Measuring geographic proximity to family medicine and continuity of care in the last year of life: A population-level retrospective cohort study using Canadian health administrative data

BACKGROUND: Family physicians provide most outpatient care in patients' last year of life, but it remains unclear how geographic distance between patients and their physicians affects continuity of care. Patients living farther from care providers may experience reduced access and more fragmented care. This study examined whether geographic proximity to a family physician is associated with relational continuity of outpatient care in the last year of life. METHODS: We conducted a population‑level retrospective cohort study of adults who died in Ontario, Canada, from 2021 to 2024, using linked health administrative data. Geographic proximity was measured using quartiles of the shortest driving distance (km) between each patient's residence and their family physician's practice location. Relational continuity was assessed using established measures capturing the concentration of visits, dispersion of care across physicians, and the temporal regularity of visits. Associations were estimated using proportional‑odds regression models adjusted for demographic, socioeconomic, and clinical factors. RESULTS: Among 400,499 patients, the mean age at death was 76.0 years, 52.2% were male, the mean (SD) distance to their family physician was 25.5 (92.0) km, with the highest quartile residing more than 14.2 km away from their family physician. Greater distance was associated with modestly lower relational continuity: each one-quartile increase in distance was linked to lower odds of higher continuity with the usual family physician (cOR: 0.88, 95%CI: 0.87, 0.88). Sensitivity analyses using travel time and Euclidean distance produced consistent findings. DISCUSSION: Geographic proximity is a significant determinant of outpatient continuity near the end of life. Patients living farther from their family physicians experience more fragmented care, underscoring the need for system-level strategies to reduce geographic barriers, including improved local access to primary care and enhanced virtual-care models.