Greater Distance From the Family Physician Was Linked to Fragmented End-of-Life Care
In Ontario’s last-year-of-life outpatient system, geography was not a neutral backdrop. It moved with the patient’s care experience: the farther people lived from their family physician, the less continuous their care tended to be.
A population-level retrospective cohort study of 400,499 adults who died between 2021 and 2024 found a consistent association between increasing travel distance and lower relational continuity with the usual family physician. The effect was modest in size but steady across analytic approaches, including sensitivity analyses using travel time and straight-line distance. In a setting where family physicians provide much of the outpatient care near the end of life, even small erosions in continuity can matter clinically, because repeated handoffs and dispersed visits make symptom management, medication review, and goals-of-care conversations harder to sustain across time.
The cohort had a mean age at death of 76.0 years, and 52.2% were male. Mean distance from home to family physician practice was 25.5 km, but the distribution was highly skewed, with the highest quartile living more than 14.2 km away. That separation translated into measurable differences in outpatient care patterns during the final year of life.
What the Continuity Measures Captured Across the Final Year
The study did not reduce continuity to a single metric. It examined three established indices designed to capture different parts of the outpatient relationship. The Usual Provider of Care index measured how concentrated a patient’s visits were with the rostered family physician. The Relative Variance index reflected how evenly spaced those visits were over time. The modified Bice-Boxerman index measured how dispersed care was across physicians overall.
Together, these measures describe whether care feels connected or scattered. For patients approaching death, that distinction carries obvious clinical weight. A physician who sees the same patient repeatedly is more likely to notice a new decline, reconcile changes in medications, and adapt care plans to shifting function and preferences. When visits spread across multiple physicians or occur at irregular intervals, the system has less memory of the patient’s trajectory.
A one-quartile increase in geographic distance was associated with lower odds of higher continuity with the usual family physician, with a cumulative odds ratio of 0.88 and a 95% confidence interval of 0.87 to 0.88. The signal remained intact when distance was recalculated using travel time and Euclidean distance. Across methods, the same pattern held: as physical proximity decreased, relational continuity weakened.
Why Geographic Distance Can Shape End-of-Life Primary Care
Distance affects more than the time it takes to reach a clinic. In primary care, it influences whether an older patient can reliably attend visits, whether family caregivers can coordinate transport, and whether a physician’s office becomes the natural default for new symptoms. Near the end of life, when fatigue, frailty, and functional decline make every trip harder, a few extra kilometers can become a practical barrier to maintaining a familiar outpatient relationship.
That barrier may be especially important in family medicine, where care is often longitudinal and cumulative. Continuity depends on repeated contact, and repeated contact is easier to preserve when the patient and physician are physically close. Geography can also interact with virtual care, home visits, caregiver capacity, and local availability of other clinicians. In urban settings, patients may live near many providers yet still receive fragmented care; in rural settings, fewer providers may paradoxically create a more concentrated pattern of care. The Ontario data suggest that, at least in the last year of life, distance itself remains an independent pressure on continuity, separate from broad rural-urban labels.
The study also sits inside a broader “distance decay” pattern seen in health services research. Patients commonly use nearby services more often than distant ones. Here, that tendency reached the period when outpatient coordination is most vulnerable and most consequential.
Ontario Data Point to a System-Level Access Problem
The cohort design relied on linked administrative data from ICES and used outpatient billings from home, office, and phone encounters during the last year of life. Patients were excluded if they lived in long-term care, lacked an identifiable family physician, or could not be assigned a reliable geographic measure of proximity. Those exclusions sharpened the question: among community-dwelling adults with known primary care attachment, does distance to the family physician alter continuity near death?
The answer was yes. Not dramatically, but consistently enough to matter for service planning. Patients who lived farther away experienced more fragmented patterns of care, and that fragmentation likely complicates the delivery of palliative conversations, medication adjustments, and symptom monitoring. Even when virtual visits are available, they do not fully erase the friction of distance, particularly when frailty, sensory impairment, or caregiver burden limit access.
One sentence captures the practical consequence: geography reached into the final year of life and changed how primary care was delivered.
What Health Systems Can Do With This Finding
The study points toward system-level strategies rather than individual blame. Improving local access to primary care would reduce the need for long travel just to preserve a longitudinal relationship. Enhanced virtual-care models may also help, especially when they are used to maintain contact rather than replace all in-person care. In end-of-life care, continuity is not a luxury feature; it is part of how symptoms are recognized, medication regimens are simplified, and patients’ preferences are carried forward across settings.
The data do not establish a causal pathway, and they do not prove that shortening distance alone would restore continuity. But they do show that physical proximity remains a measurable determinant of outpatient care coherence in the final year of life. For policymakers and primary care planners, that is a clear signal that access should be thought of not only in terms of supply, but also in terms of how far patients must travel to remain connected to the physician who knows them best.
The study leaves one important operational question open: how much of this distance effect can be offset by virtual visits, home-based care, or local team-based primary care before continuity begins to recover?