Regional variations in geographic access to inpatient hospices and Place of death: A Population-based study in England, UK.

BACKGROUND: There is much variation in hospice use with respect to geographic factors such as area-based deprivation, location of patient's residence and proximity to services location. However, little is known about how the association between geographic access to inpatient hospice and hospice deaths varies by patients' region of settlement. STUDY AIM: To examine regional differences in the association between geographic access to inpatient hospice and hospice deaths. METHODS: A regional population-based observational study in England, UK. Records of patients aged ≥ 25 years (n = 123088) who died from non-accidental causes in 2014, were extracted from the Office for National Statistics (ONS) death registry. Our cohort comprised of patients who died at home and in inpatient hospice. Decedents were allocated to each of the nine government office regions of England (London, East Midlands, West Midlands, East, Yorkshire and The Humber, South West, South East, North West and North East) through record linkage with their postcode of usual residence. We defined geographic access as a measure of drive times from patients' residential location to the nearest inpatient hospice. A modified Poisson regression estimated the association between geographic access to hospice, comparing hospice deaths (1) versus home deaths (0). We developed nine regional specific models and adjusted for regional differences in patient's clinical & socio-demographic characteristics. The strength of the association was estimated with adjusted Proportional Ratios (aPRs). FINDINGS: The percentage of deaths varied across regions (home: 86.7% in the North East to 73.0% in the South East; hospice: 13.3% in the North East to 27.0% in the South East). We found wide differences in geographic access to inpatient hospices across regions. Median drive times to hospice varied from 4.6 minutes in London to 25.9 minutes in the North East. We found a dose-response association in the East: (aPRs: 0.22-0.78); East Midlands: (aPRs: 0.33-0.63); North East (aPRs: 0.19-0.87); North West (aPRs: 0.69-0.88); South West (aPRs: 0.56-0.89) and West Midlands (aPRs: 0.28-0.92) indicating that decedents who lived further away from hospices locations (≥ 10 minutes) were less likely to die in a hospice. CONCLUSION: The clear dose-response associations in six regions underscore the importance of regional specific initiatives to improve and optimise access to hospices. Commissioners and policymakers need to do more to ensure that home death is not due to limited geographic access to inpatient hospice care.

Urban and rural differences in geographical accessibility to inpatient palliative and end-of-life (PEoLC) facilities and place of death: a national population-based study in England, UK.

BACKGROUND: Little is known about the role of geographic access to inpatient palliative and end of life care (PEoLC) facilities in place of death and how geographic access varies by settlement (urban and rural). This study aims to fill this evidence gap. METHODS: Individual-level death data in 2014 (N = 430,467, aged 25 +) were extracted from the Office for National Statistics (ONS) death registry and linked to the ONS postcode directory file to derive settlement of the deceased. Drive times from patients' place of residence to nearest inpatient PEoLC facilities were used as a proxy estimate of geographic access. A modified Poisson regression was used to examine the association between geographic access to PEoLC facilities and place of death, adjusting for patients' socio-demographic and clinical characteristics. Two models were developed to evaluate the association between geographic access to inpatient PEoLC facilities and place of death. Model 1 compared access to hospice, for hospice deaths versus home deaths, and Model 2 compared access to hospitals, for hospital deaths versus home deaths. The magnitude of association was measured using adjusted prevalence ratios (APRs). RESULTS: We found an inverse association between drive time to hospice and hospice deaths (Model 1), with a dose-response relationship. Patients who lived more than 10 min away from inpatient PEoLC facilities in rural areas (Model 1: APR range 0.49-0.80; Model 2: APR range 0.79-0.98) and urban areas (Model 1: APR range 0.50-0.83; Model 2: APR range 0.98-0.99) were less likely to die there, compared to those who lived closer (i.e. ≤ 10 min drive time). The effects were larger in rural areas compared to urban areas. CONCLUSION: Geographic access to inpatient PEoLC facilities is associated with where people die, with a stronger association seen for patients who lived in rural areas. The findings highlight the need for the formulation of end of life care policies/strategies that consider differences in settlements types. Findings should feed into local end of life policies and strategies of both developed and developing countries to improve equity in health care delivery for those approaching the end of life.

An assessment of Spain's Programa AGUA and its implications for sustainable water management in the province of Almería, southeast Spain.

Spain's Programa AGUA was proposed in 2004 as a replacement for the Spanish National Hydrological Plan and represented a fundamental policy shift in national water management from large inter-basin water transfers to a commitment to desalination. Twenty-one desalination facilities are planned for six provinces on the Spanish Mediterranean coast to supplement their water needs. These include the province of Almería that for the last 30 years has endured a net water abstraction overdraft leading to serious reservoir depletion and groundwater imbalances. Rising water use is a result of increasing demand to support irrigated agriculture (e.g. greenhouse horticulture) and for domestic needs (e.g. rapid urban growth and tourism development), which has led observers to question Almería's long-term water sustainability. Desalinated water alone is unlikely to be sufficient to make up these water deficits and water-users will have to accept a move to full-price water recovery by 2010 under the European Union (EU) Water Framework Directive of which Spain is a signatory. Anticipated water efficiencies resulting from higher water tariffs, increasing water reuse and water infrastructure improvements (including inter-basin transfers), in conjunction with increasing use of desalinated water, are expected to address the province's current water overdraft. However, Almería will need to balance its planned initiatives against long-term estimates of projected agricultural and domestic development and the environmental consequences of adopting a desalination-supported water future.