Year
2024
Degree Name
Doctor of Philosophy
Department
School of Health and Society
Abstract
Background: Despite significant advancements in cancer care over the last few decades, progress has been uneven, resulting in growing inequities that extend across the whole cancer care continuum including the accessibility and utilisation of healthcare services for individuals living with advanced cancer nearing the End-Of-Life (EOL). Research indicates that the unequal distribution of healthcare resources, often concentrated in densely populated urban areas, contributes to disparities in EOL cancer care provision across the urban-rural continuum. While current research has not established a conclusive relationship between geography and EOL cancer care, there is a pressing need for more extensive research to understand the impact of factors like rurality, travel times to healthcare services as well as the availability of resources, including generalist-led primary and allied health workforce supply, on the patterns of health service utilisation (acute, palliative, and community based care) by people with EOL cancer care needs. Additionally, a deeper exploration of the challenges faced by clinicians in rural areas when delivering EOL care is crucial to inform the best strategies to build sustainable and affordable EOL cancer care in rural and remote regions where access to specialised cancer services is often challenging.
Aim: The overall aim of this study was to investigate the relationship between geography and the provision of EOL cancer care. Precisely, the study explored the effects of individual-level and health system geographic-based barriers on the types and degree of health service usage at EOL using two objective measures: (i) rurality and travel-time estimations; and (ii) area-level generalist-led primary and allied health workforce supply. Further, it examined the current challenges, proposed solutions and recommended policy changes to improve the provision of EOL care for advanced cancer patients living in rural and remote communities from the perspective of generalist and specialist health professionals.
Methods: This study was a mixed-methods study. A systematic review was used to collate and analyse existing literature evidence examining the influence of geographic variation across urban-rural settings on the patterns of EOL healthcare service utilisation among adult cancer patients. A retrospective population-based cohort study was used to examine the impact of geographic remoteness (rurality and travel-time) on EOL care service utilisation among adult advanced cancer patients who died in an Illawarra Shoalhaven Local Health District hospital between 1 January 2015 and 31 December 2019 (n=3546). Similarly, a retrospective population-based cohort study was conducted to assess associations of area-level general practitioner and allied health workforce supply on rates of inpatient and outpatient health service use in the last year of life using multivariate models among all adult advanced cancer patients who died in an Illawarra Shoalhaven Local Health District hospital between 1 January 2015 and 31 December 2019 (n=3539). Finally, a qualitative study involving 22 generalist and specialist clinicians was used to explore key challenges and strategies to improve the provision of EOL cancer care in an underserved rural and regional Australian local health district. Data was collected using face-to-face and online focus groups.
Results: Utilisation patterns of EOL cancer care services showed variations based on geographical remoteness and treatment intent, serving as a significant predictor of acute care service dependency and an underutilisation of palliative care. Among the study cohort, shorter travel times (10-<30mins) to the nearest public hospital were associated with higher rates of inpatient specialist palliative care utilisation. Rural patients demonstrated higher rates of acute care service utilisation in their last year of life, including Emergency Department (ED) visits and Intensive Care Unit (ICU) admissions, higher rates of outpatient cancer services but lower rates of outpatient chemotherapy and radiotherapy service utilisation. Accessibility of primary and allied health workforce exacerbated urban-rural disparities in EOL cancer care, as decedents with increased accessibility to a general practitioner (GPs) were more likely to experiencing at least one ED visit. Key challenges in providing healthcare in rural and regional areas included inadequate funding for clinicians, shortages of resources, limited community awareness of palliative care, and insufficient confidence and training in EOL care. Proposed solutions included increasing Medicare rebates for palliative care and home visits, ensuring sufficient equipment and resources, utilising technology for clinician training, and enhancing rural-based training for specialist palliative care clinicians.
Conclusions: The overall findings indicate that increased geographic remoteness correlates with higher utilisation of acute care services, including Emergency Department (ED) visits and Intensive Care Unit (ICU) admissions in the last year of life for advanced cancer patients residing in rural areas. Specifically, patients living within a 10-<30-minute travel time radius to a tertiary healthcare center are more likely to receive specialist palliative care. Regional disparities in non-hospital-based EOL healthcare resources further emphasise the need for substantial investment in both specialised and multidisciplinary palliative and EOL care services in rural, regional, and remote communities to reduce the healthcare equity gap at EOL. Implementing locally-sensitive initiatives tailored to specific geographic contexts emerges as a promising approach to enhance equity in EOL cancer care in rural settings.
Recommended Citation
Cerni, Jessica, A mixed-methods analysis of the effects of geographic variation and primary and allied healthcare supply on the patterns of End-Of-Life cancer care provision among adult decedents in NSW, Australia, Doctor of Philosophy thesis, School of Health and Society, University of Wollongong, 2024. https://ro.uow.edu.au/theses1/1885
FoR codes (2020)
4202 Epidemiology, 4203 Health services and systems, 420316 Palliative care, 440609 Rural and regional geography
Unless otherwise indicated, the views expressed in this thesis are those of the author and do not necessarily represent the views of the University of Wollongong.