Providing palliative care has become a priority for health system administrators worldwide. In many countries, existing palliative care service delivery is inadequate and challenged by population aging, resulting in strained services that are increasingly unable to keep up with demand [
1‐
4]. There is also growing realization that the development of palliative care services in many jurisdictions has been piecemeal, unplanned, and largely unregulated which has ultimately exacerbated disparities in access to receiving care by geographic location and socio-economic status [
5‐
7]. At the same time, it is recognized that initiating palliative care for a patient with a life-limiting illness can reduce the burden placed on health care systems through freeing up space in acute care settings and halting curative treatments when the prognosis becomes terminal [
8]. Furthermore, it is recognized that patients should have the right to receive care that is appropriate to their needs [
9‐
11] and not be limited to simply what is available. As a result of these factors, health systems in Canada and worldwide are starting to recognize the need for improved palliative care delivery [
6,
10,
12,
13].
The equitable provision of health care services (i.e., care that is offered in a fair and just manner based on need) in an accessible fashion is a primary concern for health planners; however, 'access' can be defined in many different ways. Access to health services can, for example, refer to: availability in terms of socio-economic status or geographic location, the availability of information, wait-list times, and quality of services offered [
4,
14,
15]. Health systems must therefore take into account various aspects of accessibility when planning service delivery. Recognition that health care services are not equally or equitably accessible by all has started to drive policy making in palliative care [
16]. In British Columbia (BC), the most western province in Canada, there is increasing recognition of the need for better spatial access to palliative services for all residents. A recent framework for end-of-life care created by the BC Ministry of Health outlines a commitment to "establishing high quality end-of-life care and support as an integral part of our provincial health system" [
17]. The need for palliative services to be accessible to all residents of the province, and as close as possible to their home location is highlighted. Services located near to palliative care recipients' home communities will not only improve spatial accessibility for the patient, but will also reduce travel-time for workers making home visits and practitioners that deliver care in multiple communities. The present study examines the spatial accessibility of palliative care services for the residents of BC by employing a novel spatial analysis approach using Geographic Information Systems (GIS). The study focuses on specialized palliative care (SPC) services, but the spatial methodology introduced is relevant to a number of health service allocation problems in multiple jurisdictions.
Spatial Accessibility of Palliative Care
The influence of location and distance to health services on health outcomes are well documented [
18‐
21]. Home location has been shown to determine access to and utilization of health services, with utilization being inversely related to spatial access [
14,
20,
22]. Furthermore, it has been argued that a person's home location can also be a determinant of his/her overall level of health [
23]. Thus, people who reside closer to sites of care delivery are more likely to utilize these services and obtain better health outcomes as a result. Spatial proximity to health care services particularly affects the elderly and younger populations, individuals with physical and mental impairments, and those residing in rural and remote areas through reduced mobility associated with these populations [
22,
24‐
26].
Canadian health organizations have expressed the need to research the geographic and demographic factors that influence palliative care delivery and uptake [
27,
28]. GIS-based analyses can provide robust decision support for health service studies by uncovering the geographic and demographic determinants of service utilization. An increasingly popular use of GIS in this realm is to determine the spatial accessibility of services based on distance or travel-time from residence to site of care. Straight-line and road-network based measures of distance from residence to site of care have been used in the past to measure accessibility. However, these methods are inappropriate for modelling access in large regions like BC because of the geographic diversity characterized by mountain ranges, valleys, meandering coastlines, and a mix of urban centres and rural hinterland. Various methods of measuring travel-time have been used in modelling spatial accessibility to health care services [see [
19,
29‐
33]]. Haynes
et al. [
34] validated the use of travel-time to measure spatial accessibility by comparing a GIS-based travel-time model with actual driving time to service locations. Results were highly correlated for modelled and actual travel-time to health care service locations.
In Canada, provincial health systems are obligated to ensure access to health services for all citizens, based primarily on the principles of 'universality' and 'accessibility' which are enshrined in the Canada Health Act [
15]. GIS methods allow for evidence-based planning that can promote universally accessible health care services. In this study we determine the current spatial accessibility of palliative care services in BC using a proven vector GIS catchment method [
32]. This method is appropriate for studying access to health services in geographically diverse regions such as BC because it is based on road network travel-time from home to location of care. This study presents a description of those areas of BC that are within one hour travel-time to SPC services and the proportion of the population that existing services are reaching. Identification of communities that are greater than one hour from services is provided to shed light on possible locations where new palliative services could be implemented to service rural and remote areas in particular.
Specialized Palliative Care
There is no single, universally accepted understanding of what palliative care services or practice entail [
12,
35]. This has contributed to wide disparities in the resources, capacity, and infrastructure devoted to palliative care delivery [
1], and poses questions and challenges for palliative care research. As such, diversity is a hallmark of palliative care, evidenced by the range of treatments, sites of delivery, and populations eligible for care. Traditionally palliative care was directed at relieving pain in patients with cancer in the final stage of illness, though increasingly it is becoming available to those who require care for longer periods at end-of-life as well as those with non-cancerous conditions [
2,
36‐
38]. The type of palliative care delivered varies from pain management and comfort care to therapies and spiritual counselling [
39]. Counselling, bereavement services, and respite care for patients' families have also entered the palliative care service basket. Palliative care can be delivered by specialized practitioners, general practitioners, allied health professionals, and informal caregivers such as volunteers and family members [
25]. The care itself can be delivered in hospice residences, acute care settings, care facilities, and patients' homes [
17].
The vagaries associated with palliative care can act as roadblocks to the effective promotion and delivery of quality end-of-life care [
40]. What is needed, then, is an inclusive definition. Definitions posited by the World Health Organization (WHO) have been refined several times, mirroring the increased attention on end-of-life issues. The current WHO definition [
41] is as follows:
Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
Based on suggestions from the European School of Oncology, Ahmedzai
et al. [
42] refined the WHO definition in a way that could help to improve both service delivery and research into palliative care issues. Palliative care can be usefully sub-divided into basic and specialized categories (p. 2194).
Basic palliative care is the standard of palliative care which should be provided by all healthcare professionals, in primary or secondary care, within their normal duties to patients with life-limiting disease.
Specialised palliative care is a higher standard of palliative care provided at the expert level, by a trained multi-professional team, who must continually update their skills and knowledge, in order to manage persisting and more complex problems and to provide specialised educational and practical resources to other non-specialised members of the primary or secondary care teams. If a patient has difficult symptoms which cannot be controlled by his/her current healthcare team, he/she has a right to be referred, and the current healthcare provider has an obligation to refer, to the local palliative care team. [
42]
This distinction between basic and specialized care is useful to categorize the different types of care and locations of palliative care service delivery. Care that is delivered by general practitioners, some allied health professionals, and informal caregivers in home and acute care settings can be considered basic palliative care. Multi-focal care which is delivered by a multi-disciplinary team with some palliative care specialization in a variety of settings including the home constitutes SPC. Patients receiving SPC often have access to a wider variety of specialist treatments and support, from comfort care to intense pain management, while their families can access a host of services that can include respite care, counselling and bereavement services. These services are provided by specially trained experts, which helps to ensure the best possible quality of death and dying for patient and support for the family during the palliative stage.
Albeit not definitive, studies have found that SPC is more effective at improving patients' quality of life in their final days than basic palliative care [
43‐
45]. Also, a study by Morita
et al. [
46] found that bereaved family members of cancer patients who had received SPC were happier with the services provided compared with those who had not. Furthermore, general practitioners have acknowledged the benefits of SPC and favour referring a dying patient to a specialist at the end-of-life if this service is available [
47,
48]. Ensuring access to SPC for palliative care recipients should be prioritized because it stresses education for all stakeholders and the right to expert care for all as a human right [
1]. Reasons for establishing and/or enhancing SPC are well-grounded and the benefits have been demonstrated; however, it is impossible to have palliative experts in all communities, especially in rural and remote areas. According to the SPC model, specialists should deliver palliative care whenever possible, but in communities where SPC is not feasible, local general practitioners and informal and voluntary-sector caregivers should be trained in specialized methods.
The purpose of this study is to model spatial accessibility to palliative care in British Columbia using the SPC definition. Accessibility is determined through calculating the proportion of the total population that is within a reasonable travel-time to a SPC location. Also, geographically distant communities without SPC services are highlighted as potential candidate locations to provide SPC to surrounding rural and remote areas. The SPC definition was chosen because it provides a standard of comparison for future spatial analyses of palliative care services in other countries and regions. Furthermore, it provides a framework for our future research goals of determining appropriate locations for siting regional hubs of palliative care to serve the rural and remote regions highlighted by this study. These hubs will boast multi-professional teams to deliver SPC and will have the ability to educate local practitioners and caregivers in remote areas to provide good-quality basic palliative care where SPC is not feasible.