When we talk about rural health disparities, we often focus on getting people into the health care system: finding a doctor, reaching a hospital, getting cancer treatment or managing a chronic disease. But a recent study published in JAMA reminds journalists to consider disparities in end-of-life care, too.
The study examined more than 21 million Medicare decedents from 2013 through 2022 and found a stepwise decline in hospice use as communities became more rural. Hospice was used by 52.4% of people who died in urban areas, compared with 49.2% in large rural towns, 46.9% in small rural towns and 44.8% in isolated rural areas.
The differences persisted once people entered hospice. People in isolated rural areas had shorter hospice stays than their urban counterparts, averaging 59 days compared with 61.6 days. They were also substantially less likely to receive higher-intensity hospice services, including general inpatient hospice care and continuous home care.
This suggests that where a person lives may shape not just whether they receive hospice care, but what that care looks like.
Report beyond ‘rural vs. urban’
It is worth resisting an easy rural-versus-urban narrative here. The study does not establish why these differences exist. The researchers point to questions about the availability and financing of services, and whether nursing homes may be filling gaps in access to more intensive hospice care. The analysis also did not fully account for differences in patient characteristics beyond age and sex.
Here are some questions to consider in your reporting:
- How many hospice providers serve your rural counties?
- How far do patients and families have to travel?
- Which providers offer inpatient hospice, continuous home care or other higher-intensity services? Are there staffing shortages?
- What happens when a patient needs care that a local hospice cannot provide?
Then talk with the people living inside those numbers. Hospice nurses, social workers, physicians, nursing-home administrators and caregivers can describe what the gaps look like in practice. Ask families what they expected hospice to provide and what actually happened.
Another reminder: rurality is not binary. The researchers found a progression from urban communities to large rural towns, small rural towns and isolated rural areas. That suggests that a county labeled simply “rural” may conceal important differences in access.
End-of-life care is about where someone spends their final weeks, who is available to help, how much family caregiving is required and whether symptoms can be managed close to home. Consider opportunities to report on what equitable care looks like when the goal is no longer to cure, but to make someone’s remaining time as comfortable and supported as possible.
