Does Quality of End‐of‐Life Care Differ by Urban‐Rural Location? A Comparison of Processes and Family Evaluations of Care in the VA

PURPOSE: Several studies have identified differences in end-of-life (EOL) care between urban and rural areas, yet little is known about potential differences in care processes or family evaluations of care. The purpose of this study is to examine the relationship between rurality of residence and quality of EOL care within the Veterans Affairs healthcare system. METHODS: This study was a retrospective, cross-sectional analysis of 126,475 veterans who died from October 2009 through September 2016 in inpatient settings across 151 facilities. Using unadjusted and adjusted logistic regression, we compared quality of EOL care between urban and rural veterans using family evaluations of care and four quality of care indicators for receipt of (1) palliative care consult (2) a chaplain visit (3) death in an inpatient hospice unit, and (4) bereavement support. FINDINGS: Veterans from rural areas had lower odds of dying in an inpatient hospice unit compared to veterans from urban areas, before and after adjustment (large rural OR 0.73, 95% CI: 0.70–0.77; P < .001, small rural OR 0.81, 95% CI: 0.77–0.86; P < .001, isolated rural OR 0.87, 95% CI: 0.81–0.93; P < .001). Differences in comparisons of other quality of care indicators were small and of mixed significance. No significant differences were found in family ratings of care in fully adjusted models. CONCLUSION: Receipt of some EOL quality indicators differed with urban-rural residence for some comparisons. However, family ratings of care did not. Our findings call for further investigation into unmeasured individual characteristics and facility processes related to rurality.