Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)

Graduate Group


First Advisor

Mary Ersek


Rurality, access, and distance are important and intertwined concepts in end-of-life (EOL) care. Prior research has shown that rural residents are less likely than urban residents to use hospice, yet little is known about family-reported outcomes and other care processes associated with quality EOL care. Rural EOL care providers and caregivers describe distance to care as a challenge, but its relationship to quality has yet to be measured. The Veterans Health Administration (VA) is an ideal setting to address these gaps due to its clinically and geographically diverse patient population, and its capability to uniformly evaluate care.

We reviewed studies that compared urban and rural EOL care in the U.S. and found research gaps in population and health care delivery characteristics, and consumer satisfaction. Then, we conducted retrospective, cross-sectional analyses of Veterans who died from October 2009 through September 2016 in inpatient settings across 151 VA facilities. Using unadjusted and adjusted logistic regression, we examined evaluations of care from the Bereaved Family Survey and quality indicators for receipt of (1) a palliative care consultation (2) chaplain visit (3) death in an inpatient hospice unit, and (4) bereavement support. Comparing quality by urban-rural residence showed that rural Veterans had lower odds of dying in an inpatient hospice unit compared to urban Veterans. Differences in other quality indicators were small and of mixed significance. Finally, we compared quality between categories of Veterans based on driving time from residence to facility of death: 0-5 minutes, 5-60 minutes (reference category), and 60-360 minutes. Distance was significantly associated with all quality indicators. The strongest associations were for death in an inpatient hospice unit (0-5 minutes OR 0.77, 95% CI: 0.73-0.80; P < .001, 60-360 minutes OR 0.76, 95% CI: 0.73-0.79; P < .001), and receipt of a palliative care consultation (60-360 minutes OR 0.78, 95% CI 0.75-0.81; P < .001). In both urban-rural and distance-based analyses, family members of Veterans across all categories were equally likely to rate overall care as excellent. Our findings call for further investigation into unmeasured individual characteristics and facility processes related to rurality, in addition to other measures of access.


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