Municipal Characteristics of In-Home Death Among Care-Dependent Older Japanese Adults

Abstract

IMPORTANCEThe provision of in-home and community end-of-life care has emerged as an important policy issue for aging populations around the world. Despite most patients expressing the wish to die at home (as opposed to in the hospital), substantial geographic variation persists in the prevalence of in-home death at the end of life. OBJECTIVE To assess the association of municipal characteristics with variation in the place of death among care-dependent older people in Japan. DESIGN, SETTING, AND PARTICIPANTSIn this cross-sectional study using multilevel logistic regression, analyses were performed using national claims data under Japan's long-term care insurance system. The study population included long-term care insurance beneficiaries 65 years and older who died in 2015, excluding those who died from external causes, such as unintentional injuries. Data analyses were conducted from January 1 to April 31, 2021. EXPOSURES Predisposing, enabling, and need factors at the individual and municipal levels according to a behavioral model. MAIN OUTCOMES AND MEASURESThe outcome was whether individuals died at home or not. RESULTSThis cross-sectional study analyzed 544 836 decedents (median [IQR] age, 87 [81][82][83][84][85][86][87][88][89][90][91] years; 300 142 [55.1%] female). The proportion of in-home deaths was 10.3%. In the multilevel null model, 7.2% of the variance in the place of death was associated with municipal-level characteristics.Municipal characteristics were associated with more of the variance than were prefectural characteristics (2.7%). The largest proportional change (7.3%) in variance at the municipality level was observed when enabling factors (ie, medical and long-term care resources) were added to the model. Municipalities with a high proportion of in-home death were more likely to have a higher supply of clinics, physicians, and care workers providing in-home services per population, as well as a lower number of hospital beds and long-term care facility workers per population. CONCLUSIONS AND RELEVANCEIn this cross-sectional study, municipal characteristics explained a substantial proportion of the geographic variance in in-home death in Japan. These results suggest that municipal policy makers need to ensure an adequate supply of clinics, physicians, and care workers providing in-home services to meet the preferences of care-dependent older people who wish to spend their final days at home.

End-of-Life Preferences in Older US Adults—Bridging the “What Matters” Chasm

“…Another important finding in the current analysis 4 was that nearly half of decedents had spouses, which was associated with more in-home deaths. An estimated $500 billion of care in the US is provided by unpaid family members, who are a pillar of our medical system and yet receive little to no help or training.…”

“…In this issue of JAMA Network Open , Abe and colleagues 4 present a multilevel, cross-sectional regression analysis of long-term care claims data from 544 836 older Japanese decedents to understand the contribution of individual, municipal, and prefectural (roughly akin to state-level) characteristics on the variation in place of death. A striking result was that despite the preference of 55% of older Japanese adults for an in-home death, only 10% of decedents in this cohort actually died at home.…”

“…Municipalities with more clinics, physicians, and in-home care workers had more in-home deaths. Using mixed-effects logistic regression, Abe et al 4 found that municipal-level characteristics were associated with 7% of the variance in place of death compared with 3% for prefecture-level characteristics, and municipal characteristics were significantly associated with in-home deaths.…”

“…Bridging the “what matters” chasm is everyone’s responsibility. The data from the study by Abe et al 4 suggest that improving access to HCBS could be 1 way to reduce the discordance between preferred and actual place of death for older adults. More funding and support for HCBS are needed so that older US adults living with serious illness and their families can make decisions about care near the end of life based on what is readily available to them at home rather than on what is not.…”

Anticipated deaths with physician care (mitori) at home in one town in Japan: A preliminary report

“…Consequently, obtaining accurate numbers of cases of mitori at home is difficult in Japan. Prior studies about end‐of‐life care at home in Japan focused deaths at home 1,2 . However, including unnatural deaths at home in deaths at home is methodological issue.…”