Factors that influence the presence of a hospice in a rural community

Abstract

Purpose: The purpose of this study was to identify socioeconomic, physician-related, and rural-urban factors that may influence the presence of a Medicare-certified hospice in three rural-urban areas.

Design: This was secondary analysis of selected socioeconomic, physician-related, and rural-urban data from 3,140 counties using the 2005 Area Resource File, a county-level database. The county was the unit of analysis.

Methods: Descriptive statistics were calculated for selected socioeconomic, physician, and rural-urban variables for the data set of 3,140 counties. Logistic regression was used to identify variables that influenced the presence of a Medicare-certified hospice across three rural-urban areas.

Findings: As the rural-urban classification progressed from metropolitan (least rural) to rural-nonadjacent (most rural), the physician rate, racial-ethnic diversity, and number of counties with at least one Medicare-certified hospice decreased. However, in all three rural-urban areas only the physician rate was consistently significantly associated with the presence of a Medicare-certified hospice.

Conclusions: Given the increasing numbers of patients and families who will be facing end-of-life care issues across the globe, access to hospice care is a significant end-of-life outcome. The most rural communities are least likely to have a Medicare-certified hospice. The higher the physician rate, the more likely a county is to have a Medicare-certified hospice. The Medicare Hospice Benefit's regulations requiring a physician's certification of terminal illness may be creating a barrier to hospice care, especially in rural communities. In this study, racial-ethnic diversity decreased as the rural-urban classification progressed from metropolitan (least rural) to rural-adjacent to metro to rural-nonadjacent (the most rural). The availability of Medicare-certified hospices in the metro and rural nonadjacent counties was influenced by the minority composition of the county. More research is needed on how the interaction of rurality, race-ethnicity, and physician access may affect access to hospice in rural communities.

Clinical relevance: Increasing numbers of patients and their families across the globe will be facing end-of-life care. One of the most common barriers to end-of-life care in rural communities all over the world is physician availability. People living in rural communities with few physicians may experience less access to the comprehensive services of hospice than people living in metropolitan communities and therefore not realize important end-of-life outcomes such as symptom management, improved quality of life, financial support, and bereavement support.

Figure 1

Application of the Health Services Model to the availability of Medicare-certified Hospices.

Figure 2

A comparison of MDs per 10,000 census, mean percentage of poverty, of African Americans, of Hispanics, and counties with at least one Medicare-certified hospice across three rural-urban areas.