Dying in hospital: socioeconomic inequality trends in England

Increase in hospital care at the end of life: Retrospective analysis of the last 20 years of life of a cohort of patients

BACKGROUND

There is an increasing need for end-of-life care due to society's progressive aging. This study aimed to describe how hospitalizations evolve long-term and in the last months life of a cohort of deceased patients.

METHODS

The study population were those who died in one year who lived in a district in southern Spain. The number of hospital stays over the previous 20 years and number of contacts with the emergency department, hospitalization, outpatient clinics, and medical day hospital in the last three months of life were determined. The analyses were stratified by age, sex, and pattern of functional decline.

RESULTS

The study population included 1773 patients (82.5% of all who died in the district). The hospital stays during the last 20 years of life were concentrated in the last five years (66%) and specially in the last six months (32%). Eighty percent had contact with the hospital during their last three months of life. The older group had the minimun of stays over the last 20 years and contacts with the hospital in the last months of life.

CONCLUSIONS

The majority of hospitalizations occur at the end of life and these admissions represent a significant part of an acute-care hospital's activity. The progressive prolongation of life does not have to go necessarily along with a proportional increase in hospital stays.

The ideal and the real: Patient and bereaved family caregiver perspectives on the significance of place of death

Home has become established as the preferred place of death within health policy and practice in the UK and internationally. However, growing awareness of the structured inequalities underpinning end-of-life care and the challenges for family members undertaking care at home raise questions about the nature of patient and public preferences and priorities regarding place of death and the feasibility of home management of the complex care needs at the end-of-life. This paper presents findings from a qualitative study of 12 patients' and 34 bereaved family caregivers' perspectives and priorities regarding place of death. Participants expressed complex and nuanced accounts in which place of death was not afforded an overarching priority. The study findings point to public pragmatism and flexibility in relation to place of death, and the misalignment of current policy with public priorities that are predominantly for comfort and companionship at the end-of-life, regardless of place.

The end of life experiences of people living with socio-economic deprivation in the developed world: an integrative review

BACKGROUND

Those experiencing socioeconomic deprivation have poorer quality of health throughout their life course which can result in poorer quality of death - with decreased access to palliative care services, greater use of acute care, and reduced access to preferred place of care compared with patients from less deprived populations.

AIM

To summarise the current global evidence from developed countries on end-of-life experience for those living with socio-economic deprivation.

DESIGN

Integrative review in accordance with PRISMA. A thorough search of major databases from 2010-2020, using clear definitions of end-of-life care and well-established proxy indicators of socio-economic deprivation. Empirical research describing experience of adult patients in the last year of life care were included.

RESULTS

Forty studies were included from a total of 3508 after screening and selection. These were deemed to be of high quality; from a wide range of countries with varying healthcare systems; and encompassed all palliative care settings for patients with malignant and non-malignant diagnoses. Three global themes were identified: 1) multi-dimensional symptom burden, 2) preferences and planning and 3) health and social care interactions at the end of life.

CONCLUSIONS

Current models of healthcare services are not meeting the needs of those experiencing socioeconomic deprivation at the end-of-life. Further work is needed to understand the disparity in care, particularly around ensuring patients voices are heard and can influence service development and delivery.

Socioeconomic Disparity Trends in End-of-Life Care for Cancer and Non-Cancer Patients: Are We Closing the Gap?

Purpose

Socioeconomic disparities in end-of-life care have been reported across underlying diseases, but there is a paucity of information on potential time trends. Thus, we aimed to examine time trends in use of health-care services at the end of life according to socioeconomic position in patients dying from cancer and non-cancer diseases.

Materials and Methods

We conducted a nationwide registry-based study among adults dying from cancer or non-cancer diseases (diabetes, dementia, heart failure, ischemic heart disease, stroke, chronic liver disease, and chronic obstructive pulmonary disease) in Denmark in 2006–2016. We obtained data on patients’ educational level and income level and use of health-care services within three months before death. Use of health-care services according to educational level and income level was plotted by calendar year of death and compared by regression analyses adjusting for age, sex, comorbidity, cohabitation, and municipality.

Results

In both cancer (n = 169,694) and non-cancer patients (n = 180,350), we found limited socioeconomic disparities and no clear temporal trends in use of hospital, intensive care, emergency room, general practice, home care nurse, and hospice. In 2006/2007, one percentage point more cancer patients with high income level compared with low income level were affiliated with hospital-based specialist palliative care (adjusted mean difference: 0.01 (95% confidence interval (CI): 0.01; 0.02)), whereas this was 12 percentage points in 2016 (adjusted mean difference: 0.12 (95% CI: 0.09; 0.14)).

Conclusion

Socioeconomic disparities in specialist palliative care tended to increase over time among cancer patients but were limited and without clear time trends in use of other health-care services in both cancer and non-cancer patients.

Persistent socioeconomic inequalities in location of death and receipt of palliative care: A population-based cohort study

BACKGROUND

Providing equitable care to patients in need across the life course is a priority for many healthcare systems.

AIM

To estimate socioeconomic inequality trends in the proportions of decedents that died in the community and that received palliative care within 30 days of death (including home visits and specialist/generalist physician encounters).

DESIGN

Cohort study based on health administrative data. Socioeconomic position was measured by area-level material deprivation. Inequality gaps were quantified annually and longitudinally using the slope index of inequality (absolute gap) and relative index of inequality (relative gap).

SETTING/PARTICIPANTS

A total of 729,290 decedents aged ⩾18 years in Ontario, Canada from 2009 to 2016.

RESULTS

In 2016, the modelled absolute gap (corresponding 95% confidence interval) between the most- and least-deprived neighbourhoods in community deaths was 4.0% (2.9-5.1%), which was 8.6% (6.2-10.9%) of the overall mean (46.6%). Relative to 2009, these inequalities declined modestly. Inequalities in 2016 were evident for palliative home visits (6.8% (5.8-7.8%) absolute gap, 26.3% (22.5-30.0%) relative gap) and for physician encounters (6.8% (5.7-7.9%) absolute gap, 13.2% (11.0-15.3%) relative gap), and widened from 2009 for physician encounters only on the absolute scale. Inequalities varied considerably across disease trajectories (organ failure, terminal illness, frailty, and sudden death).

CONCLUSION

Key measures of end-of-life care are not achieved equally across socioeconomic groups. These data can be used to inform policy strategies to improve delivery of palliative and end-of-life services.

Economics of death and dying: a critical evaluation of environmental damages and healthcare reforms across the globe

The economics of death and dying highlighted that environmental factors negatively influence healthcare sustainability. Therefore, this study conducted a system-based literature review to identify the negative externality of environmental damages on global healthcare reforms. Based on 42 peer-reviewed papers in the field of healthcare reforms and 12 papers in the field of environmental hazards, we identified 25 factors associated with death and dying and 15 factors associated with health-related damages across the world respectively. We noted that environmental factors are largely responsible to affect healthcare sustainability reforms by associating with the number of healthcare diseases pertaining to air pollutants. The study suggests healthcare practitioners and environmentalists to devise long-term sustainable healthcare policies by limiting highly toxic air pollutants through technology-embodied green healthcare infrastructure to attained efficient global healthcare recovery.

Disparities In Cancer Care And Costs At The End Of Life: Evidence From England's National Health Service

In universal health care systems such as the English National Health Service, equality of access is a core principle, and health care is free at the point of delivery. However, even within a universal system, disparities in care and costs exist along a socioeconomic gradient. Little is known about socioeconomic disparities at the end of life and how they affect health care costs. This study examines disparities in end-of-life treatment costs for cancer patients in England. Analyzing data on over 250,000 colorectal, breast, prostate, and lung cancer patients from multiple national databases, we found evidence illustrating that disparities are driven largely by the greater use of emergency inpatient care among patients of lower socioeconomic status. Even within a system with free health care, differences in the use of care create disparities in cancer costs. While further studies of these barriers is required, our research suggests that disparities may be reduced through better management of needs through the use of less expensive and more effective health care settings and treatments.