Association of rurality with utilization of palliative care and hospice among Medicare beneficiaries who died from pancreatic cancer: A cohort study

Abstract

Background: Pancreatic cancer has a 5-year survival of just 10%. Services such as palliative care and hospice are thus crucial in this population, yet their geographic accessibility and utilization remains unknown.

Aim: We studied the association between rurality of patient residence and the use of palliative care and hospice.

Design, setting, and participants: Cohort study of continuously enrolled fee-for-service Medicare beneficiaries aged ≥65 diagnosed with incident pancreatic cancer between 04/01/2016-08/31/2018 and who died by 12/31/2018.

Results: In this decedent cohort of 31,460 patients, 77% lived in metropolitan areas, 11% in micropolitan areas, 7% in small towns, and 5% in rural areas. Patient demographics were largely similar across rurality; however, the proportion of White, non-Hispanic patients and social deprivation was highest in rural areas and lowest in metropolitan areas. Overall, 33% of patients used any palliative care and 77% received hospice services. After risk adjustment, there were no statistically significant differences in the use of palliative care for patients residing in metropolitan versus micropolitan, small town, or rural areas. Patients in small town (OR = 0.77, 95% CI: 0.69-0.86) and rural areas (OR = 0.75, 95% CI: 0.66-0.85) had lower adjusted odds of receiving hospice care compared to patients in metropolitan areas.

Conclusions: The use of palliative care services captured in Medicare was low, representing either underutilization or failure to accurately measure the extent of services used. While the overall level of hospice enrollment was high, patients in rural communities had relatively lower use of hospice services compared to those in metropolitan areas.

Keywords: hospice; palliative care; pancreatic cancer; rural disparities.

Figure 1.

Forming the analytic cohort of Medicare beneficiaries who were diagnosed incident pancreatic cancer and died before December 31, 2018. * includes all U.S.-residing fee-for-service Medicare beneficiaries with continuous enrollment in Medicare Parts A and B between October 1, 2015 and December 31, 2018 (or through death) who did not live in a nursing home, n= 26,832,741 beneficiaries.

Figure 2.. Proportion of patients who used (A) palliative care or (B) hospice, by rurality of patient residence.

Blue bars indicate the overall proportion using that service at any time between diagnosis and death. Green bars indicate the proportion using that service within the time period for the respective measure: at least 90 days before death for palliative care and at least 3 days before death for hospice. Note, for timeliness indicators, the denominator patient population was limited those who survived the minimum number of days to qualify for the timeliness measure, e.g., at least 90 days survival from diagnosis for palliative care measure (N=16,174) and 3-days for hospice (N=31,123).