and remote communities may be leveraged to improve care at end of life.
authors.affiliation: Centre for Health Services and Policy Research, University of British Columbia, Vancouver, Canada. ruth.lavergne@mcgill.ca.
authors.forename: M Ruth
authors.initials: MR
authors.lastname: Lavergne
authors.affiliation: School of Health Administration, Dalhousie University, Nova Scotia, Canada. lynnl@dal.ca.
authors.forename: Lynn
authors.initials: L
authors.lastname: Lethbridge
authors.affiliation: School of Health Administration, Dalhousie University, Nova Scotia, Canada. grace.johnston@dal.ca.
authors.forename: Grace
authors.initials: G
authors.lastname: Johnston
authors.affiliation: Palliative Medicine, Colchester East Hants Palliative Care Service, Nova Scotia, Canada. david.henderson@cehha.nshealth.ca.
authors.forename: David
authors.initials: D
authors.lastname: Henderson
authors.affiliation: Palliative Care Service, Cape Breton District Health Authority, Nova Scotia, Canada. dintinoaf@cbdha.nshealth.ca.
authors.forename: Anne Frances
authors.initials: AF
authors.lastname: D'Intino
authors.affiliation: Division of Palliative Medicine, Capital Health Integrated Palliative Care Service, Halifax, Nova Scotia, Canada. paul.mcIntyre@cdha.nshealth.ca.
authors.forename: Paul
authors.initials: P
authors.lastname: McIntyre
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019352:Censuses; D003644:Death Certificates; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D016247:Information Storage and Retrieval; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009674:Nova Scotia / Q000453:epidemiology; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D010166:Palliative Care / Q000706:statistics & numerical data* / Q000639:trends; D011159:Population Surveillance; D011177:Postal Service; D015397:Program Evaluation; D011610:Psychosocial Deprivation; D011788:Quality of Life; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012424:Rural Population / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D014505:Urban Population / Q000706:statistics & numerical data*
keywords: Health Service reform; North America; Palliative Care